July 27, 2009

Another Immodest Proposal: Housecalls R Us

Hatched by Dafydd

Some discussion in the comments of a previous post here center around the problem of poor people, seniors, and illegal aliens (with some obvious overlap) using emergency rooms and trauma centers as doctor's offices. That is, these patients cannot or will not, for various reasons, visit ordinary doctors' offices for their non-emergency conditions; so they clog up ERs with relatively minor injuries, illness, and conditions. Over and above the health-insurance debate, this causes problems of overcrowded ERs and real emergencies going untreated; and it can lead (along with unwarranted lawsuits and over-the-top judgments) to such centers for emergency care actually being shut down, due to the financial drain on the associated hospital.

So what can be done?

The illegal-alien component in this problem is considerable: They often can't get insurance, can't afford regular checkups -- and they're afraid to go to doctors and give a history, because they might be deported. Of course, the real solution to this component of the ER problem is to resolve the problem of illegal immigration itself. Long-time readers of Big Lizards know that I strongly support a comprehensive, four-part policy:

  • Reforming the legal immigration system to make it more rational, predictable, and just, so that we admit those most easily assimilated, rather than favored ethnicities or nationalities;
  • Building a wall to keep out those who don't qualify for legal immigration under the new standards;
  • Immunizing legal residents who are not yet citizens from the raft of minimum-wage laws -- so we get our low-wage workers not from temporaries, with no loyalty to the U.S., but from those who are in the process of becoming citizens;
  • And offering a plea-bargain (not "amnesty") to those currently here illegally, wherein they (a) pay a fine, (b) pay any back taxes they may owe, and (c) then and only then receive legal residency -- so long as (d) they have otherwise behaved themselves while living here illegally. (I also support deportation of illegals convicted of crimes here, as soon as they finish their sentences.) Naturally, we need a more technologically sophisticated "green card" with biometrics, and an upgraded and updated database of citizens, residents, and tourists.

But that's not likely to happen anytime soon. Under the Obama-Pelosi-Reid administration, we may instead very well get a "solution" that even I would call amnesty... but that hasn't even been seriously proposed yet (thank goodness). So what can we do in the meanwhile? And what can we do about American citizens and legal residents who also use the ER as a doctor's office for their children's colds or their own arthiritis?

I have a suggestion... but I don't know how much it would really help or whether there are serious impediments that would make it impractical. Thus, I throw it open to the massmind of the Big Lizards readership, many of whom have far more experience than I:

Housecalls R Us

Proposed: The federal government should encourage more young doctors to join Mobile Care Units that make housecalls and neighborhood calls. The incentive should be partial or even complete forgiveness of federally guaranteed med-school loans, along with grants to states to offer similar forgiveness of state-guaranteed loans, for doctors (especially those who speak a useful foreign language) who agree to serve their residencies in such MCUs... sort of like the program to encourage newly minted doctors to move to rural areas for their residencies.

MCUs would be focused in urban areas where urgent-care centers are overused for non-urgent situations; the idea would be to make regular medical visits to residents who would otherwise use ERs; the doctors would perform regular checkups, non-emergency treatment, and could call for emergency transport for any actual urgent medical problems they discover. The doctors would not be allowed to report suspected illegal aliens. (I believe all police should be required to report any criminal suspect here illegally to U.S. Citizenship and Immigration Services; but doctors aren't cops. Without the prohibition against MCU doctors reporting, illegals might just run and hide when the MCUs come to their neighborhood, negating the whole point.)

Each unit would be assigned to a particular neighborhood or group of neighborhoods, depending on the population of impoverished or otherwise "disadvantaged" patients (perhaps using the proxy measurement of non-emergency ER visits); some very dense neighborhoods would get multiple MCUs. This would in particular include new-immigrant-heavy neighborhoods, poor and high-crime neighborhoods, ethnic enclaves, and so forth.

The doctors would be accompanied by registered nurses (same sort of debt-forgiveness deal), and by social-service bureaucrats who could work out payment plans for patients, including signing them up for whatever subsidized insurance programs or other benefits are already available for residents (legal or illegal). Patients would be required to pay something, that "something" being determined by actual need. MCUs would also include trained and armed security guards, for obvious reasons.

Finally, the program would include some tort reform for those doctors and nurses participating in the program, raising the standard of proof required for liability and limiting judgments to some reasonable level, along with the feds offering medical malpractice insurance to the participants; this to allay fears that some junkie or wino given perfectly proper treatment will nevertheless die, and his heirs will see the death as their ticket to lifelong wealth.

As to cost, if we made 50,000 Mobile positions available per year, and if the average medical resident was able to get the feds to pay off $50,000 of his debt, that would cost $2.5 billion directly -- plus administrative, logistical, and insurance costs; call it $7.5 to $10 billion. Some of that would be direct payoffs, the rest would be block grants to states.

Does anybody here think that would help relieve the ERs, trauma-care centers, and urgent-care centers? Would it encourage more of the so-called "underclass" to get regular, non-ER medical checkups and other care? Would it save taxpayer money in the long run? Would it cause more problems than it solved? Could it even be done legally? And is it already being done on a national level, and I've just never heard about it?

I'm definitely groping for a solution here, so your input is urgently needed to solve this emergency without too much mental trauma.

Hatched by Dafydd on this day, July 27, 2009, at the time of 4:13 PM

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The following hissed in response by: Dick E


I like your idea of Mobile Care Units. I envision a doctor’s office on wheels with a nurse who is cross-trained as a lab tech. (Are there legal or labor relations problems with such cross training?) I doubt there could be much more in a mobile unit -- x-ray, etc. would be too expensive.

I’m not sure how MCU’s would work financially, though. Unless you have a consistent stream of patients, it could be more expensive per capita than ER care. One or two no-shows per day could throw the whole system out of whack.

The problem with house calls is that primary care medicine has changed greatly from the good old days. When I was a kid and went to the doctor, I saw the doctor. Once in a while he came to our house -- alone, of course. These days, doctors’ time is way too expensive for that, so the entire system is geared around relieving the physician of routine tasks like taking vitals signs, compiling history, drawing blood for testing, etc. And do we really want to pay someone $200,000 a year for commuting time? (If you’re talking about using the MCU itself as a house call vehicle, that means two or more people plus the vehicle and equipment are all tied up from the time they leave home base until they return.)

Unfortunately, I’m not sure I have a viable alternative. I thought about a network of small community clinics, each consisting of two or three doctors, the same number of nurses, and a lab tech who doubles as a receptionist. If you put one of these every few blocks, the distance wouldn’t be much greater than to wherever the MCU parks. Plus, it’s always there for urgent care. Put an x-ray machine and tech in about a third of the locations. Anything more specialized would still require a trip to the main clinic.

Trouble with this scenario is, all the clinics probably need to be part of the same organization. That’s not likely with out present system of competing medical providers. It could happen with ObamaCare, but even there I think it’s unlikely. A single payer could do it, but they are probably even more inclined than our current system to concentrate resources in large centers.

The above is not a professional opinion, of course, but I seem to be the only one so far to opine.

The above hissed in response by: Dick E [TypeKey Profile Page] at July 27, 2009 10:17 PM

The following hissed in response by: BlueNight

So that old Far Side about the Vaccination Truck that tries to fool kids by playing Ice Cream Truck music... that would be real?

We need more real-world solutions inspired by Far Side.

The above hissed in response by: BlueNight [TypeKey Profile Page] at July 27, 2009 11:54 PM

The following hissed in response by: Elyjf

You mean they'll be almost as sophisticated as my vet? The back of that pickup has a mobile lab, x-ray, ultrasound, dispensary, and tools to restrain anything up to 3000 lbs. You want to see blood in the streets, come watch us put a ring through the nose of that 2000 lb steer I forgot to do when he was little---

The above hissed in response by: Elyjf [TypeKey Profile Page] at July 28, 2009 5:04 AM

The following hissed in response by: wtanksleyjr

I don't know whether house calls will work -- it actually might help, but it would cost a lot.

Another solution would be to partially deregulate medicine, so that the AMA isn't the only organization that can say who can practice medicine. Allow nurse organizations to do so as well, using their "nurse practitioner" role. Doing this in full might be impractical, so it might work to have a NP legally permitted to independently practice medicine as defined by a flowchart drawn up by MDs. (Studies show that flowcharts have better outcomes than MDs using their independent best judgment, by the way.)


The above hissed in response by: wtanksleyjr [TypeKey Profile Page] at July 28, 2009 9:28 AM

The following hissed in response by: Geoman

Simple legal reform - can't sue for free health care. It falls under good Samaritan rules.

The above hissed in response by: Geoman [TypeKey Profile Page] at July 28, 2009 9:43 AM

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