David Butler (Guest Patient Author)

I have a varied experience with health care - including in-patient, out-patient, and alternative care. I have a severe form of arthritis called ankylosing spondylitis. For about eight years prior to diagnosis of the disease, I had been treated with chiropractic . For the past eleven years I have dealt with this through use of traditional medicine - including having total hip replacement of both of my hips. I used out-patient physical therapy after both surgeries with great success. I currently see a specialist twice yearly and daily take NSAID's for joint swelling and pain management.

My wife, a lifetime non-smoker, was diagnosed with stage IV adenocarcinoma of the lung with multiple brain tumors in September 2008. She was treated with chemotherapy and radiation in 2008. She was given only one to three months to live in December 2008. She has done alternative treatment since and has outlived the physician's prognosis. She did have a metastasis in the spinal cord late 2009 and had surgery to remove the tumor in February this year. She spent two weeks in the hospital followed by three weeks in a nursing facility. She is currently at home and visited twice weekly each by a home nurse, a physical therapist, and an occupational therapist.

My oldest daughter was diagnosed with asthma at eleven months of age. Early on she was treated in the emergency room three times. Since then, she has visited a specialist yearly and manages the disease preventatively through medication.

I have been on permanent disability since 2001. I have had all types of insurances over the years. While working I had major medical coverage and health savings accounts. I have been without coverage in the past as well. Currently, I am on Medicare and Medicaid.


When I consider "health care reform", I see it from diverse perspectives. We should approach reform with the consideration of as many situations as possible. I believe there are three main categories of citizens.

• The wealthy should be able to save as much as possible (tax free) and buy the insurance of their choice without penalty. It is only fair that they are able to use what they earned to buy what they want for their own health and the health of their families. We would all want to have that opportunity if we had extra money to do so. In fact, some who are extremely wealthy probably do not even need insurance at all - or they could buy catastrophe health insurance. But, the rest of us (most of us) do need insurance coverage.


• The "middle class" working person needs affordable health insurance and a tax free opportunity to save for premiums, deductibles, and other non-covered costs. Really part of the "upper middle class", the small business owner needs affordable insurance as well. Perhaps they could allow business owners to have their own group insurance.


• And the poor, the elderly, the disabled, the displaced family, the unemployed, the financially irresponsible all need help with coverage and premiums. Obviously most of the people of this category did not choose to be in this category - with the exception of the irresponsible or the one who is wilfully poor. In those cases there should either be forced responsibility and perhaps even penalty. We tend to do just the opposite many times. We penalize the wealthy and the hard worker while allowing for irresponsibility by not scrutinizing the need - whether it is legitimate or "self-inflicted". Of course all children should be covered irregardless of social status. The "needy" group of people need public or donation-based coverage.

When we think of health care reform, we need to consider it as a goal not as a guarantee. We live in an imperfect world and it is impossible to solve every problem. But we can aim at implementing as much good as possible for the welfare of as many as possible. Things I believe are thought to be important to most are:

• accessibility - the goal is for all to be covered
• affordability - how much will this cost and who is the source of funding
• quality - safe and timely care
• specificity - to meet the needs of each individual and problem
• diversity - to cover a multitude of differing illnesses and medical/personal situations
• necessity - not wasteful
• individuality - not forced by law or policy, personal choice (agreed with one's physician)

The following is my personal beliefs about and approach to health care:

• preventative care - proactive vs. reactive
• informed patients - self taught or professionally schooled to make wise decisions and choices of care
• educated decisions by patient - not exclusively by the physician
• decisions by patient and physician concurrence - without government interference
• needs-based care, not protocol - this offers flexibility of care
• non-invasive, non-medical options explored first
• to treat dental and eye care as part of medical care
• independence of choice
• variety of options from which to choose (traditional, alternative, health education)
• less government regulation over the consumer, the physician, and pharmaceutical companies

And for all this to work properly

• greed issues addressed - by patient (not abusing the system), by the physician (not overcharging insurance, not performing unnecessary proceedures), by the pharmaceutical companies (reasonable pricing)
• humility of the physician - they are not omniscient, willing to refer patient to more qualified physician
• integrity of the physician - honest and necessary treatment of patients
• realistic patients - physicians unable to fix everything - they are "practicing" medicine and sometimes make honest mistakes - we do not need to be litigious in all cases.

Stephanie La Liberte (Guest Student Author)

I am currently a student at the University of Wisconsin Madison going into the medical field as an optometrist or radiologist. I feel out-patient care is essential for health care. Not only is out-patient care beneficial for patients well-being, but it is also cost-effective. Patients are released sooner which allows a faster recovery. Out-patient care is also less expensive for the patient and the insurance companies.

However, I also feel that insurance companies have too much control over out-patient care. Many times insurance companies make the decision as to when a patient is ready to be released by setting protocols for doctors to follow. However, not every person is the same and may not fit into a protocol. Patients react to anesthetic differently and may require more or less recovery time after surgery. Patients being sent home too early acquire additional health problems later.

I feel out-patient care is essential for treatment, but doctors should make decisions and not be forced to follow a protocol established by an insurance company.

The Payer Perspective

My current role is the manager of a claims department and my educational background is in the area of medicals records. In my twenty-five years of experience in health care, I've worked on both the provider and payer sides. Currently being on the payer side, we monitor for many regulatory changes for example claim submission requirements, receipt of claims via paper or in a compliant electronic format, and monitoring for annual changes with procedural or diagnosis coding changes. ICD-10 is on the horizon for implementation in 2013 which will also take a great deal of effort from the payer community. We recently implemented mental health parity meaning the we are required to pay for mental health services that same as any other medical care. Our membership includes commercial, self-funded and governmental programs.

With the enactment of Health Care Reform on March 23, 2010, the initial impact will be on payers to modify the benefit structure to ensure compliance six months after enactment, or as early as plan year renewals after September 23, 2010. The immediate and visible changes for 2010include: no pre-existing limits on children up to age 19, no maximum lifetime benefits on essential benefits, no annual limits on essential benefits, coverage and no cost-sharing on routine preventive services and dependent coverage up to age 26. Other reform changes are scheduled for 2014, 2019 and potentially later. There will certainly be challenges as we modify our processes to comply with the required changes, but our focus will remain on being compliant and providing quality services to our membership population.

In some situatons, a self-funded group (meaning they fund 100% of the medical costs incurred by their employees) may elect if they will comply with changes in mandated benefits. Therefore, the focus of my comments will be limited to coverage offered to the commercial membership (meaning that the health plan is paying for care from the premiums collected).

The reform supports the removal of annual benefit limits, but to implement, we do need the clarification on the definition of essential benefits. Legislation changes effective January 1 2010 for Wisconsin residents already accommodates for the ability to cover dependents up to age 26. The reform split the removal of pre-existing considitions requiring that it is removed for children this year and adults at a later date and in conjunction with health exchanges.

In our current commercial benefit structure, our members do have coverage available to them allowing them to receive specific preventive services from participating network providers at 100% coverage. Our benefit is follows the adult and childe preventive care guidelines which allows for consistent benefit application. The primary outpatient care that can be received and paid at 100% on the initial services is: an annual physical and/or gynecological exam, mammogram, pap smear, lab for fasting blood sugar, lipid panel, prostate specific antigen, routine childhood and adult immunizations and a screening colonoscopy after age 50 or earlier if family history. Our quality department staff monitors the care received and send reminders as appropriate to encourage that member's schedule this care.

In our interpretation, we and our membership should be in a ready postion in the implementation or enactment of the reform.

Jeanne DeHaro (Guest Patient Author)

As one of millions of Americans about to face changes in health care and how it is provided, I'm very unsure, but keeping an open mind, hoping that this huge, complicated plan will benefit all. The status quo is not OK, and change is always certain to travel a bumpy road. I listen patiently to all of the mixed messages among politicians, and honestly, I keep my mouth shut hoping to latch on to some clear stream of enlightenment from the media or experts decoding the changes. I simply am not clear on the facts. Who really is? Truly? Be honest. I'm still waiting for clarity. However, I do have some clear wishes of the plan.

First, I would like to see health care simplified for the elderly. Every year they go through reapplication processes , often having to change providers because of income changes slightly above or slightly below qualifying status for one plan or another or the plan. They have deadlines to meet that make them insane, and sometimes kill them financially if they missed a window of application. It has to be gentler and easier. It is confusing as an advocate for an elderly parent, and I can only imagine how confusing it is for the elderly themselves, especially those without advocates. I do not look forward to getting old, simply due to insurance "baggage" that elderly have to deal with. There is a lot of stress and depression among elderly suffering with these constant worries of having needs met without having to always live on the edge of fixed incomes. I believe the elderly have to make decisions that adversely affect their health because of restricting financial choices. This may be way overly simplified thinking, but once you have reached a certain age, you have earned the right to your care...hassle free, perhaps, just free.

I also hope the plan provides services for preventive health. Down the pike it would cost a lot less to pay out for services that keep us healthy rather than have to make us well after we are sick.

I hope the plan will allow patients and doctors to make choices based on patient needs, not a prescribed set of procedures/mandates that often cost way more and are not always needed. What a waste of tax dollars!

I also truly see the need for doctors and other health care providers to start making house calls, especially for those at high risk. More and more people are getting ill just from going to clinics and hospitals for routine care and coming home with resistant illnesses or illnesses they did not have before they went. Without intent, these places have become breeding grounds for super resistant bugs that are killing people.

I would also like to see routine nursing care brought back into our schools...something funded outside of school budgets that is a mandated right. I see great possibilities for coordinating community services of a preventative nature (intergenerational) right on school sites.

I cannot say I know a lot about what is coming. What I do know is what I hope it can be or become.

McKenzie Holthaus (Guest student author)

As a student that is going to the health profession as an athletic trainer, I feel that out-patient care is very essential for treatment and recovery methods. In our training facility, we deal with several athletes that had just been released from surgery. It is our job to help them rehab and strengthen those treated areas. One of my first experiences with out-patient care was this spring. I took an athlete to a surgery center to have an ACL and meniscal repair. After the process of recovering from anesthesia, the patient was released into my care. The next day we started therapy and rehabilitative exercises. Without out-patient care, the patients expenses would be greatly increased. By allowing patients to be released, it allows them to start their recovery process and saves them and their insurance company quite a bit of money. Most out-patient staff members are very well trained in the service that they provide. In these situations, all the care a patients needs is provided in one place, for example, the athletic training facility.

Reform Proposal3: Community Health Centers

Our third reform on outpatient and primary care will emphasize and focus on increasing the amount of community health centers. Community health centers (CHC) are non-profit organizations that operate under the US Public Health Services and the US Department of Health and Human Services. Required by law, CHCs are located in medically underserved areas throughout the U.S. and they work to enhance the health status of all people seeking care regardless of their abilities to pay. These areas areas are frequently characterized by geographic, economic, or cultural barriers that limit access to primary health care for a substantial portion of the population. CHCs alter their services to family-oriented primary and preventative health care (Shi and Singh 2008, 272).
The original community health centers were designed with significant community involvement to ensure they remained responsive to specific community needs. In 1965 funding was approved for the first two neighborhood health centers in Boston (1965) and Mound Bayou, Mississippi (1967). CHCs are located in all 50 states with 890 health center grantees that provided services through 3,600 inclusive health care sites (Taylor, 2004). CHCs provide a wide variety of care including dental, obstetric/gynecologic, family practice and pediatric based on the demand for care. Many centers have created long-standing systems of care that include outreach programs, case management, transportation, translation services, alcohol and drug abuse screening and treatment, mental health services, health education, and social services (Shi and Singh 2008, 272). With a combination of low incomes, linguistic barriers, and often poor status, the CHCs’ patients receive access to comprehensive primary care as well as enabling services (Taylor, 2004). CHCs follow a sliding-fee scale depending on the patient’s income. As shown by 2004 national data, more than 40 percent of the patients served by CHCs are uninsured, 73 percent have incomes below 200 percent of the federal poverty level, and about 60 percent are racial/ethnic minorities. (Shi and Singh 2008, 272) CHCs enhance access to patients health status and preventative care, they provide cost effective care to the population, and they work to decrease health disparities of the poor and underserved population. With an abundance of community health centers, the health disparities seen in the underserved population would be diminished even more. The growth of CHCs would help those 1,500 counties across every state that have disenfranchised populations and do not have a single health center.
Nearly eighteen billion dollars a year is wasted on unnecessary visits to hospital emergency rooms for health care that could and should be provided by a health center (nachc.com). Emergency rooms across the United States are being overused for non-emergency care. In areas without CHCs, people opt for the emergency room to seek health care. Non-urgent emergency room use is a problem from both a health care cost and quality standpoint. It was estimated by the 2003 National Hospital Ambulatory Medical Care Survey (NHAMCS) that there was a reported 114 million visits to hospital emergency rooms that year, with only 15% of these visits considered emergencies. (Brim 2008, 15) While some people choose to take advantage of emergency rooms, there really are other options that can be cost efficient and offer much better care. Emergency rooms lack the continuity of care that a community health center provides and they are not intended to promote the prevention that a CHC can provide. By adding more CHCs, the uninsured would be able to seek primary care without having to overcrowd the emergency rooms. In turn, emergency rooms would have fewer patients using them, which would increase the quality of care to those who are in urgent need of care by an emergency room. The overall quality of care that emergency rooms provide would be greatly influenced and help to lower the costs of emergency rooms as the non-urgent use of them declines.
A study was done by The Journal of Rural Health (2009) in Georgia to compare uninsured emergency department visit rates between rural counties that have a CHC clinic site and rural counties without a CHC presence. The study was completed to see if findings pertaining to primary care access did in fact reduce emergency department visit rates. The data collected showed that uninsured emergency department visits represent a significant problem in Georgia. National data shows a positive association between primary care shortage densities and emergency visit densities.
CHCs play an important role in reducing access barriers to primary care services in rural areas. Rural CHC patients are more likely to receive certain preventative services and experience lower rates of low birth weight. It is clearly recognized that the importance of CHCs in improving access to primary care for underserved populations is at an all time high.

References:
Rust, George, Peter Baltrus, Jiali Ye, Elvan Daniels, Alexander Quarshie, Paul Boumbulian, and Harry Strothers. "Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties," Journal of Rural Health 25, no. 1 (December 2008): 8-16.
Taylor, Jess. "The Fundmentals of Community Health Centers." National Health Policy Forum (2004). 22 Mar. 2009 https://uwlax.edu/exchweb/bin/redir.asp?URL=http://www.aoa.org/documents/Fundamentals-of-CHC.pdf

Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach (4th ed., pp. 274-275). Sudbury, MA: Jones and Bartlett Publishers.
Brim, Carla. 2008. A descriptive analysis of the non-urgent use of emergency departments. Nurse Researcher 15, no. 3: 72-88.

Community Health Centers: Meeting Rural Health Needs. (2009 ,January). Retrieved March 23, 2010, from http://www.nach.org/Health%20Center%20Services.cfm

Reform 4

Congress should pass legislation that promotes convenient and time efficient outpatient care. This would be achieved by putting in place more general practitioner clinics with specialists also on hand. The U.S. would follow a system more like the one in place in Europe. A patient goes in to be seen by a general practitioner for whatever ailment, the general practitioner is able to identify what type of problem the patient is experiencing and then refer them to a specialist in the building. The patient is then able to be seen by that specialist, most likely, that same day. This would be much more cost and time efficient than the urgent care clinics that we currently have in place in the U.S.
According to Shi and Singh, evidence suggests that a high proportion of primary care professionals/general practitioners in a population results in lower health care expenditures. There are two key factors that determine the proportion of general practitioners to specialists that are needed to ensure the sufficient use of primary care. One is how firmly the health care system utilizes the concept of gatekeeping. If the general practitioner clinics demonstrate some slight leniency of how quickly and easily they refer a patient to see a specialist, the issues may be resolved quicker. This, in turn, will cost less for the patient and health care system. The second factor is influencing the primary care providers/general practitioners to urge their populations to make use of the primary care services. If the use of primary care is increased, it will reduce the need for more expensive secondary and tertiary care methods, therefore reducing costs for the patients, and most importantly increasing early detection and the overall health status of the population.
Congress should regulate the concept of gatekeeping. As it is right now, patients are making appointments to see specialists that they might not even need to see. Specialists are booked for weeks and sometimes it’s really difficult to make an appointment with one. If more general practitioner clinics were put in place, specialists would be more accessible and patient outcomes could be improved. Patient satisfaction would be improved as well as patient retention.


References:

Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach (4th ed., pp. 252-253). Sudbury, MA: Jones and Bartlett Publishers.

Brunner, S. (2009, October 1). Analysis of national general practitioner patient survey data in England. Retrieved from http://www.medicalnewstoday.com/articles/165807.php

Centre for Reviews and, D. (2002). Does primary medical practitioner involvement with a specialist team improve patient outcomes: a systematic review (Structured abstract). British Journal of General Practice, 52934-939. Retrieved from Database of Abstracts of Reviews of Effects database.

Mas, C., Albaret, M., Sorum, P., & Mullet, E. (2010). French general practitioners vary in their attitudes toward treating terminally ill patients. Palliative Medicine, 24(1), 60-67. doi:10.1177/0269216309107012.
Piterman, L., & Koritsas, S. (2005). Part II. General practitioner-specialist referral process. Internal Medicine Journal, 35(8), 491-496. Retrieved from MEDLINE with Full Text database.