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Tuesday, January 29, 2008

How to Obtain Health Care Without Insurance

For the 50 million people without insurance in the United States, this blog is for you. How do you obtain health care if you have no insurance? There are four basic methods for accessing care sans health insurance financing and they are; pay with cash or credit per clinical visit, frequent public health centers in urban areas, access community health centers in rural and metropolitan areas, and use the old standby, hospital emergency departments. The average person who is without insurance may feel there are no options other than paying out of pocket for treatment and worse yet, frequenting the emergency room for care. The lack of health insurance does limit the number of clinicians who will serve the patient, but there are two institutional remedies in America, the public health system and federally qualified health clinics. Both of these organizations are designed to provide primary health care on an as-needed basis for under-served populations, including the uninsured.

CHC-Community Health Center
Community Health Centers were authorized in 1975 to promote health care for medically under-served populations. There are 3,709 federally qualified health care centers in the United States and 89 are in Washington State. One of the most famous federally qualified health centers is the Pike Market Clinic. Other well-known FQHCs in the Puget Sound area are Puget Sound Neighborhood Health Centers and SeaMar Clinics. These clinics must periodically reapply for federal funding to support the health care they provide to rural and poor urban communities. The centers also have to conform to certain governance standards, including community representation on the board, and auditing for government grant compliance. Not all "community health centers" are federally qualified health centers. The federal agency Health Resources Services Administration (HRSA) rate community health centers number one for outcome driven results, which means good value for their patients. The Bush Administration has continued to support CHC’s and increased relative funding for them. Patients must have a primary care provider in a community health clinic in order to have continuity of care. Patients will be expected to contribute to the cost of their care based on their level of household income. Also, the community clinic typically has an on-site pharmacy, so the patient can get his or her prescription filled there as well. All Community Health Clinics with pharmacies offer discounted pharmaceutical pricing, because of a federal provision called 340B Drug Pricing.

PHD-Public Health Department
Public Health Departments are most robust in larger cities, like Seattle, WA or Portland, OR but smaller communities, like Bremerton, WA have public health programs as well. In smaller communities the health department may be more involved in disease surveillance and health inspection of public facilities. However, even in smaller cities the health department is involved in emergency planning, executing public health directives like childhood immunizations, and disease investigation( like E Coli). In urban areas residents can go to the public health clinic for primary care, just like they would go to their family doctor, but payment for services is based on a sliding fee scale according to the patient’s income. Lab work is often done on the premises to save money for the health department. Both community health clinics and health departments also accept insurance for reimbursement. You might wonder why someone would choose to go to a public health department if they have insurance and the answer is convenience and also continuity. For example, if a patient has immunization records at the health department, it may be easier to continue to maintain those in one location.

DSH-Disproportionate Share Hospital
The urban poor do frequent the emergency departments of urban hospitals in droves, which is costly for the community and the facility. Consequently the federal government created a program called disproportionate share funding for hospitals that are designated as serving this population. This is a federal subsidy for hospitals so they can continue to provide care for patients who can’t pay and have no where else to go. There are 1,291 disproportionate share hospitals in the United States and 12 of those are deemed critical access hospitals in Washington State, according to the Health and Human Services administrative agency HRSA. The DSH facility in Seattle is Harborview Medical Center.

340B-Discounted Prescription Drug Program
Qualifying health care facilities are eligible for 340B drug discounts based on the 1992 Veterans Health Care Act. So, you can go to a community health clinic or the public health department or in a true emergency situation, the DSH hospital, for treatment. To obtain discounted prescription drug costs go to a community health clinic with its own pharmacy or to a DSH hospital. You do not have to be admitted to the hospital to have your script filled in the hospital pharmacy. Your script should be 25% to 40% less expensive at these facilities, than at your local pharmacy.

Take Charge of Your Health
The next time you need health care and are without insurance, consider the community clinic and public health alternatives to the emergency department of a hospital. The hospital ED is expensive, will require a lengthy wait (several hours), and misplaces resources for primary care, which are geared to urgent care. According to the Washington State Hospital Association hospitals in the state incurred 217 million dollars in costs for charity care in 2005. Remember there are health care alternatives to the emergency department, right in your neighborhood, accessible to all, and reimbursement is based on your income. Be smart about your health, its better for everybody.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Saturday, January 19, 2008

Five Things you need to ask yourself about Health Care Reforms

Since 2008 is an election year, there will be much attention on domestic issues and the elephant in the room is health care reform. This healthpolicymaven blog reviews five fundamental questions and their importance in creating a more effective health care system for Americans.
Does everyone have access to some type of primary care?
Is the United States government optimizing its purchasing power for public programs?
Are provider reimbursements in line with health care goals?
Is there a mechanism for eliminating unnecessary and costly redundancies in a fragmented delivery system?
Is the financing of health care for the country adequate and equitable?

Access to Care
First of all, access to care is not the same as access to health insurance. Health insurance is one of the financing mechanisms for health care, it does not provide care. Secondly, access means adequacy of supply in relation to the demand for services, especially primary care services. Presently there are significant shortages of nurses, obstetricians, pediatricians, and mental health professionals for the juvenile population in the United States. Increasing the demand for health care services without provisions for stemming shortages in providers will only exacerbate the lack of access.
The United States could improve access for its residents by increasing funding to universities, enabling more professionals to be developed in areas of shortages. Since universities are publicly funded, it is incumbent on the state legislatures to have the political will to act. Do we have to wait until facilities close before we address the supply issue? Another critical element for access is alignment of reimbursements with social needs, such as pediatrics. Presently medical schools throughout the United States encourage doctors to pursue specialties because of the high cost of a medical education and the ability to earn more money. As a society this disparity can be addressed in two ways, by reducing tuition costs for professionals going into areas of need, and by increasing Medicare and Medicaid reimbursements for targeted services.

Optimizing Government Purchasing
The largest single provider for health care in the United States is the government, through its Medicare, Medicaid, Veterans Administration, and Community Health programs. As such, the federal government has the greatest influence on reimbursements for providers and ultimately, what the health care consumer pays for services. Changes in Medicare drive changes in private health care plans as well. One of the areas where the government failed to utilize its mass purchasing power was in the Medicare Prescription drug program, which was enacted in 2006. Medicare subscribers now have a limited prescription drug benefit, but at market prices. This is a failure of a monopoly to exert its purchasing power, which has cost the taxpayers millions. Is it unreasonable to expect the prescription drug industry to offer a group discount to its largest customer base? This practice is deployed in private industry all of the time. When I worked for a large hospital network, one of the performance improvement efforts was to optimize bulk purchasing for pharmaceuticals. The Bush Administration failed to negotiate effectively with the pharmacy industry. For consideration of a proposed deep discount for Medicare pharmaceuticals, the government could offer streamlined administration for the pharmacy industry as an enticement to lower prices.

Reimbursement Alignment with Desired Outcomes
One of the problems with health care access is the primary payer for health care, the government, does not reinforce primary care delivery with adequate financial reimbursements. Until this changes we will not see a major increase in supply of pediatricians, obstetricians, and other primary care providers. The entire Medicare reimbursement system is based on paying for transactions, like surgical procedures, and not for wellness driven processes. It is not fair to expect physicians and other providers to offer health services for free or at a financial loss. There is no other sector of the economy that is expected to offer services for free or in a nonviable manner. This problem drives family practitioners out of business. Ideas for improving the reimbursement methods include paying a stipend for continuity of care over a period of years, not just per visit. Also, recognize best practices and incorporate that into the rewarded financial allocations. Medicare is experimenting with recognizing diabetic care and other chronic disease management programs differently, and this is a step in the right direction.

Streamlining the Healthcare System
The United States has 50 different health care systems, because each state has its own insurance and Medicare practices. This creates unnecessary burdens on benefit administrators in the private and public sectors. One way to streamline health care is to establish common templates for claims processes, as has been done by the Health Care Forum in Washington State, a consortium of healthcare providers who work towards process improvements. Another method is to encourage adoption of electronic processes, which all major health care entities are already doing. The question is, how many different standards do we need? For private sector suppliers of electronic medical records and claims administration, differentiation in services is essential to their success, but this is not in the best interest of the consumer, as it adds to the ultimate cost for plan administration. It would be more effective to create regional purchasing pools for health care, where the electronic platform, claims process, and deployment will be standardized. Standardization saves time, reduces errors, and is a common element of effective business practices. An example of a regional purchasing pool would be the Pacific Northwest WAMI Region, which includes Washington, Alaska, Montana, and Idaho, but could also include Oregon.
All health purchasing cooperative gains would be cycled through to residents of each state participating in a health care purchasing cooperative. Financial success through regional purchasing pools would include the following elements:
Saving money in administration expenditures
Reduced volatility in health insurance premiums
Reductions in expenses from mass purchasing
Other criteria for success would include simplified claims processing, because we do not need 50 different claims adjudication systems. Private payers, like insurance companies and third party administrators could have an opportunity to administer these regional contracts, through a competitive bid process. Ultimately, reducing differentiation will optimize administrative simplification and administrative efficiency.
Due to brevity, this article does not address the need to review the unnecessary deployment of technology, for example, the excessive use of Magnetic Resonance Imaging and unnecessary procedures. These services respond to a complex system that recognizes procedures for higher reimbursements, avoidance of malpractice claims in our tortuous society, consumer demands, and a highly incentivized medical supply sector.

Financing Healthcare
Presently the United States has a fragmented method of financing health care services to its residents, including; government programs, private insurance plans ($12,106 is the average premium for a family according to the nonprofit Kaiser Family Foundation), individual contributions, and unpaid services. Services that are paid with payroll taxes include Medicare and state workers compensation taxes. Other government programs, like Medicaid are funded through state general funds, federal allowances, and sin taxes from alcohol and cigarette consumption. Ways to finance a national health care mandate to cover all residents include: increasing the FICA/FUTA payroll tax, creating a new tax, like a Canadian Value Added Tax, or using an income tax method.
According to the Kaiser Foundation 2007 Primer on Health Care Costs, premiums for private sector health care grew 87% between 2000 and 2006, which is four times the rate of wage growth. Every person covered on a private health insurance plan is paying for services that are not reimbursed to hospitals and other providers, due to gaps in Medicaid reimbursement and the uninsured. The current method of paying for health care in America is not sustainable. The question that should be asked isn’t how much more will a national health care mandate cost, but how will we deploy our resources? We are already spending the money, just not effectively or fairly. How much longer are Americans willing to spend 25% more for health care than any other country, with 12% of the national population lacking basic access to health care, and millions of people without primary care? The present health care delivery system uses resources from both the private and public sector disproportionately to the benefits for most participants. It is time for a change in health care delivery, but lets look at making sound systemic changes, not just add-ons to a poorly designed system.

This article was written by Roberta E. Winter, MHA, MPA

Friday, January 11, 2008

Former Governor's Death With Dignity Initiative

Booth Gardner, former Washington State Governor is campaigning to have physician-assisted suicide legalized in Washington State. Since the New York Times published an article on his initiative the same week the healthpolicymaven posted an article about palliative care and medical directives, a closer look at the ramifications of the proposed legislation follows.

Gardner is traveling throughout the state soliciting support for an Oregon style assisted suicide law, which would allow physicians to provide patients with suicide medication dosing under very specific circumstances. A similar measure was put before Washington voters in 1991 and defeated by 54% of the voters. Though suicide is legal in Washington, physician aided death is not.

Here are the provisions for the proposed Death with Dignity referendum if it copies Oregon State Law:
-Permits legally competent patients who are at least eighteen years of age, state residents, and who suffer from a terminal disease, to obtain lethal prescriptions
-The patient must make two requests to end to their suffering, with at least a fifteen day separation between the pleas
-Patient must obtain two separate opinions from physicians indicating the patient has less than six months to live
-Would allow Physicians to prescribe a lethal dose of medications to patients, but not administer the drugs
-The state would track the number of assisted suicides, just as it tracks other causes of death

Oregon’s Death with Dignity Law was passed with a 51% majority in 1994, and enacted in 1997 after overcoming legal challenges. Oregon has reported just 292 assisted suicides over the last ten years. Though 455 people in that time frame obtained prescriptions for lethal medications, only 64% acted on the desire to end their life. When you compare the number of Oregonians who died a natural death from similar causes, less than one tenth of one percent of the residents opted for assisted suicide.

Difference between terminal sedation and euthanasia
It is important to differentiate terminal sedation from euthanasia and both practices were analyzed in a Netherlands study in 2006. In the Netherlands study, clinical practices were reviewed for 410 physicians and their patients who were primarily diagnosed with cancer. The report showed that patients who requested euthanasia were typically more concerned about loss of dignity and were less anxious (15%) than patients requesting sedation (37%). Physicians reported that terminal sedation had shortened participant’s lives by one week in 27% of the cases, whereas 73% of the euthanasia cases were shortened by a week.

Opponents of suicide frequently express concerns that the uninsured and vulnerable will be taken advantage of with a formalized right to assisted suicide. First, lets hope the United States decides to provide health care for all of its residents in the near future. Secondly, since such a small portion of the population who are eligible for assisted suicide in Oregon and elsewhere, actually make this election, there is minimal financial incentive for a health care system to hasten the death process. Using the Netherlands example of a life reduced by one week, we could apply the Medicare reimbursement to the number of patients who would make that choice. This scenario would depend on whether or not the patient was in an acute care or long-term care facility and the location of the facility. Lets assume all of the patients were Medicare eligible and use the Oregon average of 38 assisted suicides per year to calculate the potential reduction in Medicare charges. According to the Washington State Hospital Association, the average Washington State hospital payment under Medicare was $4,603 in 2005, with an average length of stay of 4.37 days. Based on the Netherlands study we could assume Washington might save $1,053 per day or $7,373 per patient, by avoiding a week of inpatient care for end-of-life treatment. In this example, the maximum savings to Medicare would be $280,183 for this population over an entire year.

Who else does it
Other countries have legalized assisted suicide protocols, foremost of which is Netherlands, who report 2,000 assisted suicides per year. Netherlands is the only country that also permits legal euthanasia. In 2002, the Council of Europe conducted a comprehensive survey on assisted suicide provisions, which found eight countries that responded they did not outlaw the practice of assisted suicides. However, only four countries had legal and transparent provisions for assistance with suicide: Netherlands, Switzerland, Belgium, and Oregon State in the U.S.A.

Certainly some practitioners in the medical profession may raise concerns about violation of the Hippocratic oath for assisting patients with suicide. However, in a 1998 survey of oncologists, the Journal of the American Medical Association reported 16% indicated they had anonymously assisted in patient suicides. So, it would seem the practice of helping patients end their suffering is not new, just lacking in formality for Washington and other states. Gardner needs to have 225,000 signatures by July to get this initiative on the ballot in November.

Thursday, January 3, 2008

The Cost to Die; An Insiders View on Terminally ill Patients and Advanced Directives

February 2, 2008, is the one-year anniversary of my brother’s death, due to the collapse of his pulmonary function following complications from a kidney transplant. Because he couldn’t breathe on his own, following a failed final course of treatment for the pneumonia, the decision was made to remove his breathing tube. It took approximately three weeks from the time of his initial plea until he was at peace. Though Russell entered the Hospital with a Do Not Recessitate (DNR) and had instructions on what he would agree to for treatment, the process of allowing a patient to die on his own terms is not a simple one. My sister, an experienced hospice nurse, held his medical power of attorney. Once the family had gathered we discussed his wishes and everyone was in agreement. A meeting with a member of the ethics committee of the hospital was required, followed by explicit instructions for the transplant unit. With each shift change we needed to make sure the directives for no additional interventions were respected. The failure of a transplant patient is hard on everyone in the unit as the intensity of the care creates bonds between the patient and the staff. When the day came to allow my brother to pass, we surrounded the hospital bed, the anesthesiologist administered some morphine, and he breathed shallowly until he went from white to gray in the space of a few minutes.

Though we were all grateful that he was allowed to ease his suffering and die with dignity, the complexity of the process confounds those who must navigate the health care system. Even though we had several family members present with significant health care expertise, an entire family in agreement with the protocol, written Advanced Directives upon admission, and an informed patient, it was still mentally and organizationally difficult taking the final step. I note there was one family in the transplant unit, whose elderly father had been on life support one month prior to my brother and was still there when we left. The lesson is; though your paper work may be in order, you will still need to navigate each exchange in the care continuum with people who are trained to cure. Sometimes death is the only way to alleviate the suffering of a love one.

According to the Agency for Health Care Research and Quality, 36% of the health care expenditures in the United States are for Medicare patients, who comprised 13% of the population in 2002 and are expected to grow to 30% by 2030. Increasingly these patients are left to die in hospitals because there are no family members, absent family, or lack of facilities for patients requiring end stage of life care. We have plenty of conversations about quality of life in health care but what about a good death? Is being hooked up to machines, wasting away immobile, and suffering from bed sores a life of quality?

Alternatives to hospital deaths for the terminally ill include in-home hospice care, long term care facilities with hospice programs, private duty nursing, and of course, family member care. According to the Kaiser Family Foundation’s June 2007 report on Medicare Spending, 30% of all expenses paid in 2004 were for long term care facilities. The average cost per beneficiary was $12,763. Average spending in the last year of life was $22,107 for Medicare recipients. Only 2% of Medicare reimbursements went for hospice care, 4% for home health care and 5% for skilled nursing facilities in 2006. This means the balance of 19% of the long-term care expenditures went to pay for hospital services for patients with long-term stays. Given the growth in our Medicare population and the ability for hospitals to keep patients alive longer with increasingly invasive procedures, as a society we need to review the equity of this spending pattern and the efficaciousness for patient care.

One of the alternatives to inpatient acute care for the terminally ill is in-home palliative care. In July of 2007, the Journal of American Geriatrics published the results of a study assessing patient satisfaction for in-home palliative care versus inpatient care. The randomized trial was sited within two different HMO organizations located in two states, for patients who were diagnosed with a year or less to live. The study showed an increase in patient care satisfaction and a reduction in the use of medical services and corresponding cost of care for end stage treatments. Perhaps more importantly, the patients who received in-home care were less likely to visit the emergency department or be admitted to the hospital, than patients treated through typical acute care modalities.

One of the challenges in determining health care policy is to assign values to patient health and intervention outcomes. A Canadian study, published in December of 2006 reviewed valuation methods for assessing human life outcomes. The Canadian study suggested setting a common threshold of cost effectiveness that could be applied to all health care interventions. Since health care resources are limited, based on the ability to pay, either through taxes, premiums, or direct reimbursement, examination of the value achieved for a publicly funded health care program seems reasonable. Medicare data indicates that more than 16% of all health care expenditures is spent in the last month of life. Methods currently used in the United Kingdom and Canada include weighing year of life gained to the cost of the services. The legal community has become adept at valuing human lives for tort actions, so certainly the health care community can work towards a reasonable method for measuring value versus the cost of the intervention.

In March of 2007, Congressman Towns introduced a bill, Physician Assistants Continuity of Care Act, to allow Physician Assistants to order post hospital care, home health services, and hospice care under the Medicare program. The impetus for this action was a perceived delay in appropriate patient care because PA’s were not allowed to recommend these services. Not only would this provision provide continuity of care for the patient, but it would also save Medicare unnecessary expenses. The bill was voted down in March.

Barriers remaining to improve palliative care in hospital settings include quality of life and a dignified death. There are hospital based palliative care programs with specific programs for end-of-life treatments and demonstrated cost savings, as cited in the Evidence Base for Developing a Palliative Care Service article published in the Medsurg Nursing Journal in June 2007. These include the development of a multi-disciplinary support team for terminally ill patients, separate hospice wings for acutely ill and terminal patients, alignment of patient care with the patient’s wishes, and a hospital consulting service for the administration of palliative care off-site. The following criteria were listed as success factors of palliative care programs:

Early discussions on end-of-life procedures/processes
Patient outcomes include less time spent in intensive care units
Avoidance of unnecessary tests and procedures
Better pain management through measures linked to patient satisfaction surveys and medical record integration
Reduction in the length of stay
Reduction in hospital charges
Reduction in hospital readmission

In conclusion, since we have a huge population ready to become Medicare eligible and there are proven methods for addressing end-of-life care besides acute hospital settings, isn’t it about time the United States develops some standards for delivering appropriate palliative care to terminally ill patients?