Category Archives: Health Care Access

Aug 21 2013
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Influencing Young Doctors

The news media has recently covered some innovative programs that are influencing the choices and attitudes of the next generation of doctors.

American Medical News reports on the Buddy Program, which pairs first-year medical students with early-stage Alzheimer’s patients and their caregivers. The program empowers patients, and also serves as a valuable learning tool for the students, heightening “their sensitivity and empathy toward people with the disease.” The program was developed at the Northwestern University Alzheimer’s Disease Center in Chicago; Boston University, Dartmouth College, and Washington University have replicated it.

NPR reports on a program at the University of Missouri School of Medicine that is encouraging more young doctors to pursue primary care in rural areas. During the summers, the school has been sending medical students to work alongside country doctors. While school officials caution they can’t be sure about the reasons, they have discovered that students who took part in the summer program were more likely to become primary care doctors who practice family medicine.  Some 46 percent of participants are choosing to work in the country after completing their medical training.

Read more about the Buddy Program in American Medical News.
Read more about the University of Missouri’s summer in the country program on NPR.org.

Aug 14 2013
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U.S. Needs Primary Prevention, Especially for the Poor and Underserved

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.

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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.

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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.

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Aug 13 2013
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Right, Privilege—or Tragedy of the Commons?

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.

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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.

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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.[1] 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.

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Aug 12 2013
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Drawing a Line in the Sand: Where Do We Stand on Universal Health Care?

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.

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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.

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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.

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Aug 9 2013
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Medical Innovation Should Not Overshadow Primary Care

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.

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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?”

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Jul 8 2013
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Dental Benefits to be Restored for Low-Income Californians

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.

Read more about the state budget in the Fresno Bee.
Read the California Dental Association news release.

Jun 27 2013
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The Role of Emergency Departments

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.

Read the report.

Jun 21 2013
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"My Definition of Diversity Was Altered When I Had the Opportunity to Experience Life Differently"

Cindy Anderson, PhD, RN, WHNP-BC, FAHA, FAAN, is a professor and associate dean for research at the College of Nursing & Professional Disciplines, University of North Dakota. A Robert Wood Johnson Nurse Faculty Scholar, she received a Bachelor of Science degree in Nursing from Salem State College, and both a Master of Science degree in parent-child nursing and a PhD in physiology from the University of North Dakota. This is part of a series of posts looking at diversity in the health care workforce.

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I was born and raised in the Boston area which we always referred to as the “melting pot.”  My grandparents emigrated from Eastern Europe and I grew up hearing stories of the “Old Country” which included both fond memories and atrocities that drove them to leave their homes and find a better way of life in America. As a second-generation American, I have always embraced the common and unique perspectives of others from a variety of backgrounds.

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I began my career as an Air Force nurse, advancing my opportunity to engage with others from varied backgrounds and cultures. In the course of my career, I found myself stationed at the Grand Forks Air Force Base in North Dakota. My initial perceptions were based upon the stereotype that North Dakota was a rural, isolated state with little diversity. My misperceptions were quickly reversed when I had a chance to engage with the community. My awareness and respect for the unique diversity of rural North Dakota has steadily grown over the last three decades which I have been fortunate to spend in this great state.

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Jun 11 2013
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The Chicago Parent Program: An Effective Tool for Low-Income, Urban Parents

Deborah Gross, DNSc, RN, FAAN, is the Leonard and Helen Stulman Endowed Chair in Mental Health & Psychiatric Nursing at the Johns Hopkins University Schools of Nursing, Medicine, and Public Health. She is also an alumna of the Robert Wood Johnson Executive Nurse Fellows program (2006-2009).

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As a child psychiatric nurse, my mission is to make a difference in the lives of families with young children, particularly those living in low-income, urban communities. 

There is now wide consensus that early childhood is the most cost-effective time for targeting prevention and early intervention. The foundation for children’s mental health is formed during the first five years of life, when 90 percent of brain development occurs. Since parents are the primary mediators of their young children’s earliest social and learning environments, any effort to promote mental health in young children must first and foremost engage parents and help them build up their strengths and caregiving capacities.

Nearly 20 years ago, I began searching the literature for parenting programs that had a strong evidence base and demonstrated substantial and enduring effects on parenting quality and children’s behavior. What I discovered is that the strongest programs available had been originally developed and tested on White, middle-class families. As a result, their content and delivery methods were often built on values and assumptions many families I knew could not relate to. 

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May 22 2013
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More Americans Visiting Emergency Departments for Dental Care

A new research brief from the American Dental Association’s Health Policy Resources Center finds that an increasing number of Americans visited emergency departments (ED) for dental-related care between 2000 and 2010, as a percentage of total dental visits. ED visits for dental care increased from 1.1 million in 2000 to 2.1 million in 2010.

The increase was primarily among young adults (age 21 to 34), which the researchers hypothesize is due to a decline in dental benefits among this age group. Young adults were more likely than others to report that they could not afford dental care in the past 12 months, the brief says, and recent studies have shown that there has been a shift in the pattern of dental benefits.

“Unfortunately, the Affordable Care Act (ACA) did little to address the issue of dental utilization in emergency departments,” the brief says. The law does not mandate dental benefits for adults, and insurance plans sold through most states’ exchanges are unlikely to include dental benefits. However, pilot programs in some states have shown promise for diverting patients with dental complaints from EDs and increasing their access to dental care.

“In the coming years, advocates for oral health will have to consider other innovative ways to increase access to dental care in order to decrease dental care utilization in hospital emergency departments,” the brief concludes. “Without further interventions from policy makers, dental ED visits are likely to increase in the future, straining our health care system and increasing overall health care costs. Now more than ever, innovative solutions are needed to improve access and oral health.”

Read the brief on patients visiting emergency departments for dental care.