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You are here: Home / Economics / C.R.E.A.M. / “Shovel-Ready Clinics”

“Shovel-Ready Clinics”

by Anne Laurie|  December 2, 201111:04 am| 34 Comments

This post is in: C.R.E.A.M., World's Best Healthcare (If You Can Afford It)

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This is an intriguing proposal, although I don’t know enough about the background behind its boosters to judge its real-world value. Jeffrey Leonard, in the Washington Monthly, wants to bring the SBA to the implementation of the ACA:

… In 2014, a little more than two short years away, the provisions in the Affordable Care Act (ACA) that are designed to expand coverage will kick in, initiating a deluge of insurance-card-carrying Americans into the health care system. These disproportionately low-income, newly insured people will live in every state and community in the country. Unless we act now, they stand to join the ranks of the “medically disenfranchised”—the more than 50 million already insured Americans who have no regular access to primary health care for lack of physicians and facilities in their local communities. Think our transportation infrastructure is under stress? Our health care infrastructure is like an already clogged highway system that’s about to take on 32 million new vehicles overnight.
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These three problems—the economy’s failure to create jobs, the banking sector’s unwillingness to lend, and the health care system’s lack of capacity to meet an accelerating rise in demand—might seem intractable, especially in a deadlocked Washington where no new money is likely to be put on the table. But if we could take off our ideological blinders for a moment—if conservatives could stop seeing every federal action as an assault on freedom, and liberals could get beyond their belief that spending more federal money is the way out of every problem—we would find a modest answer to all three of these problems staring us in the face.
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Part of the solution is relatively uncontroversial. As Congress and the president have acknowledged, the way to meet the flood of new patients coming down the pike is to expand the nation’s existing network of community health centers— nonprofit clinics that offer primary care to the medically under-served, often in rural areas or inner cities. But to get this done, there’s no need to appropriate billions more in direct government spending. Rather, there is a way to lure skittish banks into lending private capital to finance a health center construction boom in all fifty states, simply by tweaking the language of an existing federal lending program. Doing so would save money in the long run by providing cost-effective primary care to those who desperately need it. And it would quickly create tens of thousands of jobs, many of them in the hard-hit construction sector. Moreover, unlike the roads, bridges, and other complex infrastructure projects the Obama administration wants to fund, few of which are shovel ready, health center projects could get the hammers swinging in months, not years….

Anybody with more information or experience want to explain why this is / isn’t a workable idea?

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34Comments

  1. 1.

    Villago Delenda Est

    December 2, 2011 at 11:08 am

    There is, of course, the issue of who will staff such newly constructed clinics if they are built.

    The AMA has to be brought low. Their fucking medieval guild mentality must be eliminated.

  2. 2.

    Monkey Business

    December 2, 2011 at 11:13 am

    @Villago Delenda Est: I’m going to take a swing at this one: doctors and nurses?

  3. 3.

    Villago Delenda Est

    December 2, 2011 at 11:17 am

    @Monkey Business:

    Is there an adequate supply of doctors and nurses who are currently collecting unemployment to be instantly put to work as staff in these new clinics?

    No? Then we have a problem.

  4. 4.

    Benjamin Franklin

    December 2, 2011 at 11:22 am

    ,” or sign long-term leases for their own space,”

    “Anybody with more information or experience want to explain why this is / isn’t a workable idea?”

    New construction is out without some legislative ‘tweaking’ (and we know how that will go)

    But leasing is an agreement with the Lessor. If we take all these empty Industrial warehouse built during the bubble, and now vacant, the lessor will build to suit.
    Therefore no ‘start up’ costs accrue to the lessee. Construction Jobs will still populate.

    Et Voila !

  5. 5.

    Soonergrunt

    December 2, 2011 at 11:22 am

    We need an attendant increase in the education and placement of Physician’s Assistants and Nurse Practitioners in these rural clinics. Without qualified people to staff them at reasonable reimbursement rates, they will run into the same problem that VA has run into in some places as we’ve tried to expand our outreach to the rural areas.

  6. 6.

    Villago Delenda Est

    December 2, 2011 at 11:27 am

    As long as you’ve got a parochial trade group putting restraints on the market for their own benefit, the free market will be unable to respond.

    Even if medical care operated the way an electronics store does in the market. Even then.

    None of the glibertarian/Rethug types understands any of this, because they have NO FUCKING IDEA how actual free markets function, because there are no free markets in this corporate dominated country, by design and conspiracy.

  7. 7.

    Yevgraf

    December 2, 2011 at 11:28 am

    @Soonergrunt:

    We need an attendant increase in the education and placement of Physician’s Assistants and Nurse Practitioners in these rural clinics. Without qualified people to staff them at reasonable reimbursement rates, they will run into the same problem that VA has run into in some places as we’ve tried to expand our outreach to the rural areas.

    There’s an angry guy on line three for you. Says he’s from the AMA, and is demanding a word with you before he tees off on his next round.

    Shall I put him on hold?

  8. 8.

    Someguy

    December 2, 2011 at 11:30 am

    After fighting so hard to federalize medicine and to establish bodies to limit fees, why would you want to use federal tax dollars to subsidize businesses for a new class of money grubbing doctors? They can go work for Columbia if they want to get rich. No need to do it on our dime. Besides, the notion of community clinics, and doctors making a profit, is inherently self-contradictory.

  9. 9.

    burnspbesq

    December 2, 2011 at 11:32 am

    @Villago Delenda Est:

    That’s quite a non sequitur you’ve got there. Care to explain?

  10. 10.

    Robert Waldmann

    December 2, 2011 at 11:37 am

    As far as I know, the proposal is excellent. However the Ballance is very irritating. The claim “liberals could get beyond their belief that spending more federal money is the way out of every problem” is hard to reconcile with the (second) latest roll call vote in the Senate by which liberals voted to extend the payroll tax holiday. That would have increased the deficit, but it is not “spending more”.

    Also liberals were not eager to handle our problems in Iraq by spending more money.

    And liberals just loved TARP (OK I’m a liberal and I love TARP but I’m the only one).

    The throwaway line is obviously false. The claim about liberals has no basis whatsoever, and the author must know it is false. The point is that, to be serious and bipartisan, one has to punch hippies.

  11. 11.

    burnspbesq

    December 2, 2011 at 11:38 am

    @Yevgraf:

    Smart doctors won’t fight leverage in service delivery. They’ll own it. Leverage is the key to profitability in every other branch of professional services. No reason why it can’t work in medicine.

    P.S. your ignorance and bias are showing.

  12. 12.

    Yevgraf

    December 2, 2011 at 11:40 am

    @Villago Delenda Est:

    As long as you’ve got a parochial trade group putting restraints on the market for their own benefit, the free market will be unable to respond.

    Its just another version of regulatory capture by a really shortsighted bunch of rotten businessmen.

  13. 13.

    Villago Delenda Est

    December 2, 2011 at 11:40 am

    @burnspbesq:

    The AMA. Making sure that the supply of doctors is kept low, to maximize their profit.

    Admittedly, a great deal of what is needed in medical care for the vast majority of patients does not require an MD. A nurse, a physician’s assistant, or a nurse practitioner can perform much of the work. But is there a ready supply of them to staff these clinics?

    Still, some people will INSIST on seeing “the doctor”. And there’s still the issue that only “the doctor” can write the prescriptions for whatever medications are required.

    So, unless you’ve got the properly trained personnel laying around without stuff to do to to staff the clinics (and the AMA does its job of making sure that the supply of doctors is tightly controlled to insure that this free market shit doesn’t rain on their parade) then you’ll have problems with such an initiative. You’ll be building clinics that will never provide care, for lack of a staff to provide it.

  14. 14.

    Belafon (formerly anonevent)

    December 2, 2011 at 11:41 am

    This is similar to getting phone and electricity to rural areas in the 20th century, or high speed internet today: Companies are not going to move in unless infrastructure is in place. Banks aren’t going to loan – even if they were willing – for something that has a low chance of covering the loan.

    Anecdote – My manager lives a few miles outside of Greenville, Tx. When he calls the phone company to ask when they are going to get high speed internet access to his area, they reply that he has the oldest remining telephone hardware in the state. According to him, they make it sound like it should be something to be proud of.

  15. 15.

    Yevgraf

    December 2, 2011 at 11:43 am

    @burnspbesq:

    Smart doctors won’t fight leverage in service delivery.

    There’s your problem, right there in bold. The glorified plumbers are convinced of their own godhead, and society enables them in their delusion. I’ve dealt with them in matters of business and their divorces for years – they blunder about in business because everyone has convinced them of their brilliance for so many years.

  16. 16.

    PWL

    December 2, 2011 at 11:52 am

    One word for ya: Politics. That’s why it will never work.

  17. 17.

    bza

    December 2, 2011 at 11:53 am

    I oversaw the construction of a community clinic operating out of the space of another not-for-profit, and funded by the ARRA, that was by all accounts ‘shovel ready.’ Unfortunately, even these projects (as ready to go as possible but for a lack of funding) can take an extended amount of time to complete. The specific project I was involved in was started in 2009 and has yet to fully open as an operating outpatient clinic. I am all for these projects, but the reality for some of the specific projects is that there are significant hurdles (finalizing design, permitting, construction, etc.) before seeing them to fruition.

  18. 18.

    Maude

    December 2, 2011 at 12:11 pm

    @Belafon (formerly anonevent):
    In other words they are saying bite me.

  19. 19.

    Anonymous At Work

    December 2, 2011 at 12:47 pm

    Not enough doctors and nurses. Nurses get so many exemptions from just about every law because they are so vital and in such short supply. But the job is so genuinely hard that it’s not a licensure failure issue.
    But doctors…the costs associated with becoming a licensed doctor (who are the only persons that can legally diagnose) are such that almost all doctors won’t want to work in such areas because of the low pay.

  20. 20.

    CarolDuhart2

    December 2, 2011 at 1:00 pm

    Answers: 1) Loan forgiveness at 100% if they work in one of those clinics for at least 10 years, and if they decide to settle in for a rural practice, low low rates for loans to expand there and tax credits. I’d practically would throw them the money.

    2)Make them employees of say, the Federal Health Service or Va or whatever, and expand those services into the underserved areas. Steady salary, Federal benefits, and America covers the overhead.

  21. 21.

    Hoodie

    December 2, 2011 at 1:02 pm

    Seems like you could extend the loan guarantee idea to loans for education of PAs and NPs and for construction by hospitals or medical practice groups of complementary telemedicine infrastructure that enables them to serve in a supervisory role for the PAs and NPs in the clinics. The latter would give the docs some new sources of leverage without requiring them to relocate and would ameliorate the transportation issues involved in serving rural locations.

  22. 22.

    CarolDuhart2

    December 2, 2011 at 1:20 pm

    That too, hoodie. Nurses, Clerical Help, whatever who serves those areas could also get loan forgiveness. Telemedicine would work too, with a shuttle service to transport patients to regional centers with residential facilities so that people could stay there at a low cost for treatment. Then the satellite in-town facilities could hire a nurse or EMT for first responder treatment.

    I also wonder if we couldn’t loosen up things for foreign doctors from programs that are the equivalent of our own in standards. We probably lose the skills of refugee and foreign doctors who can’t afford to go to our expensive medical skills, but who would be perfectly qualified to give care. Perhaps we could have them serve an apprenticeship in those areas as a way of paying for whatever retraining they required, or certify them at a lower level of care so they can still use their skills.

    Another idea: mobile medicine anyone? Have a clinic van or truck come around so often for primary care with local nurses to do followup. A cross between home visits and distant local offices just might do it for some places.

  23. 23.

    tamied

    December 2, 2011 at 1:41 pm

    @Anonymous At Work: One thing that could help would be to reduce the size of the student loan debt for working in the rural areas.

    I see I’ve been beaten to the punch.

  24. 24.

    Tim I

    December 2, 2011 at 3:12 pm

    I live with a physician, who daily receives unsolicited job offers from rural practice groups. I also have another friend who is married to a family practitioner in a tiny town in western Ohio.

    There appears to be a boom in such medical practices. The doctors own and operate their own small hospital and their own diagnostic equipment. They make a healthy living and own a stake in an ongoing enterprise.

    I don’t think that these organizations do anything to reduce costs – in fact they probably push them up, by doing more testing and hospitalizing of patients, than would be absolutely necessary.

    Perhaps a better model, is provided by the large chain pharmacies. I’ve become a fan of CVS’s Minute Clinic. It’s a much better way to get a flu shot than making a doctor’s appointment.

    I’ve talked to the Physician there and she says that most evenings there is a line of people seeking treatment They charge between $69 and &189 for their service, which is a fraction of what an ER visit would cost.

    This is a model that could work to dramatically bring down medical costs.

  25. 25.

    mb

    December 2, 2011 at 3:15 pm

    IIRC, the ACA was supposed to provide for several billion in increased funding for community healthcare centers. Bernie Sanders secured this funding in the final days of the HCR battle to ameliorate the loss of the public option.

  26. 26.

    Ruckus

    December 2, 2011 at 3:16 pm

    @Anonymous At Work:
    A PA can prescribe limited meds. Not the higher scheduled stuff but a lot of every day needs can be meet by a PA. At least that’s how it works in CA.
    Seeing the PA in my docs office instead of the doc is about 1/2 to 2/3 the cost to me. And that’s not insubstantial, a doc visit for about 5 min of consult was $100 last time I went.

  27. 27.

    Mnemosyne

    December 2, 2011 at 3:18 pm

    @Villago Delenda Est:

    And there’s still the issue that only “the doctor” can write the prescriptions for whatever medications are required.

    Depends on the state. 12 states allow nurse practitioners to write any prescription; 13 others allow anything below Schedule II. So it depends on your state laws. If you think your state is too restrictive, you should lobby to change that — I’m sure you could get the support of a whole bunch of NPs and PAs.

    Even in restrictive states, you should be able to set up a clinic with a staff of NPs or PAs with one supervising physician and that should cover just about any situation.

    But that doesn’t solve the nursing shortage, of course. IIRC, part of the problem is that a lot of universities closed their nursing programs because they’re very expensive to run without the massive donations you can expect from medical school graduates.

  28. 28.

    PurpleGirl

    December 2, 2011 at 4:34 pm

    @Soonergrunt: You’ve hit one of the important problems, to wit, the training of new nurses and comparable staff. Not only is there a shortage of nurses, there is a shortage of teachers and professors of nursing. (Besides that problem, schools have not shown enthusiasm for expanding open slots for students.)

  29. 29.

    burnspbesq

    December 2, 2011 at 5:25 pm

    Am I the only person in the room who has ever used a Cisco Telepresence system? News flash: that commercial from a couple of years ago with Ellen Page is thw way this is going to work.

  30. 30.

    cpinva

    December 3, 2011 at 1:18 am

    @Robert Waldmann: since payroll taxes (FICA) are trust funds, not part of the general revenue, they have no direct affect on the budget deficit. the only time they would, is when the bonds held by the SS trust fund need to be cashed in, to cover required payments not met by current collections. well, that and the interest payments on the bonds.

  31. 31.

    cpinva

    December 3, 2011 at 1:30 am

    there is currently a national shortage of GP’s, RN’s. LPN’s and PA’s, all of whom would be required to staff these new community clinics. it takes a while to train these people, at least to the point where they don’t routinely kill you by accident. all but the GP’s can be (and are now) trained by the nation’s community colleges, possibly the most cost-efficient way to accomplish this.

    GP’s are another matter, since it still requires a medical school education, and GP’s are the bottom rung of the dr. food chain. there is going to have to be some kind of incentive provided, to convince med school students to become GP’s, as opposed to going into the more profitable specialties, along with convincing them to practice in less inviting rural locations.

    the nation is probably going to have to invest in a few more medical schools, to accomodate the additional demand. maybe they could be located in some of those rural areas, in conjuction with teaching hospitals?

  32. 32.

    mclaren

    December 3, 2011 at 2:25 am

    Anybody with more information or experience want to explain why this is / isn’t a workable idea?

    Sure. I’ll explain.

    The problem isn’t the lack of physical health care facilities — it’s the lack of doctors and nurses to staff ’em, and that lack is deliberate.

    Take a look at this article and this chart

    salaries in the U.S. vs. various European countries and Canada, showing that MDs in the U.S. make about $200,000, which is between 2 and 5 times as much as doctors make in other countries. How do we explain the significantly higher physician salaries in the U.S.?

    One explanation is the restriction on the number of medical schools, and the subsequent restriction on the number of medical students, and ultimately the number of physicians. Consider the difference between law schools and medical schools.

    In 1963, there were only 135 law schools in the U.S. (data here), and now there are 200, which is almost a 50% increase over the last 45 years in the number of U.S. law schools. Unfortunately, we’ve witnessed exactly the opposite trend in the number of medical schools. There are 130 medical schools in the U.S. (data here), which is 22% fewer than the number of medical schools 100 years ago (166 medical schools, source), even though the U.S. population has increased by 300%. Consider also that the number of medical students in the U.S. has remained constant at 67,000 for at least the period between 1994 and 2005, according to this report, and perhaps much longer.

    Source: “The Medical Cartel: Why are MD Salaries So High?”by Mark J. Perry, 24 June 2009.

    You people seem to be laboring under the delusion that America’s sky-high medical costs are some sort of accident. No, they’re deliberate. The American Medical Association deliberately restricts the number of medical schools in order to artificially inflate American doctors’ salaries by 200% to 500% compared to the salaries of doctors in other first world countries.

    Get a clue. Building more clinics won’t do jack shit. We need more doctors, a lot more, and more nurses, a whole shit-ton more. And the total number of doctors and nurses is being artificially and deliberately held down in order to inflate their already insanely overpriced salaries, and it’s being held down by a cartel of people who run the American medical industry.

  33. 33.

    AA+ Bonds

    December 3, 2011 at 3:40 am

    Yeah cool except if the federal government doesn’t provide health care it won’t happen

  34. 34.

    AA+ Bonds

    December 3, 2011 at 3:42 am

    Socialize all medicine and ban private health insurance, we clearly can’t handle it as a country

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