BIEF
~~~~~~~~~~
THE
CHALLENGE
OF
PROVIDING
HEALTH
CARE
FOR
THE
POOR:
PUBLIC
HOSPITAL
PERSPECTIVE
Asa
G.
Yancey,
Sr.,
MD
Atlanta,
Georgia
The
impending,
or
allegedly
existing,
"doctor
glut"
in
America
does
not
apply
to
health
care
for
the
poor.
Hospitals
that
have
as
their
primary
purpose
the
treat-
ment
of
no-
and
low-income
people
have
large
medical
staffs
and
house
staffs,
but
most
would
benefit
from
the
services
of
additional
physi-
cians,
especially
to
decrease
the
time
factor
in
making
medical
de-
cisions
and
in
treating
patients.
In
a
recent
survey
of
the
Surgi-
cal
Emergency
Clinic
at
Grady
Memorial
Hospital,
15
physicians
and
six
physician
assistants
cared
for
about
600
patients
in
a
48-hour
period.
On
an
average,
each
phy-
sician
was
responsible
for
or
treated
approximately
20
surgical
patients
each
day
during
his
or
her
tour
of
duty.
Peak
loads
occur
dur-
ing
the
24-hour
period,
which
ac-
centuate
the
waiting
time
during
the
busiest
period
of
the
day.
From
Grady
Memorial
Hospital
and
Emory
University
School
of
Medicine,
At-
lanta,
Georgia.
Presented
at
the
National
Conference
on
Health
Care
for
the
Poor,
Meharry
Medical
College,
Nashville,
Ten-
nessee,
October
7-8,
1985.
Requests
for
reprints
should
be
addressed
to
Dr.
Asa
G.
Yancey,
Sr,
2845
Engle
Road
NW,
At-
lanta,
GA
30318.
GRADY
MEMORIAL
HOSPITAL
Grady
Memorial
Hospital,
At-
lanta,
Georgia,
is
a
918-bed
(plus
116
bassinets)
public
teaching
hos-
pital,
owned
by
The
Fulton-De-
Kalb
Hospital
Authority.
It
was
es-
tablished
in
1892
for
the
purpose
of
providing
medical
care
to
individ-
uals
who
were
unable
to
pay
for
their
treatment.
This
continues
to
be
Grady
Hospital's
primary
goal.
I
frequently
state
that
one
cannot
dump
a
patient
on
Grady
Hospital,
because
our
reason
for
being
is
to
provide
therapy
for
the
unfortu-
nate.
Of
course,
a
patient
may
be
untimely,
insensitively
or
even
with
poor
judgment
transferred
from
another
hospital
to
Grady
Hos-
pital,
for
example,
without
con-
trolling
obvious
secondary
shock.
This
may
be
regarded
as
being
dumped
upon.
Nevertheless,
Grady
Hospital
welcomes
the
patient
who
is
inadequately
funded.
Approximately
46,412
patients
are
admitted'
to
Grady
each
year,
and
there
are
about
813,461
patient
visits
in
approximately
200
outpa-
tient
clinic
sites
each
year.
Atlanta
has
a
percentage
of
poor
people
that
is
among
the
highest
for
large
cities
in
the
nation.
There
are
about
965,000
people
living
below
the
poverty
level
in
the
State
of
Georgia.
Only
about
50
percent
(450,000)
of
these
persons,
living
below
the
poverty
level,
have
Medicaid.
Fifty-five
percent
of
this
number
are
black,
though
the
per-
centage
of
black
people
in
Georgia
is
26
percent.
Georgia
increased
its
benefits
to
Medicaid
recipients
in
1985,
and
will
recognize
low
in-
come
and
pregnancy
as
factors
for
inclusion.
The
total
number
of
transfers
from
other
hospitals
to
Grady
Hospital
for
the
first
seven
months
of
the
calendar
year
1985
(January
1985
through
July
1985,
inclusive)
was
312.
This
was
about
the
same
number
of
transfers
for
a
similar
period
in
1984.
The
relatively
small
number
of
transfers
from
other
hospitals
to
Grady
Hospital
may
be,
in
part,
accounted
for
in
that
Grady
operates
a
fleet
of
20
ambu-
lances,
and
indigent
patients
are
often
brought
to
Grady
initially
rather
than
being
transported
else-
where.
We
do
not
have
records
at
this
time
on
the
number
of
outpa-
tients
that
are
sent
or
transferred
to
Grady
Hospital.
Grady
Hospital
is
the
only
public
hospital
in
metropolitan
Atlanta
that
is
dedicated
to
the
therapy
of
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
79,
NO.
1,
1987
107
HEALTH
CARE
FOR
THE
POOR
poor
patients.
Several
counties
in
Georgia
have
no
public
hospital
or
ongoing
financial
arrangements
for
the
health
care
of
their
county
poor,
and
doubtless
some
of
these
persons
come
to
Grady
with
a
rela-
tive
or
friend
claiming
residence.
These
counties
should
be
required
to
pay
promptly
for
the
health
care
costs
of
their
constituents.
EMORY
UNIVERSITY
SCHOOL
OF
MEDICINE
The
Emory
University
School
of
Medicine
Graduate
Medical
Edu-
cation
Program
had
737
residents
and
fellows
for
the
1985-1986
aca-
demic
year,
and
most
of
the
patient
care
was
performed
by
these
house
officers.
There
were
about
479
active
staff
and
485
visiting
staff
members
at
Grady
from
the
Emory
Univer-
sity
faculty
for
1985.
The
supervi-
sion
of
all
house
officers
has
been
the
duty
and
responsibility
of
Emory
University
for
well
over
50
years,
and
continues
to
be.
The
Morehouse
School
of
Medicine
became
an
official
part-
ner
at
Grady
Hospital
on
July
1,
1984.
Morehouse
School
of
Medi-
cine
faculty
are
members
of
the
active
medical
staff
at
Grady
and
are
expected
to
participate
in-
creasingly
in
the
supervision
of
residents.
At
present,
there
are
10
to
12
Morehouse
faculty
members
on
the
active
Grady
medical
staff,
with
Morehouse
continuing
to
seek
and
appoint
clinical
faculty.
Of
the
total
residents
and
fel-
lows,
approximately
56
(7.6
per-
cent)
were
of
the
black
minority
for
the
academic
year
1985
to
1986.
The
maximum
percentage
of
black
minority
residents
in
the
Emory-
Grady
Graduate
Medical
Educa-
tion
Program
was
11.0
percent
dur-
ing
the
academic
year
1980
to
1981,
with
approximately
69
of
622
house
officers.
The
Association
of
Amer-
ican
Medical
Colleges
recom-
mended
that
Afro-American
stu-
dents
should
constitute
12
percent
(to
approximate
the
Afro-American
percentage
of
the
national
popula-
tion)
of
the
medical
students
in
the
nation's
127
schools
of
medicine.
This
percentage
has
never
been
reached,
but
the
percentage
of
black
minority
residents
at
Em-
ory-Grady
has
been
higher
than
the
student
percentage
in
the
nation's
medical
schools
for
over
eight
years,
which
is
a
laudable
situation.
Afro-Americans
represent
26
per-
cent
of
the
population
of
the
State
of
Georgia;
thus,
the
accomplish-
ments
have
been
impressive,
but
there
are
goals
yet
to
be
attained.
PROGRAMS
AT
GRADY
MEMORIAL
HOSPITAL
The
Grady
Sickle
Cell
Center
treats
patients
with
this
chronic
ill-
ness
and
its
many
complications.
The
State
of
Georgia
funds
the
Grady
Sickle
Cell
Center,
which
treated
1,755
adults
and
children
during
the
three-month
period
of
April
through
June
1985.
The
care
for
this
special
segment
of
low-
income
people
of
our
community
adds
to
their
comfort
and
well-
being
and
reduces
the
frequency
of
inpatient
hospital
therapy.
This
permits
them
to
have
more
time
at
home
with
relatives
and
friends.
Grady
Hospital,
by
virtue
of
being
a
large,
public,
teaching
in-
stitution,
has
many
services
that
a
small
hospital
would
have
difficulty
in
maintaining.
There
are
five
specialized
emergency
clinics
(medicine,
surgery,
gynecology-
obstetrics,
pediatrics,
and
psychi-
atry);
multiple,
specialized
inten-
sive
care
units;
disaster-prepared-
ness
units,
with
as
many
as
335
residents
present
during
the
day
and
significantly
large
numbers
at
night;
high-risk
premature
infant
in-
tensive
care
unit;
high-risk
mater-
nity
care
unit;
nephrology
intensive
care
unit;
burn
center;
24-hour
emergency
psychiatric
clinic;
re-
habilitation
medicine
ward;
trauma
teams;
Sickle
Cell
Disease
Center;
and
State
Poison
Control
Center.
The
Gynecology
and
Obstetrics
Service
reported
a
total
of
6,585
hospital
deliveries
during
the
calendar
year
1984.
Of
these,
1,527
(23.2
percent)
were
by
cesarean
section.2
There
was
a
perinatal
mortality
rate
of
21.9/1,000
births,
and
a
maternal
mortality
rate
of
75.9/100,000
total
births;
these
statistics
are
the
lowest
in
the
his-
tory
of
the
institution.
Of
the
6,585
deliveries,
496
were
to
mothers
11
through
16
years
of
age,
and
1,589
were
of
mothers
17
through
19
years
of
age,
for
a
total
of
2,048
mothers
11
through
19
years
of
age.
The
neonatal
high-risk
intensive
care
unit
has
one
of
the
best
re-
cords
for
the
care
of
high-risk
neo-
nates
in
the
Southeast.
There
has
been
an
increasing
survival
rate
over
the
past
10
years
from
18.6
to
47.7
percent
in
the
newborn
whose
birthweight
is
less
than
1,000
g.
There
were
291
admissions
to the
neonatal
high-risk
intensive
care
unit
in
the
calendar
year
1984,
and
2,137
infants
were
admitted
to
the
special
care
nurseries
of
the
hospi-
tal
(Office
of
A.
W.
Brann,
Jr.,
Sep-
tember
3,
1984,
unpublished
data).
Funds
are
being
sought
for
an
outpatient
clinic
for
AIDS.
Fulton
and
DeKalb
Counties
(from
taxes
on
property
within
the
two
counties)
paid
into
the
Grady
Memorial
Hospital
budget,
for
the
calendar
year
1984,
$51,084,750.
Total
expenses
were
$131,620,450.
Patient
eligibility
allowance
was
$30,869,250
for
1984,
which
means
that
patients
were
allowed
$30.8
108
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
79,
NO.
1,
1987
HEALTH
CARE
FOR
THE
POOR
million
off
of
their
hospital
charges
if
they
were
unable
to
pay.
For
the
year
1983,
22.0
percent
of
Grady
Hospital
patients
had
Medicaid,
20.0
percent
had
Medi-
care
and
17.4
percent
had
private
or
other
hospitalization,
but
37.4
percent
had
no
third-party
cover-
age
whatsoever.
If
the
uninsured
group
had
had
Medicaid,
hospital
revenues
would
have
been
signifi-
cantly
increased,
allowing
for
the
purchase
of
more
sophisticated
di-
agnostic
and
therapeutic
equipment
and
increased physician
and
nurse
staff
positions.
Public
teaching
hospitals
throughout
the
nation
should
have
the
best
and
latest
equipment
in
order
to
provide
high-quality
care
for
the
poor
and
the
best
instruc-
tion
for
young
doctors
and
nurses.
Accordingly,
funding
should
be
from
federal,
state,
and
local
ori-
gins.
The
counties
and
State
of
Georgia
would
be
aided
by
an
ex-
pansion
of
Medicaid
in
which
each
state
dollar
brings
in
two
federal
dollars
for
health
care
for
the
poor.
Many
hard
working,
well-motivat-
ed,
low-income
persons,
such
as
maids,
barbers,
beauty
parlor
workers,
small
shop
owners,
and
minimum
wage
earners,
should
pay
a
small
amount-based
on
a
rea-
sonable
schedule
or
scale-into
Medicaid.
This
maintains
their
human
dignity
and
thus
provides
them
with
a
third-party
pay
source
for
their
health
care
needs.
This
large
group
of
approx-
imately
25
million
indigent
people
should
be
accorded
health
insur-
ance.
Counties
in
Georgia
without
a
public
hospital
for
the
poor
would
better
serve
their
constituents,
by
placing
a
much
larger
number,
or
preferably
all,
of
these
low-income
people
on
Medicaid.
These
low-in-
come
individuals
have
inadequate
means
of
paying
for
their
health
care
and
often
delay
seeking
aid
until
they
are
seriously
ill.
These
severely
ill
persons
constitute
a
significant
factor
in
causing
dispro-
portionate
complications
among
patients
in
public
hospitals.
The
higher
mortality
rate
among
black
people
because
of
uncontrolled
cancer
is
likely
the
result
of
delays
in
seeking
medical
assistance.
Grady
Hospital
maintains
a
fi-
nancial
eligibility
scale
of
charges
for
services
rendered.
This
sched-
ule
of
charges
varies
with
income
and
number
of
persons
in
the
family.
Patients
with
a
"G"
card
pay
nothing
for
inpatient
or
outpa-
tient
care.
An
individual
with
an
"A"
card
would
pay
a
$5.00/day
maximum-inpatient
charge
and
$2.00
to
$4.00/day
for
outpatient
or
emergency
clinic
visit.
Poor
people
are
more
likely
to
live
in
houses
with
faulty
electrical
wiring
and
use
heating
methods
that
are
conducive
to
fire.
The
Grady
Hospital
Burn
Center
pro-
vides
this
special
care
to
not
only
residents
of
Fulton
and
DeKalb
Counties,
but
to
burn
victims
from
other
counties
as
well.
Most
of
these
counties
do
not
have
a
burn
unit,
but
poor
persons
of
have-not
counties
must,
and
do
have
their
burn
therapy
supported
by
individ-
uals
of
other
regions.
Medicaid,
or
a
similar
third-party
pay
source
for
low-income
people,
could
aid-
in
the
funding
of
this
burn
center
that
admits
approximately
300
patients
per
year.
Friends,
relatives,
and
patients
grow
impatient
waiting
in
emer-
gency
clinics.
The
average
time
spent
for
examination
and
treat-
ment
in
the
Surgical
Emergency
Clinic
was
3.69
hours
in
1972.
More
staff
is
currently
available,
and
the
great
majority
of
cases
are
cared
for
from
beginning
to
com-
pletion
of
care
within
two
to
six
hours.
There
are
many
delays
be-
yond
six
hours,
but
some
patients
are
served
in
less
than
two
hours.
Two
trauma
teams
alternate
days
at
Grady
Hospital
and
for
the
se-
verely
injured
(gunshot
wound
or
automobile
accident),
the
rapidity
and
effectiveness
of
response
are
highly
satisfactory.
These
trauma
surgeons
are
constantly
present
within
the
hospital.
Many
patients
and
relatives
do
not
fully
appre-
ciate
the
battery
of
x-rays,
electro-
cardiograms,
and
blood
chemistries
that
patients
receive
within
the
space
of
a
few
hours,
which
would
require
one
to
three
days
in
some
private
and
other
settings.
Malpractice-asserted
claims
and
lawsuits
have
increased
in
recent
years.
They
are
at
a
crisis
state
throughout
the
nation
and
are
a
serious
matter
for
public
teaching
hospitals.
Low-income
and
illiter-
ate
people
are
well
informed
as
to
how
to
secure
compensation
when
medical
therapy
goes
awry,
or
is
perceived
as
having
gone
awry.
They
are
becoming
more
adept
at
filing
claims
for
small
mishaps
in
order
to
collect
relatively
small
sums,
realizing
hospitals
often
will
pay
rather
than
assume
the
possi-
bility
of
higher
expense
and
of
time-consuming
trials.
Federal
and
state
legislation
are
needed
to
control
contingency
fees,
exhorbitant
awards
for
pain,
suffer-
ing,
and
loss
of
consortium.
There
is
a
need
to
place
a
higher
percent-
age
of
the
appropriate
malpractice
award
in
the
hands
of
the
injured
and
devise
a
means
of
reducing
the
expense
for
litigation
through
set-
tlement
and
reform
of
tort
laws.
Individual
physician
insurance
premiums
are
out
of
control.
Pa-
tients
entering
a
hospital
may
very
well,
in
the
future,
be
required
to
register
for
misadventure
insur-
ance.
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
79,
NO.
1,
1987
109
HEALTH
CARE
FOR
THE
POOR
Physicians
and
nurses
must
exert
ever-stronger
efforts
to
document
the
practice
of
logical,
high-quality
medicine.
The
stand-
ards
of
care
in
medicine
are
not
al-
ways
clearly
defined
(eg,
restraint
of
patients
on
stretchers
and
in
wheelchairs)
and
need
to
be
more
clearly
defined.
All
persons,
inclusive
of
the
poor,
should
be
compensated
when
unjustly
injured;
however,
means
must
be
found
to
prevent
the
de-
struction
of
public
teaching
hospi-
tals,
other
health
institutions,
and
private
physicians
because
of
dis-
astrously
high
professional
liability
awards
and
high
insurance
premi-
ums.
How
would
poor
people,
without
a
third-party
pay
source,
secure
therapy
for
their
illnesses
and
injuries
without
the
public
teaching
hospitals?
Disabling
ill-
ness
and
death
without
available
high-quality
health
care
simply
must
not
be
tolerated
in
our
nation.
The
Diabetic
Day
Care
Program
at
Grady
Hospital
has
been
an
ef-
fective
cost-containment
program
and
therapeutic
and
education
re-
source
for
poor
and
funded
diabetic
patients
in
the
prevention
of
keto-
acidosis,
lower
extremity
amputa-
tion,
and
end-stage
renal
disease.
Approximately
11,000
patients3
have
been
treated
in
this clinic
from
1971
through
1982.
Through
greatly
improved
therapy
and
education
of
diabetic
patients,
there
has
been
a
reduction
in
amputations
from
13.3/1,000
patients
to
6.72
amputa-
tions
per
1,000
patients,
and
a
re-
duction
in
ketoacidosis
from
41.2
episodes
per
1,000
patients
to
20.6
episodes
per
1,000
patients.
These
improvements
occurred
in
the
late
1970s.
The
association
of
this
public
teaching
hospital
with
the
Emory
University
Graduate
Medical
Edu-
cation
Program
provides
excel-
lence
of
medical
care
using
methods
that
are
in
the
vanguard
of
medical
knowledge.
The
public
recognizes
the
know-how
of
the
young
house
officers,
and
many
not-so-poor
patients
elect
to
choose
public
hospitals.
The
Poison
Control
Center
at
Grady
assists
the
poor,
the
wealthy,
the
uneducated,
and
the
physicians
of
Georgia.
Persons
in
most
states
of
the
nation,
and
be-
yond,
frequently
seek
the
services
of
this
Poison
Control
Center.
In
1984,
the
Poison
Control
Center
re-
sponded
to
5,964
professional
calls
and
33,265
nonprofessional
calls,
totaling
39,229
inquires
regarding
toxic
exposures.
These
calls
were
from
42
states,
Puerto
Rico,
Saudi
Arabia,
Canada,
and
the
Virgin
Is-
lands.
Follow-up
calls
produced
a
total
of
91,430
inquires,
of
which
42,559
were
from
the
159
counties
of
the
State
of
Georgia.
The
Emory-Grady
Family
Plan-
ning
Program
served
23,008
patient
visits
during
the
year,
July
1,
1984
to
June
30,
1985.
Ages
of
patients
involved
ranged
from
9
years
to
patients
in
their
50s,
with
the
maximum
number
of
patient
visits
occurring
between
the
ages
of
15
to
34
years.
There
is
a
fundamental
and
co-
gent
need
to
have
skilled
nursing
homes
to
admit
patients
promptly
that
require
extra
care,
such
as
those
with
tracheotomies
and
col-
ostomies
and
obese
patients
or
pa-
tients
with
decubitus
ulcers
who
are
not
candidates
for
reconstruc-
tive
surgery.
Many
nursing
homes
with
an
empty
bed
will
pick
and
choose
easy-to-care-for
patients
and
refuse
to
accept
difficult
cases.
This
is
especially
the
situation
with
the
poor,
because
only
the
fixed
rates
of
a
third-party
source
are
available.
Legislation
may
have
to
be
used
to
remedy
this
situation,
if
education
does
not
suffice.
There
is
a
negative
impact
on
public
hospi-
tals
as
social
workers
labor
to
find
beds
to
provide
hospital
space
for
new
patients
in
need
of
acute
hospi-
tal
care.
Grady
Memorial
Hospital
has
an
audiovisual
department
for
patient
education
in
health
care.
This
de-
partment
develops
printed
dis-
charge
instructions,
teaching
book-
lets,
slides,
and
numerous
vid-
eotapes,
which
are
projected
on
closed-circuit
television
for
patient
education
purposes.
Education
to
minimize
the
occurrence
of
obesity,
and
drug,
alcohol,
and
tobacco
abuse,
and
purposeful
and
accidental
trauma
would
add
to
the
quality
and
lon-
gevity
of
life.
The
high
homicide
statistics
across
the
nation,
notably
in
our
major
cities,
are
not
reflec-
tive
of
the
much
larger
numbers
of
efforts
by
one
human
being
to
take
another's
life.
Intentional
trauma
is
a
significant
factor
in
reduced
longevity
in
the
black
man.
So
many
people
have
not
yet
learned
to
walk
away-in
dignity-as
a
dis-
agreement
degenerates
into
a
quar-
rel.
A
poised
leavetaking
is
an
ef-
fective
way
to
reduce
intentional
trauma.
Homicide
rates
do
not
re-
flect
the
true
attack
rate
with
the
intention
to
maim
or
kill,
for
surgi-
cal
trauma
teams
conserve
the
lives
of
approximately
80
percent
of
those
attacked.
Public
teaching
hospitals
are
exceedingly
effective
in
the
promptness
of
response
and
procedural
care
of
patients
se-
verely
traumatized
by
guns,
knives,
or
blunt
instruments.
A
courteous,
empathetic,
sen-
sitive
approach
is
essential
for
the
health
care
of
poor
people
and
for
individuals
at
all
levels
of
education
and
income.
Patients
in
public
hospitals
are
there
primarily
for
di-
agnosis
and
treatment,
with
the
110
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
79,
NO.
1,
1987
HEALTH
CARE
FOR
THE
POOR
education
of
medical
students
and
residents
serving
in
a
supportive
role.
The
best
medical
education
accompanies
excellent
patient
care,
be
it
in
internal
medicine
or
procedural
techniques;
and
all
medications
and
procedures
must
be
foremost
for
the
benefit
of
the
patient-and
not
primarily
for
the
learning
and
education
of
a
health
care
person.
Patients
must
be
ad-
mitted
on
need
for
care,
not
for
the
interest
of
the
admitting
house
offi-
cer.
Health
care
providers
are
re-
minded
at
intervals
that
rich
and
poor,
educated
and
illiterate
people
react
similarly
to
excellent,
consid-
erate
health
services.
Practice
does
not
make
for
perfection
in
medi-
cine;
only
excellent
practice
per-
mits
a
close
approximation
to
per-
fection.
Poor
people
know
of
the
pres-
ence
and
accessibility
of
the
public
teaching
hospital
in
their
commu-
nity,
yet
they
report
to
the
hosiptal
later
than
the
higher
income,
pri-
vate
hospital
individuals
for
care
of
conditions
such
as
breast
cancer
and
carcinoma
of
the
cervix.
Six
times4'5
more
Grady
breast
cancer
patients
present
with
distant
spread
of
the
cancer
than
in
other
met-
ropolitan
Atlanta,
Fulton,
and
De-
Kalb
Counties
hospitals.
The
rea-
sons
for
delay
are
complex:
less
personal
attention;
frequently
a
dif-
ferent
physician
on
each
visit;
long
waiting
periods
for
service;
diffi-
culty
in
travel
to
and
from
the
hos-
pital;
less
education
regarding
the
value
of
prevention
and
early
treatment
of
disease;
realization
that
there
will
be
some
expense
associated
with
a
visit
to
the
hospi-
tal,
which
may
diminish
signifi-
cantly
patients'
hand-to-mouth
monetary
existences;
fear
of
being
told
of
the
presence
of
a
devastat-
ing
disease;
a
false
human
hope
that
all
will
be
well
tomorrow;
and
factors
of
motivation
within
human
beings
that
are
unknown
at
this
time.
SUMMARY
Listed
below
are
suggested
so-
lutions
to
the
needs
of
public
teach-
ing
hospitals
to
meet
the
challenge
of
providing
high-quality
care
to
the
poor.
1.
Medicaid
or
some
similar
third-party
pay
source
should
be
expanded
to
provide
hospitaliza-
tion
insurance
based
on
family
and
individual
income.
Approximately
25
million
people
without
hospi-
talization
and
health
insurance,
but
with
some
income,
should
pay
a
reduced
fee.
(Persons
with
no
in-
come
or
monetary
source
would
continue
to
be
provided
for
at
no
cost.)
Thus,
the
income
to
public
hospitals
would
be
enhanced
so
that
they
could
provide
additional
physicians,
nurses,
and
improved
diagnostic
and
therapeutic
equip-
ment.
2.
Medicare,
Medicaid,
and
diagnosis-related
groups
should
continue
to
compensate
public
hospitals
for
the
higher
costs
asso-
ciated
with
poor
persons
with
mul-
tisystem
illnesses,
graduate
medi-
cal
education,
and
patients
with
se-
vere
trauma.
3.
Urge
and,
if
necessary,
re-
quire
nursing
homes
to
accept
pa-
tients
that
need
extra
care,
such
as
those
with
colostomies,
tracheos-
tomies,
and
obese
patients
and
those
with
inoperable
decubitus
ul-
cers
that
preclude
plastic
and
re-
constructive
surgery.
4.
Reduce
waiting
times
and
provide
more
privacy.
5.
Further
and
improve
atten-
tion
to
factors
of
empathy,
cour-
tesy,
and
sensitivity
to
the
needs
of
low-income
people.
6.
Augment
health
education.
7.
State
and
federal
govern-
ments
should
be
urged
to
adopt
measures
to
control
the
medical
liability
crisis
due
to
the
numerous
malpractice
claims
and
lawsuits
with
exhorbitant
awards.
8.
Increase
the
number
of
black
and
other
minority
physicians
and
others
who
will
serve
the
poor.
9.
Educate
patients
about
the
tests,
x-rays,
and
electrocardio-
grams
they
might
need,
which
may
take
several
hours.
The
therapy
provided
by
medical
school-asso-
ciated
hospitals
is
in
the
vanguard
of
medical
knowledge.
The
impending,
or
allegedly
existing,
"doctor
glut"
in
America
does
not
apply
to
health
care
for
the
poor.
Acknowledgment
Many
administrators
at
Grady
Memo-
rial
Hospital
provided
data
for
this
article.
Sincere
appreciation
is
expressed
to
the
many
administrators
at
Grady
Memorial
Hospital
who
were
most
helpful
in
ac-
cumulating
these
data.
Literature
Cited
1.
Thirty-ninth
Annual
Report-1984.
Grady
Memorial
Hospital,
Atlanta,
Ga.
2.
1984
Annual
Report.
The
Obstetric
Service
and
Perinatal
Pathology
Service,
Grady
Memorial
Hospital.
Prepared
by
the
Department
of
Gynecology
and
Obstet-
rics,
Emory
University
School
of
Medicine,
Atlanta.
3.
Davidson
JK.
The
Grady
Memorial
Hospital
Diabetes
Unit
Ambulatory
Care
Program.
Proceedings
of
the
Second
European
Symposium
of
the
Diabetes
Education
Study
Group,
Geneva,
June
3-6,
1982,
and
selected
topics
held
at
workshops
of
the
DESG.
Excerpta
Medica,
1983.
4.
Knutsen
P,
Petrek
JA.
Early
and
late
detection
of
cancer
in
Metropolitan
At-
lanta.
J
Med
Assoc
Ga;
1981;
70:753-755.
5.
Murray
W.
A
Retrospective
Study
of
Squamous
Cell
Carcinoma
of
Cervix
Ut-
eri.
Presented
at
Gynecology-Obstetrics
Residents'
Research
Day
Program,
Grady
Memorial
Hospital,
Atlanta,
1978.
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
79,
NO.
1,
1987
111
