There are many well intentioned proposals to improve health care in the United States. Ultimately, all of them rely on the participation of the majority of patients and medical care providers with the goal that everyone will have access to health care and everyone will pay their fair share of the costs. Currently, our public and private systems do not collect nor distribute the money they get from taxes and from premiums so as to assure that everyone has access to quality health care. Those who currently control the political process do not want to replace the private system and do not want to pay for universal health care if they have to make sacrifices in other domestic and military budgets. It does not appear that the health care reform desires of the general public and the medical care providers are going to be met by political means. Consequently, organization of patients and providers of medical services will be needed at the local level to solve the problems related to caring for all patients in a given community. Usually, existing associations and churches take the lead in such needed grass roots developments. TBT is that kind of grass roots organization.
TBT is a faith centered group of men and women who recognize that Jesus asked people to be the light of the world and some people have done that, but most of us have not shed much light on anything. Our goal is to be with the poor and to do works of mercy. One of those works is to make health care available to those who need it. Unfortunately, our current health care system does not adequately meet the needs of anyone since it also leaves those who can afford it at great risk, in that they could lose their fortunes just in trying to stay healthy. It may be that there are many reasons why health care in America has failed to care for everyone, especially the poor. However, those who know what must be done are not absolved of the responsibility to care for people in their communities and for the poor. It is also a great truth that the church - communities of faithful people - must meet many of these needs through intelligent and careful use of its resources.
The members of TBT understand that the problems with healthcare exist both on the local and national level. While much of our attention is focused on how to address the local needs, we also hope to demonstrate that there are better models for health care than those we see being used.
Getting care for everyone will require improvements in our health care delivery systems. Among our members and friends are people who have learned the art of medicine, the administration of health care facilities, and the art business. We believe that by God’s grace, we will be able to make the needed improvements. We know that in the United States the problem is a failure to include everyone in a system that makes health care services available regardless of employment or insurance. In other countries the total lack of money, physicians, and facilities are the underlying causes of failure to provide health care to everyone. We do not lack these resources in our country, so we should be able to have universal health care. We want to use our best knowledge and skill to fix what is wrong in each community we serve. We have begun this work in Texas and Oregon but hope to develop a model that can be used elsewhere to provide health care to everyone.
We believe that it is possible to structure physician groups in such a way that they can deliver efficient care without the influence of larger business organizations. Some of our members have written a book about that and published it on this web site. These business organizations and the bureaucracy that surround them consume a large piece of the health care dollar. Local physician groups can deliver excellent care at a reasonable cost. The monies saved in effective administration can be used to meet the needs of those in the community who do not have the means to pay for health care.
One of the expected problems in reaching our goal of reform is the natural inclination people have to acquire material wealth. Having more income and saving on expenses are the two most obvious ways to achieve this naturally desired wealth. In health care, that means doctors usually want more income while patients and their insurers want to pay less in fees. Because most people in the United States use insurance systems for funding health care, these natural inclinations must be controlled. Insurance is budgeting and sharing costs. If it is to be the way in which health care is financed, then the patients and their employers who pay fees -- and physicians and hospitals who receive fees -- must, together, accept primary responsibility for budget management. Neither party can shift budget management to a third party, such as an insurer. That shift, which has been characteristic of the health care system in the United States, causes the insurers to take a much greater portion of the available health care funds than distribution of funds and accounting requires. It has led to systems of third party control that interfere with the rights of patients and physicians. If it sounds as if we are advocating for a non-profit insurance company as an administrator, we are not. We are advocating that the insurers make their profits in competition with each other for administration but not in taking surpluses from the health care funds they administer.
The health care funds are also eroded when physicians and other types of health care providers overcharge for their services and over-utilize health care facilities and diagnostic procedures. Finally, patients who are not paying directly for the health care they receive have little regard for its cost and much demand for services.
Solutions come from actions based on the virtues of love, peace, truth, tolerance, and cooperation. The virtues listed have been included in the incorporated name of Tomorrow’s Bread Today. It is a reminder of who we must be and what we must do to reach our goals.
One small step we can take to begin the reform of health care is through cooperation. The routine expenses of individuals for primary health care services are best used if not funded through insurance contracts, but through cooperation between patients and medical care providers. Families and individuals in specific geographical locations can form cooperatives in which the patient members will use member physicians and nurses to deliver primary health care. Each patient can then pay the health care providers who work at these facilities a small monthly fee, or retainer, for their professional services. We have determined from our experience the fee amount averages about $30 -$45 per patient, adult or child. The cooperative dues are $20 per month per person and helps to fund the charity needs of the organization's membership. We have also determined that a single physician or nurse-practitioner has the time and capacity to serve between 1,000 and 1,500 patients a year. The lower number usual means that the patients have more serious illnesses and require more frequent attention and counsel. The predetermined fee amount was based on the usual take home earnings of the physician or nurse-practitioner and his or her medical staff. That amount should be equal to or greater than what the medical professionals could earn in a private primary care practice. Of course, this is a private practice too, but without third party participation in the payments or medical decision making or an interest in the confidential medical records of the patients. The Cooperative, by taking responsibility for finding physicians, nurses and other health care providers who are willing to accept a fee schedule similar to the published Medicare prices and a monthly retainer payment plan for patients, greatly reduces the business costs of the medical services through use of group purchasing power. The Cooperative creates a financial partnership between physicians and patients where they can pay the physician easily and fairly while reducing the expenses of administration, facilities and unneeded medical care services.
The most important thing accomplished in this division of responsibilities is the removal of any connection between financial reward and the care and treatment of patients. The profit motives and the dependence on third party payment for routine care is the most corrupting influence in health care and the cause of the misrepresentation of the medical record by health care providers. In the absence of a universal and equally inexpensive health insurance system, the cooperative is the individual’s and the physician’s best alternative.
The contractual arrangement between the patient and the primary care provider is a very simple payment agreement. An example of such an agreement is linked to this paper via the book we have published. It was drawn by an attorney for use by members of our cooperative after research into similar agreements that have been used by physicians over the last ten years. Since patients are paying an amount that is the equivalent of what they normally spend on an annual basis for primary health care there is no sharing of risk among patients. Further, they are no services guaranteed to patients beyond what can be delivered by the primary care provider in his or her facility, so there is no sharing of cost for services from other health care providers. It is not insurance but only part of the personal budget of the individual patient and the monthly collections of fees for service by the primary care provider.
The limitation of this system is that patients must sometimes use other medical care providers and facilities to solve their health problems. They could make similar payment arrangements with other specialist health care providers, but it is more likely and practical for them to purchase insurance for those occasions. It could be through three different sources, public (such as Medicare and Medicaid), private (HMOs and indemnity insurers) or charity from non-profit health care organizations. At this time, these insurance and charity systems are flawed and often difficult to access by a large part of the population. In our surveys of more than 4,000 people in the Houston area, about 40% did not have access to health care through insurance or charity. When they needed care in emergencies, getting care was difficult to arrange and usually resulted in poor care and little or no payment for the physician or hospital provider. In these circumstances the Co-operative can at least be a patient advocate to properly guide the patient through the system and its red tape in the least adversarial manner. It can also be the vehicle for obtaining group health insurance that is without exclusions for preexisting conditions, which the cooperative has been able to get through the Senior Patient Association in a group policies underwritten by Pan American Life Insurance and Partner's Re.
Getting neighbors to work together cooperatively in such areas as primary health care is very difficult in our society. The relationships between people are mostly through family, schools, churches, and work. The networks of relationships extend through many geographical locations and are seldom within a single neighborhood. In some ways the cooperative forces neighborhood relationships, but it is a good way for everyone in the community to mutually benefit. We don’t need to look outside for great wisdom or support, the cooperative is neither complicated nor would it be helped by a patron regardless of how well the intentions. The little that each of us would do for one another exceeds what could be done by any patron. Noam Chomsky said, “It’s only if we all do something a different way that we’ll all benefit a lot more. The costs to you – an individual – to work to create the possibilities to do things together can be severe. It’s only if lots of people begin to do it, and do it seriously, that you get real benefits.”