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.

Reform Proposal Two: Complementary and Alternative Medicine

By: Rachel Boldt

Our second reform proposal for outpatient and primary care requires Congress to take action to mandate the integration of researched-based methods of complementary and alternative medicine (CAM) with current insurance covered, conventional medicine services. CAM is defined by the National Center for Complementary and Alternative Medicine (NCCAM) as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.” CAM therapies incorporate a large spectrum of treatment options like, “homeopathy, herbal formulas, use of other natural products as preventive and treatment agents, acupuncture, meditation, yoga exercises, biofeedback, and spiritual guidance or prayer…chiropractic care is also largely regarded as a complementary treatment” (Shi and Singh, p. 274). Treatments are frequently undergoing research, which impacts what is used and considered to be alternative medicine (Mayo Clinic). “Complementary medicine” refers to the use of an alternative medicine therapy with conventional therapy, and “integrative medicine” refers to the use of a complementary therapy with a conventional one (Mayo Clinic).

The use of CAM practices is on the rise in the U.S., with 40% of adults reportedly using them (Mayo Clinic). Typical causes for these alternative therapies “were back problems, allergies, fatigue, arthritis, and headaches” (Shi and Singh, p. 275). Most people have to pay for CAM services and products out-of-pocket, and when health insurance companies do offer coverage, it varies by state and is often limited (NCCAM). Americans spend more than $34 billion per year out-of-pocket on CAM therapies (BMC Complementary and Alternative Medicine, 2005). Results of studies from BMC Complementary and Alternative Medicine (2005) focusing on the economic evaluation of CAM therapies show many to be cost-effective compared to conventional care, including: “acupuncture for migraine, manual therapy for neck pain, self-administered stress management for cancer patients undergoing chemotherapy, biofeedback for patients with ‘functional’ disorders (eg, irritable bowel syndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients” (BMC Complementary and Alternative Medicine, 2005). As this study demonstrated, certain CAM therapies would provide cost-effective alternatives to conventional care. Certain CAM therapies cost less and, depending on the patient, may be more effective, resulting in decreased cost and improved outcomes than comparable conventional methods.

Standard conventional physician training does not include CAM therapies, thus they may not be capable to recommend or address concerns regarding them (Mayo Clinic). Under our reform proposal, research based methods of CAM would be integrated into the health care system and covered under all health insurance plans. As a result, primary care physicians would see greater need and incentive to become more knowledgeable on CAM therapies. This may lead to greater utilization, referral, and access to research based CAM therapies.

There are different treatment methods used within complementary medicine, but the reoccurring theme among them is to “treat the patient as a whole person rather than treating a specific symptom or symptoms” (Institute for Complementary and Natural Medicine). David Rakel, M.D., founder and director of the University of Wisconsin Integrative Medicine Program and an assistant professor in the department of family medicine at the UW School of Medicine and Public Health, believes in directing individuals to become healthier through the understanding of “their bio, psycho, social, spiritual uniqueness.” He stresses the importance of taking time to hear each individual’s story, as being a good listener “allows for more efficient health care decisions and really gets at the root of healing” (Dr. Rakel, UW Health). These practices can have a positive impact on quality. Treating the patient as a whole and allowing them the option to use methods of CAM would increase satisfaction and efficiency. This results in patients’ specific needs and values being incorporated into their plan of care development and implementation, and improving the patient and physician relationship.

CAM is important because it takes a holistic approach, not just focusing on current symptoms, but on all areas of a patient’s health and well-being. Some believe CAM is less important than conventional medicine because it is not highly regulated and the effectiveness and safety of some treatments have not been evaluated through scientific studies (Shi and Singh, p. 275). However, recently there have been prominent advances in CAM research. NCCAM is the lead agency for scientific research on CAM (NCCAM). Funds for the center have risen from $2 million in 1993 to $122.7 million in 2006 (Shi and Singh, p. 275). The focus of NCCAM is to research and scientifically evaluate CAM practices, and to effectively report their findings (NCCAM). This coincides with an increasing number of medical schools in the U.S. offering some instruction in alternative medicine (Shi and Singh, p. 275).

References (APA):

Herman, P. M., Craig, B. M., & Caspi, O. (2005). Is complementary and alternative medicine (CAM) cost-effective? A systematic review. BMC Complementary and Alternative Medicine, 5(11). doi:10.1186/1472-6882-5-11.

Institute for Complementary and Natural Medicine. (n.d.). What is complementary and alternative medicine (CAM)? Retrieved March 12, 2010, from http://www.i-c-m.org.uk/about/complementary

Mayo Clinic staff. (2009, October 24). Complementary and alternative medicine: What is it? Retrieved March 14, 2010, from http://www.mayoclinic.com/health/alternative-medicine/PN00001

National Center for Complementary and Alternative Medicine. (2007, February). Complementary and alternative medicine. Retrieved March 12, 2010, from http://nccam.nih.gov/

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.

UW Health – University of Wisconsin Hospital – Madison, (2008, February 14). David P. Rakel, MD, [Video profile]. Retrieved March 14, 2010, from http://findadoctor.uwhealth.org/findadoctor/profile.jsp?provider=7215

Reform Proposal 1

By Kaylin Holthaus

Congress should pass and enforce a legislation that promotes access to quality primary care for all United States citizens. In doing so, Congress will pass legislation on the production of tax deductible outpatient and primary care, and also mandate that all individuals who are employed have the option, and are encouraged, to create a Health Savings Account (HSA). With these new legislations, a new door will open to provide greater access to primary care without the burden of a deductible or co-pay for using such services. Also, Congress will mandate that outpatient and primary care medical facilities are accessible or in close proximity to the community in which individuals live. The Comprehensive Health Care Act states the following about the creation of tax deductions and Health Savings Accounts.

“Specifically, the Comprehensive Health Care Act:

1. Provides all Americans with a tax credit for 100% of health care expenses. The tax credit is fully refundable against both income and payroll taxes.
2. Allows individuals to roll over unused amounts in cafeteria plans and Flexible Savings Accounts (FSA).
3. Makes every American eligible for a Health Savings Account (HSA), removes the requirement that individuals must obtain a high-deductible insurance policy to open an HSA; allows individuals to use their HSA to make premiums payments for high-deductible policy; and allows senior citizens to use their HSA to purchase Medigap policies.
4. Repeals the 7.5% threshold for the deduction of medical expenses, thus making all medical expenses tax deductible.” ¹

“A Health Savings Account (HSA) is a special account owned by an individual used to pay for current and future medical expenses.”² Health Savings Accounts are already in use today, but with our reform, Congress would allow all individuals who are currently employed to develop a HSA. The Health Savings Accounts can be used to pay for any type of medical expense an individual may obtain, either past, present, or future. An individual may pay into their account at any time and can contribute any amount of money from their own paycheck. The money set aside in a HSA then accumulates interest just like a checking account or savings account people have at their banks that allows for means of paying for unexpected or necessary medical expenses. The accumulated money, if not used in a year, can roll over. The Health Savings Accounts are structured as long-term accounts that individuals will have access to without penalties or fees charged towards accumulated funds. “A health savings account (HSA) is an account into which you can deposit tax-free money to be used for future medical expenses. Health savings accounts were established in 2003 and are becoming more common. Health savings accounts are part of a larger trend known as consumer-directed or consumer-driven health care. HSAs and consumer-driven health care plans have been promoted by companies and the government as one way to help control health care costs. The goal of an HSA is to reduce the money spent on health care by placing more of the responsibility on you to shop for health care.”³

Congress will mandate that medical expenses will be tax deductible without consideration of gross income. With medical expenses being tax deductible, there will be less tax dollars retained by the government. This will put a constraint on the government and help with the reduction of unnecessary spending which limits the Government to spend what they can afford. This in return will slowly reduce our national debt. “A deduction is allowed only for expenses primarily paid for the prevention or alleviation of a physical or mental defect or illness. Medical care expenses include payments for the diagnosis, cure, mitigation, treatment, or prevention of disease, or treatment affecting any structure or function of the body. The cost of drugs is deductible only for drugs that require a prescription, except for insulin.” ⁴

According to Shi and Singh, “One of the goals of primary care is to bring health care as close as possible to where people live and work. In other words, true primary care is community based. It represents convenience and easy accessibility.”⁵ With the pass of this reform, communities will receive federally funded satellite clinics. Members of communities should be allowed primary and outpatient care in close proximity. With the close proximity of outpatient and primary care, patients are able to have access to medical care without having the expense of travel to an outpatient and primary care facilities. This will also include close proximity for free clinics for those who do or do not have health insurance or directly for the poor. “Free clinics have three main characteristics: (1) services are provided at no charge or at a very nominal charge [based on one’s ability to pay], (2) they are not directly supported or operated by a government agency or health department, and (3) services are delivered mainly by trained volunteer staff.”⁵ These clinics also include women’s health medical care facilities. The cost of adding these addition clinics based on need may be an added expense, but with this added cost, the access is improved and the quality of outpatient and primary care for individuals and the facilities will increase.

Based on this proposal citizens will have access to their primary care practitioners to provide screenings for medical disorders or diseases. This access will allow practitioners to manage care in an outpatient setting and reduce the need for inpatient services. The focus should remain on maintaining wellness at a tax-deductible benefit. Overall health care relies on all levels of access and quality of medical care.

References:

1 Ron Paul, http://www.lewrockwell.com/paul/paul407.html

2 http://www.ustreas.gov/offices/public-affairs/hsa/pdf/all-about-HSAs_072208.pdf

3 Mayo Clinic Staff, . (2008, May). Health savings accounts: Is an HSA right for you? . Retrieved March 1, 2010, from http://www.mayoclinic.com/health/health-savings-accounts/ga00053

4 http://www.irs.gov/taxtopics/tc502.html

5 Shi, L., & Singh, D. A. (2008). Delivering Health Care in America A Systems Approach (Fourth ed. , pp. 243-287). Jones and Bartlett Publishers.

History/Overview

By: Greg Aspenson

Outpatient care refers to any visit that is less than 24 hours. Outpatients are not required to spend the night in the hospital and are able to come and go on the same day.¹ Today outpatient care is referred to as ambulatory care. But unlike the term ambulatory care, outpatient care is more comprehensive because not all patients “walk” (ambulatory) to a care facility, but instead can arrive by air or land ambulance to a hospital ED that provides secondary and tertiary care. An essential part of outpatient care is primary care. The main services that primary care provides is, prevention, diagnostic and therapeutic services, health education, counseling, and minor surgery.

Outpatient care has been around for a long time and due to innovation in technology and medical services, many patients are now receiving their care same day without lengthy visits and overnight stays. Decades ago, many physicians would have patients visit their clinics, which were independent of hospital facilities, or they would visit their patients personally in the comfort of their own home. The patient-physician relationship in those days was very strong because in general the physician would take on many medical services. As medical technology advanced and services expanded, outpatient care began to shift to hospitals settings. With the increasing costs of inpatient care and the increasing innovation in medical technology, outpatient care became the dominant approach. Just a couple decades ago, chemotherapy and mastectomy patients were in the hospital for at least a week. Nowadays patients are receiving these type of treatments in outpatient care facilities.

An example of the shift from inpatient to outpatient care happened in the 1990's at the Nation Jewish Hospital. In 1995, the Nation Jewish hospital set up a day-treatment program in pediatrics that provided day treatment for children.² The reason for this shift was increasing technology and better services, as well as to control costs. According to Michael S. Ewer, M.D., special assistant to the vice president and chief medical officer at M.D. Anderson, “Much of the move toward outpatient care in this country has been driven by third-party payers in an effort to control expenses.”³ Michael S. Ewer also mentioned that it benefited patients by challenging health care providers to provide an effective and safe way to provide outpatient care. As well as driving down health care costs, 90 percent of patients according to Carmen P. Escalate, M.D., an associate professor in the Department of General Internal Medicine, Ambulatory Treatment, and Emergency Care, would rather come in daily then be admitted for the whole five days.

Outpatient care is most likely to endure as long as costs are kept down. It is also to the advantage of hospitals and other care facilities to treat patients quickly and send them on their way. Today there is a shortage of inpatient hospital beds throughout the country, which could lead to overcrowding. The best option would be to provide inpatient beds for the very sick. Unfortunately, the aging population is stuck with a higher co-payment through Medicare which is leading to less routine primary care doctor visits, resulting in more expensive care and worsening health down the road; according to a New York Times article.⁴ Hospital administrators are realizing that they need to keep a strong preference for outpatient care if they plan to keep their organization from crumbling. We as a group believe costs are crucial when it comes to outpatient/primary care. If Medicare co-payments increase then we agree that individuals will not seek the care they need until its to late and inpatient care will result, which in-turn will become more costly.

Shi, Leiyu and Douglas A. Singh. “Delivering Health Care inAmerica: A Systems

Approach.” 4^th Ed. Sudbury, MA: Joans and Barlett Publishers, 2008. (247,250-251)

¹ Jeffries, Melissa. "How Inpatient and Outpatient Benefits Work". .

² "Clinical History (3 of 3)". National Jewish Health. .

³ Meeting the Rising Demand for Outpatient Care 49.11 (2004). Outpatient Care. OncoLog. Web. 21 Feb. 2010. .

⁴ Rabin, Roni C. "Aging: Higher Co-Payments Tied to Costlier Care." New York Times - Health. New York Times, 1 Feb. 2010. Web. 21 Feb. 2010. .

Team Beliefs and Values

By: Cassandra DeHaro

I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

- President Barack Obama, February 24, 20091

Barack Obama’s words are powerful and strong and he is justified in saying we need reform. Americans need a better health care system in order to live the “American dream” to the best of their ability. Our group’s political stance is affiliated with moderate/independent ways of thinking. We have a wide spectrum of thoughts in our group that will help us to bring unique reform ideas to the table. We all agree that our health care system cannot operate the way it has been and that reform must occur, and, like Obama, we want to involve the best ideas from both parties. Though our beliefs range on the political spectrum, we all have some similar beliefs and values about what an exceptional health care system looks like. Because values are the foundations for beliefs, we have stated three values and three beliefs that we believe suit our specific topic best.

We value health as a responsibility to the individual, provider, and government, not as a service to be taken advantage of. Like the Institute of Medicine (ION) Committee, we believe that all citizens and providers have certain levels of accountability. Providers are responsible for “providing quality care, [satisfying their patients], using resources efficiently, and behaving in an ethical manner”.2 Likewise patients also have a level of accountability for their own health. Patients are responsible for their health because they can influence it. We also recognize there are other determinants of health that patients and providers cannot control, like their genetic make-up, and some social and environmental factors. Therefore, we believe the government also has responsibility for the health and wellness of its citizens.

We value quality community-oriented primary care as it is central to the health care delivery system.2 Without primary care (annual doctor visits, patient education, mammograms, colonoscopies, etc.), our health care costs would sky rocket for things that could have been prevented in the first place. We believe that community-oriented primary care would lower costs, and allow the health system to run more efficiently because the use of epidemiological data would be used to help communities understand their specific needs.

We value out-patient care because according to an article in Hospital Review Magazine, out-patient care “lead[s] to quicker recovery times and an estimated $100 billion to $120 billion in savings due to shorter inpatient stays”. 2 We believe no one should be denied coverage for any reason including (but not limited to) age, health status, occupation, family history, and/or pre-existing conditions. Out-patient care typically allows patients to feel more comfortable in their own home. This way they are not paying for a stay in a hospital bed when they can just be given care at home. We also believe that a patient and a doctor should collaborate on which option is best (in-patient or out-patient care) and make the decision accordingly. Each patient will have their needs assessed and their coverage will not be based on cost or other limitations.

Our “premiums have been rising three times faster than wages over the past few years” and will continue to skyrocket.4 Our health care system is unsustainable for most Americans, businesses, and the federal government. Our plan will decrease administrative costs and also lower the cost to make health care more accessible to Americans. Not only will our reform make health care more accessible, we will also keep its quality level high by creating incentives, like bonuses to providers, for keeping people healthy.

We don’t necessarily think our plan is “better” than everyone else’s, but we do recognize our plan as an exceptional lot of ideas. Our team does not want to point fingers and say “this is right” and “this is wrong” but rather we want to find the shades of gray in between. We understand that this project is a journey and if we so desire to, we can change and make better our stance. Our values will not change but how we go about implementing them may. Our team recognizes that awareness and learning about health care reform is a journey, not a guilt trip.

Some Americans believe that we do not need health care reform in America and that it is not an imminent issue for Americans today. According to Joe Biden, about 14,000 Americans lose their health insurance everyday and thousands of people are denied insurance because of pre-existing conditions. The Declaration of Independence states that unalienable rights were given to us by the creator which include, “life, liberty, and the pursuit of happiness”. 3 We believe that when people are struggling with life, liberty, and their pursuit of happiness, that they cannot be the best and most productive members of society as possible. Therefore, for the sake of one’s friends, neighbors, family, community members etc., it is imperative that health care is obtainable by all.

1“Health Care: The Presidents Plan.” February 24, 2009. whitehouse.gov. February 13,

2010. <>.

2 Shi, Leiyu and Douglas A. Singh. “Delivering Health Care in America: A Systems

Approach.” 4^th Ed. Sudbury, MA: Joans and Barlett Publishers, 2008. (247,250-251)

3 “New Study Finds Out-patient Care is the Fastest Growing Segment of Healthcare”.

http://www.hospitalreviewmagazine.com/. January 5, 2009. Hospital Review Magazine. February 13, 2010. .

4Biden, Joe. “Vice President Biden Asks For Your Help: Why We Need Reform Now.” Q August 25, 2009. Online video clip. Whitehouse.gov. February 13, 3010. f <http://www.whitehouse.gov/realitycheck/771>.

5Jefferson, Thomas. “The Declaration of Independence.” http://www.ushistory.org. 2010. .

Welcome

Welcome to our team blog. We are excited to embark on this great journey to find a solution to a problem that has been reeking havoc on our nation: Health Care. Please feel free to comment on any or all of the ideas posted. We look forward to reading your comments! Thank you!