Category Archives: Access and barriers to care
Kristi Henderson, DNP, NP-BC, FAEN, is the chief advanced practice officer and director of telehealth for the University of Mississippi Medical Center, where she holds dual appointments in the School of Medicine and School of Nursing. She has an administrative and clinical practice as a family and acute care nurse practitioner, and is a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow. This post is part of the “Health Care in 2014” series.
As we ring in the New Year, do any of these scenarios ring true for you or your family?
- There is someone who suffers from diabetes but lives an hour from a diabetes specialist. They can’t stay in the community where they live for treatment and an already-taxing diagnosis becomes a burden to treat. What if there was a way that the diabetes specialist, diabetes educator, pharmacist, ophthalmologist, and nutritionist could all be brought to this patient virtually by way of today’s technology? What if there was a way for a treatment plan to be customized to each patient and adjusted in real-time from information uploaded from a smartphone?
- There is someone who has heart failure and for every ‘flare up’ the only option is to go to the local emergency room (ER). Medication and check-up regimens are followed every year but the ER visits are the only way to see a health care provider at a moment’s notice. What if health stats, vital signs, and symptoms could all be tracked by the health care provider to identify subtle changes early on, or when symptoms begin to worsen, and interventions could avoid an ER visit? Imagine if symptoms, vital signs, weight and medication side effects were monitored while a patient with heart failure goes about their day, not just at their scheduled check-ups.
Telepresence robots are expanding access to specialists in rural hospitals experiencing shortages of physicians, and in other hospitals throughout the country, reports the Associated Press.
Devices such as the RP-VITA, introduced earlier this year, can be controlled remotely with a desktop computer, laptop, or iPad, allowing physicians to interact with patients through video-conferencing via a large screen that projects the doctor's face. An auto-drive function allows the robot to find its way to patients' rooms, and sensors help it avoid obstacles. It also gives the physician access to clinical data and medical images.
Dignity Health, a hospital system with facilities in Arizona, California, and Nevada, started using telepresence robots five years ago to promptly evaluate patients who had potentially suffered strokes. Dignity now has robots in emergency rooms and intensive care units at about 20 California hospitals, giving them access to specialists in areas such as neurology, cardiology, neonatology, pediatrics, and mental health.
For nearly 25 years, Robert Wood Johnson Foundation Community Health Leader Carmen Velásquez, MA, has helped members of Chicago’s immigrant community access the health care they need. She founded the Alivio Medical Center in 1988, which has now grown to six locations that serve 25,000 patients annually. Two more clinics are slated to open later this year.
In recognition of her work, Illinois Governor Pat Quinn proclaimed October 2, 2013 “Carmen Velásquez Day.” At an event celebrating Latino Heritage Month at the National Museum of Mexican Art in Chicago, Quinn called Velásquez “a true pioneer in public health policy and health care affordability.”
“As the immigrant population in the Pilsen neighborhood grew in the 1980s, Carmen Velásquez was among the first to see the crying need for a health clinic, so she went out and built Alivio Medical Center,” he said. “Hundreds of thousands of Illinoisans are alive today thanks to her, proving that one person truly can make a difference.”
The U.S. Department of Health & Human Services (HHS) last week released a report that looks at Medicare patients’ access to care before and after the enactment of the Affordable Care Act. The report from HHS’s Office of the Assistant Secretary for Planning and Evaluation finds that Medicare beneficiaries’ access to care has remained high and stable in recent years.
The percentage of office-based physicians accepting new Medicare patients remained stable from 2005 to 2012, at approximately 90 percent. That rate is “quite similar” to the number of physicians accepting new privately insured patients during the same time period, the report says.
The report also finds that the number of providers participating in and billing Medicare steadily increased during those years.
“Based on multiple data sources, Medicare beneficiaries’ access to care appears to be excellent: it has been stable over the past five years and is comparable to or better than access reported by privately insured individuals,” the report says.
Adrian L. Ware, MSc, is a third-year graduate student in public health at Meharry Medical College. He holds a BSc in biology from Alabama Agricultural and Mechanical University, and an MSc in biology and alternative medicine from Alabama Agricultural and Mechanical University. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. He aspires to become a Christian psychiatrist serving the poor and underserved. Read all the blog posts in this series.
With innovation, brilliance, passion, and robust planning, public health students and practitioners ask: How can we protect the health of the nation? According to the Centers for Disease Control and Prevention, seven out of ten deaths in the United States are caused by chronic disease. The need for more cost-effective, comprehensive care has never been greater. Within the world of public health, there are three levels of prevention: primary, secondary, and tertiary.
Primary prevention reduces both the incidence and prevalence of a disease, because the focus is on preventing the disease before it develops. This can change the health of the nation for the better. Secondary and tertiary prevention are also significant.
It is well known that emergency care is vastly important, given the sheer complexity of episodic clinical cases that present to the emergency room in “life or death” situations. These “provisions” are necessary for the United States to uphold its high ideals of liberty and justice for all. Adequate, culturally competent, comprehensive health care for all citizens is a social justice issue, and a fundamental right. To this point, our health system’s extreme emphasis on tertiary care is amongst the most fiscally irresponsible ways to improve the health of the nation.
Matthew M. Davis, MD, MAPP, is associate professor of pediatrics, of internal medicine, and of public policy at the University of Michigan in Ann Arbor and co-director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. In February, he coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Davis and his coauthors, both RWJF Clinical Scholars, as well as others from RWJF programs, to respond to the question. Davis’ response follows. Read all the blog posts in this series.
The debate about whether health care is a right or a privilege is familiar and polarized. A quick online search in this topic area yields strong statements, deeply held convictions, and stern admonishments for those who hold opposite views.
As RWJF Clinical Scholars Kate Vickery, MD, and Kori Sauser, MD, (2012-14) point out in their recent blog posts, primary care physicians and emergency physicians can agree that the Emergency Medical Treatment and Active Labor Act (EMTALA)—by focusing exclusively on assuring access to emergency care—fails to ensure that health care is a right for all individuals in the United States across all health care settings.
As the three of us wrote in a Journal of the American Medical Association commentary earlier this year, the Patient Protection and Affordable Care Act (PPACA) will likely fall short of ensuring health-care-as-a-right-for-all as well. That’s largely because one-to-two dozen Americans (or more) will likely remain uninsured even with implementation of all of the coverage provisions of the PPACA. Congress did not have the appetite for even broader coverage initiatives that were considered in PPACA discussions but ultimately left out of the legislation.
Kori Sauser, MD, is an emergency medicine physician and a Robert Wood Johnson Foundation (RWJF)/U.S Department of Veterans Affairs Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Sauser and her coauthors, both affiliated with the RWJF Clinical Scholars program, to respond. Sauser’s response follows. Read all the blog posts in this series.
I am struck by the fact that we are still discussing whether health care is a right or a privilege, because it has been long-determined that the medical care that I provide is a right. As an emergency physician, I am held to the standards of the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates that I provide basic, stabilizing treatment to all who present to the emergency department (ED), regardless of ability to pay.
So when a patient presents to the ED when I am working a shift, I take care of the patient appropriately and without a thought to their payment status. When “Juan,” a young Mexican day laborer without insurance presents with an advanced toe infection as a consequence of his undiagnosed diabetes, I am able to start his diagnostic work-up and treatment, and to admit him to the hospital for continued antibiotics and definitive care of the toe.
Katherine Vickery, MD, is a family medicine resident and a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Vickery and her coauthors, both affiliated with the RWJF Clinical Scholars program, as well as others from RWJF programs to respond to the question. Vickery’s response follows. Read all the blog posts in this series.
Before I joined the Robert Wood Johnson Foundation’s Clinical Scholars program, I trained in family medicine at a federally-qualified, or community health center, United Family Medicine, in St. Paul, Minn.
Many of my patients, and the struggles they faced in trying to access health care, motivate the work I’m doing as a scholar. At the top of this list is “Juan,” a 35-year-old Mexican man working as a day laborer to support his family.
I became Juan’s doctor after a hospitalization where his toe was amputated due to advanced infection resulting from his undiagnosed type II diabetes. He had no insurance and had not seen a doctor in years. The preventability of Juan’s amputation and treatability of his disease was always a frustration to me, and I began to wonder, “What kind of backwards system do we have that ensures a man’s access to a costly hospitalization to remove his toe but bars him from the primary care which can prevent or diagnose and easily treat his disease?”
In 2009, budget shortfalls spurred California lawmakers to eliminate virtually all dental benefits under its Adult Denti-Cal program, leaving millions in the state without adequate dental care. But in late June, Governor Jerry Brown signed a budget that restores virtually all of those dental benefits to the 3 million low-income Californians who qualify for the program.
The 2013-2014 state budget also expands other health care services for low-income Californians through an expansion of the state’s Medicaid program (Medi-Cal) under the Affordable Care Act. An estimated 1.6 million additional Californians will receive coverage under this expansion by 2015.
The dental benefits won’t be available until May 1, 2014, but California Dental Association President Lindsey Robinson, DDS, issued a statement called it a significant achievement. “We look forward to working with the administration to effectively implement Adult Denti-Cal, a vital service that will benefit the health of millions of Californians,” she said.
Emergency departments (EDs) play a key role in the nation’s health care system, according to a RAND Corporation study commissioned by the Emergency Medicine Action Fund, and policy-makers should pay closer attention to their operations—particularly their role as a “gateway to inpatient treatment.” It also is important to better integrate EDs into inpatient and outpatient settings, the new report says.
EDs have become an important source for hospital admissions. Nearly all of the inpatient admissions growth between 2003 and 2009 was due to an increase in scheduled admissions from EDs, the report finds, particularly among Medicare beneficiaries. As a result of this shift, ED physicians served as the major decision makers for approximately half of all hospital admissions.
The study also finds that most patients visited the ED for a non-emergent health problem because they believed they lacked a viable alternative or because they were sent by a health care provider. “Almost all of the physicians we interviewed—specialist and primary care alike—confirmed that office-based physicians increasingly rely on EDs to evaluate complex patients with potentially serious problems, rather than managing these patient themselves,” the report says. EDs also support primary care practices by performing complex diagnostic workups.
“Evidence generated by our study and other published work indicates that efforts to reduce non-emergent and non-urgent use of EDs are most likely to succeed if they focus on providing convenient and affordable options outside the ED, rather than directing ED staff to turn patients away,” the study concludes. EDs should be better integrated into inpatient and outpatient settings through more interconnected health information technology, greater user of care coordination, and interprofessional collaboration.