Medical organization, medical care and lower income groups

Abstract This paper is addressed to an important policy question, very much at the center of American attention: how can high quality of medical care be achieved for all our population? Although my analyses and recommendations are directed at the local scene, I believe they are pertinent—with qualifications which will be touched on my closing pages—to many another country. The chief reason is that although medical organization throughout the world varies widely in the scope of population covered and in how populations are serviced, the assumptions about medical care are relatively standard—and often they are built without scrutiny into the very fabric of a nation's system of medical care. About my own country, I question in this paper whether its citizens can realistically expect anything like high quality of care without considerably more far-reaching reforms in our present system of medical and health care than are instituted by present legislation, or assumed in current planning. (And I have chosen deliberately not to discuss another important issue— whether equality of care can even be approached without radical changes in American social structure.) My argument, briefly summarized, is as follows: 1. (1) The national commitment to quality medical care for all citizens has led to important legislation, now having its impact at local levels. The emphasis is on extending and improving a basically sound system of medical organization so that medical care can be offered faster, more effectively, more efficiently, and to all sectors of our population. 2. (2) Behind this emphasis on delivering improved care is the assumption that hitherto medically disadvantaged groups—notably the lower economic groups—can be reached without radical transformation of the system of medical care. 3. (3) This assumption is dubious. If so, then major reforms in medical organization are required, otherwise the current great inequities in the distribution of medical care will continue. 4. (4) The medical system has never adequately serviced lower income groups in the past, because it was not designed to do so. Lower income styles of life are sufficiently different so that they must specifically be taken into account in organising medical care for these sectors of the population. Professionals have not been trained, and generally are not now being trained, in the special skills necessary to deliver quality care to these people. 5. (5) The recommendations that I give are based on the necessity for breaking a vicious cycle which characterizes the medical care of lower income patients. First, we must speed up the initial visit of the patient for medical care. Second, we must improve the experiences which he has in the medical facilities. Third, we must improve the communication, given and received, about necessary regimens. Fourth, we must increase the likelihood that the patient will properly carry out his regimen at home. Fifth, we must increase the likelihood of necessary revisits to the medical facility. And sixth, we must decrease the time between the necessary revisits. (Since this vicious cycle also operates, although to a lesser extent, with higher income patients, my recommendations are directed at improving care for those patients also.) 6. (6) I suggest a number of recommendations, each directed at breaking some phase of the vicious cycle and deriving from considerations of the life-styles of lower income Americans. These recommendations do not necessarily require additional resources or finances; but a rearrangement of tasks and organization, invention of new organizational mechanisms, and the reallocation of expenditures. By no means are all the recommendations which I suggest original: what makes these recommendations different is that they are related to each other through the guiding idea of a “vicious cycle”. 7. (7) To insure sufficiently broad action really to break this cycle, I argue one further recommendation. We need responsibility at four levels: professional, institutional, lay and governmental. Professional societies and schools must take responsibility for certain reforms bearing on the total restraining cycle. Medical facilities also need to consider how broadly across the cycle they can act. I argue that we need also to enlist the responsible efforts of lower income people; and further, that governmental responsibility for inducing needed reforms—as outlined in this paper—is also requisite. In general, then, I argue that the national commitment to high quality of medical care necessitates reforms far beyond those usually envisioned in current planning and legislation. These reforms can be joined with the more usual, and certainly very necessary, recommendations for increased expenditure and manpower in order to improve medical care across the board [1].