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Reengineering the Health Infrastructure

The U.S. healthcare system has exhibited jagged cracks for a long time but not until Covid-19 did we realize how extensive the problem really is.  Over the past several years we have fostered a system that has forgotten its primary mission: caring for patients and healing the sick.  This mission reflected in the Hipporcratic Oath, pledged by every physician when they graduate medical school is one whch all healthcare professional on the front lines of care live by. The oath is as follows:

I respect the hard-won scientific gains of those physicians in whose steps I walk and gladly share such knowledge as is mine with those who are to follow.

I will apply for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism

I will remember that there is art to medicine as well as science and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug. 

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery. 

I will respect the privacy of my patients for their problems are not disclosed to me that the world may know.  Most especially must I treat carefully in matters of life and death.  If it is given to me to save a life all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.  Above all, I must not play at God.

I will remember that I do not treat a fever chart,  or a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.  My responsibility includes these related problems, if I am to care adequately for the sick. 

I will prevent disease whenever I can, for prevention is preferable to cure. 

I will remember that I remain a member of society with special obligations to my fellow human beings, those sound of mind and body as well as the infirm. 

These principles of care were part of the culture of care until the second half of the 20th century when, for a variety of reasons, a focus on the budgets of healthcare institutions replaced the ethics of charity and compassion.  This was particularly evident when patients sought care at a healthcare institution where a condition of receiving care was based on the patient’s ability to pay the bill.  It showed up at the pharmacy where the price of many vital life-saving medications are no longer affordable to the average individual.

For example, in the middle of the largest medical crisis we have ever experienced, one young man in Georgia who was feeling ill went to the ER of the local hospital to get a Covid-19 test.  The test was administered but was never sent out.  The young man was sent home without a result and with a bill of $9,000 for the test.  This story which was reported on the CBS morning news last week is a mere suggestion of what  has been going on and what is coming.  There are hospitals in America that have recently instituted a new practice of hiring debt collectors who threaten patients who have delinquent bills with court appearances  and  jail time. The patients are given the choice of setting up a payment plan, having their wages or bank account garnished or have a lien put on their property if they fail to comply.  If the patient fails to show up in court they can be arrested and there are judges who will sentence them to jail time, whether they are sick or healthy at the time.

(When Medical Debt Collectors Decide who Gets Arrested: Pro Publica,

To date  4/6/20  there are approximately 350,000 reported cases of Covid-19 in the U.S., over 1.2 million worldwide. As we try to grapple with these numbers and the strain they put on the healthcare system, we are faced with some startling realizations that we did not even think about a few weeks ago.  Large urban hospitals and academic teaching centers,  which today derive so much of their income from elective surgeries and outpatient procedures are feeling the pinch  as they are being asked to cancel all non-essential procedures to enable the system to handle  Covid-19 patients.   The revenue impact is devasting and could result in many closures, especially in areas where they are already too few public hospital.

Many rural hospitals, that have been struggling for a long time to make ends meet are also on the brink of closure.   About 60 million peple, nearly one in five Americans,currently live in rural areas of the United States and depend on their local hospitals for care.  In 2019, 18 rural hospital closed because they did not have the capital to keep operating and also suffered from severe doctor shortages.  Across the US.119 rural hospital have closed since 2010, including locations in Texas, Oklahoma, Tennessee, Kansas, Georgia, Alabama.and Missouri. Rural hospitals serve complex patient populations who tend to have multiple chronic conditions, are older and more economically disadvantaged. The closings leave these rural American residents with nowhere to go for care.

Although no one could ever have anticipated this pandemic, engulfing us as quickly as it did, who would ever have believed that in our nation, the wealthiest nation in the world, we would experience such severe shortages of equipment and supplies to cope with this emergency?  Who would have believed  that with the current infrastructure,  major hospitals  that derive their operating budgets from elective surgeries to  keep them solvent could fall into bankruptcy?  Who would ever have suspected the level of unpreparedness of our leaders and our healthcare system?

Initial lessons learned from Covid-19 are multifold and point to the hard fact that we must undergo radical change that involves a complete reengineering of our healthcare infrastructure, pricing and delivery of care services, if we are to serve the needs of the citizens of the United States of America. There are some obvious actions our nation must take, once we have gone through the height of this pandemic:

  1. Congress must pass legislation that completely revamps the pricing structures and reimbursement strategies to  make it possible for all citizens to receive care at an equitable price for that care including: basic healthcare, in-hospital procedures, medications and co-pays.
  2. Our leaders must develop strategies to foster an environment where hospitals and care clinics are able to remain solvent and serve the communities where they are located, while protecting the basic principles of our free enterprise syste.
  3. Oversight of the pharmaceutical industry and healthcare payers needs to be put into place with stronger regulation.
  4. Greater assistance needs to be provided to medical and nursing schools to develop a strong corps of healthcare professionals (particularly primary care doctors, nurse practitioners, nurses  and physician assistants who are trained to address and care for the sick in every corner of the U.S.
  5.  The supply chain needs to be restructured  so we are dependent only on our own U.S. manufacturers for vital supplies, equipment and medications that are  made in America, so that the shortages experienced during Covid-19  will never happen again.