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.