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Kirksville Community Health Care Discussion Report

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Kirksville Missouri Community Healthcare Discussion

In response to the call for input from the Obama-Biden Transition Team, I attempted to provide a forum through which members of our community could voice their thoughts regarding health care. The entire project was put together within a single week. It was advertised using email and with the help of the Kirksville Daily Express which covered the event. The timing was less than ideal with A.T. Still University and Truman State University on Christmas break and many interested parties having previous commitments. A significant portion of the content was received by email and through comments posted on the website I constructed.  Given the circumstances, the breadth and depth of the input is remarkable.

The three primary topics presented for discussion were the Availability, Quality and Cost of Care. These are, of course, intricately related to each other. For example, as cost decreases, availability increases and because charges for those without coverage are passed on, increased availability decreases cost. As cost goes down, more people get preventive care and more preventive care reduces cost. It is not surprising therefore, that there are extensive interrelationships between the subtopics identified.

 There was one, overriding concept that emerged:

National Partnership

To be successful, any plan must make maximum use of all resources. While it is essential that the national government take broad and effective action, a singular “top down” approach cannot solve all of the problems. We must blend community, regional, as well as national energy and creativity to weave a wellness support system that is worthy of America.

Action Plan (local): This report will be posted on the website that was developed: http://drpurcell.tripod.com/healthcare/

The site will also be maintained and used as a clearinghouse for local healthcare information. We will attempt to stimulate discussion on relevant topics and plan and execute another community wide meeting within the next six months. We encourage all interested parties to contact their elected representatives and make their views known. At such point as a responsible plan is presented at the national and/or state level(s), we will offer our support. 

Action Plan (state): A copy of this report will be forwarded to Rebecca McClanahan, our state representative, and Jay Nixon, the governor of Missouri. We urge them to work cooperatively with local entities and national officials to enact a cohesive and comprehensive health care plan.

Action Plan (national): A copy of this report will be presented to the Obama-Biden Transition team. While we understand that their primary goal is change at the national level, we strongly urge you to work cooperatively with local entities and state officials to enact a cohesive and comprehensive health care plan. We commend you for this call for local input.

 

Availability of Care

Quality health care for all is an unequivocal imperative. The fact that more than 45 million Americans currently have no health care safety net is a national disgrace. We pay more than twice as much per capita for health care as any other country and are the only industrialized national that does not provide universal care. This fact, more than any other speaks to the imperative for change. For a poignant personal account of the need for affordable universal coverage please see appendix.

Keep What Works. We should maintain and improve programs currently in place that are making a positive difference. Currently one of the most effective approaches to providing universal care is that of community health centers designed to provide care for the underserved. Many of these, including our Northeast Community Health Council, are delivering quality services in a highly cost effective manner.  Rather than attempting to shift the underserved en bloc into other systems, it would be more effective to selectively build on what is already in place. This would, of course, depend on strong local participation in policy and administration. It may be that, in some instances, such programs could provide primary care (at a very reasonable cost) which could be combined with a catastrophic insurance plan. Since cost and efficacy are issues, it may be easier to modify what is already functional than start from scratch. Additionally, those on site may understand local nuances and fit niches which could be overlooked.

Action Plan (local): We will aid the distribution of information regarding programs provided by the Northeast Community Health Council, support them in their work and do what we can to help them grow.

Action Plan (state): Care programs in the State of Missouri have been cut. We urge the state legislature to support responsible programs to provide services to those in need, especially children.

Action Plan (national): We urge national policy makers to take a good look at programs which are already functioning and see how they can be adapted into a new system.

 

Physical Access in Rural Communities. Rural communities have unique health care issues which need to be addressed. Simply getting to the doctor or hospital can present difficulties due to the distance that needs to be traveled. When specialized care is needed, an office appointment may turn into a day-long affair. There are basically two approaches to solving this problem: provide transportation for the patient and bring the care facilities nearer. Transportation is expensive and time consuming. Rural communities offer a smaller patient pool and fewer opportunities. This makes them less attractive to young physicians starting out with significant educational debt.

Action Plan (local): Publicize the need for transportation volunteers and provide networking to place those in need with drivers.

Action Plan (state): We urge the state legislature to include a plan for transportation as an integral part of health care policy. We also support provisions for the maintenance of roadways.

Action Plan (national): We support plans to improve the nation’s highways because of their importance in providing health care to rural communities.

Small Business. Particularly in these troubled economic times, it is difficult for small business owners to provide health care benefits to their workers. This represents a significant portion of the work force. Since employer provided health insurance is a key component of universal coverage, it is important to provide small businesses a way to comply. Tax breaks are one way to assist. It may be that some primary care providers could offer services which would be paid from an employer pool. This would be combined with a catastrophic insurance plan to provide complete coverage at a lower cost than conventional insurance programs. For commentary on “episodes-of-care” plans, please see Physician Practice Options in the appendix.

Action Plan (local): Investigate local provider interest in developing such a program.

Action Plan (state): We support creative plans to help small businesses provide health care coverage to their workers.

Action Plan (national): We support creative plans to help small businesses provide health care coverage to their workers.

Number of Caregivers. There is a forecast of a shortage of physicians, especially in primary care. This would increase waiting times, decrease the amount of time patients can spend with the physician and negatively affect the availability of care. It would exacerbate the current difficulties with rural care. Among the factors contributing to this prediction is increasing dissatisfaction with medicine as a vocation (Harvard gazette) which is largely fueled by the constraints of managed care. We are already in the midst of a full blown nursing shortage which grows with each passing year. Understaffing poses a direct danger to patients and the situation is so bad that many busy hospitals would be forced to close areas of operation if the bare minimum nurse to patient ratios required by law were fully enforced. The stress of understaffing takes its total on nurses and leads to the loss of talented people from the workforce.   If we want universal care, we must ensure that there are enough caregivers. For references, please see appendix.

Action Plan (local): Promote careers in health care through programs like AHEC. Support our local educational programs (ATSU, TSU, MACC) in recruiting qualified applicants.

Action Plan (state): We support plans to enhance the education of young people in our state and to keep graduates from our excellent medical and nursing programs here in Missouri.

Action Plan (national): Congress presently subsidizes nursing programs and provides college loans. It would be an excellent perk if we could offer affordable health care for those in health related (and other) educational programs (please see attachment).

Cost of Care

The cost of health care continues to spiral out of control. To be available, care must be affordable. If other countries are providing excellent universal health care for less than half of what we spend per capita, something is wrong.

Prevention vs “Dramatic” Care. There simply is no more pragmatic way to deal with the escalating cost of health care than to shift emphasis from spectacular attempts to deal with very advanced disease to prevention of disease in the first place. A major factor in achieving this goal is quality universal primary care. We must also place a great deal more emphasis on healthy lifestyles. More than 90% of the illness in this country is preventable. Perhaps the most glaring example is the national “epidemic” of metabolic disease leading to type 2 diabetes. We currently spend exorbitant funds to deal with related health problems while industries grow rich marketing the causes of disease. Prevention needs to be more than a slogan and it entails more than screenings and immunizations.  

Action Plan (local): Educate our youth in healthy lifestyles. We must seek creative ways to present wellness information and “sell” its benefits from grade school on up. As a community, we need to expand the types of healthy and fun activities available.

Action Plan (state): We urge the state legislature to restore and improve upon health care programs especially “well child” programs which provide proper nutrition.

Action Plan (national): Preventive care should be a requirement for all health care plans. This should include personal health counseling, smoking cessation, dietary management, substance abuse counseling, exercise programs and stress management.

Education. The single most valuable tool which we have to address the health care problems in our country is education.  Education is the key to prevention. We need to train health care educators who can work with physicians to provide information to patients since doctors simply do not have the time to adequately perform these duties. We need to educate our youth in healthy lifestyles before they acquire destructive habits. Will this cost money? Absolutely, but in the long run it will save not only in terms of cost of care, it will increase productivity and create jobs in the process.

Action Plan (local): Mobilize our particularly rich educational pool from ATSU and TSU to work with all aspects of the community to get the word out.

Action Plan (state): Increase health education in the school system.

Action Plan (national): The best quality scientific information should be distributed as widely as possible. For example, we can save the lives of our young people and prevent unnecessary abortion by teaching them about condoms. We need support for state and local health education projects. We also need to see that every bright young person that wants to become a doctor or a nurse can fulfill that dream.

Medical Recordkeeping. The technological advancements of the past 25 years have been remarkable. Electronic information systems have connected mankind globally and put unbelievable information at our fingertips. Medical “paperwork” has grown exponentially, but we have failed to use technology to its full advantage. The time has come for a national/international database of medical information that can be accessed and added to wherever a person is. This has lifesaving potential and could cut costs by eliminating duplication. It would be an elegant convenience and powerful tool for patients and care givers. The big stumbling block to making this happen is the assurance of the privacy of the records. Every person must have the ability to view and modify their records. Records must be accessible only by the express permission of the patient or a person with the expressed legal right to offer that permission. Are there some complicated and sticky issues involved? Undoubtedly, but this can no longer be used as an excuse not to move forward.

Action Plan (local): Educate people about the need for moving into the 21st century and using the rich technology we have available to organize and access medical information.

Action Plan (state): Provide funds for the study and implementation of modern record systems.

Action Plan (national): Provide funds for the study and implementation of modern record systems.

Uniform Billing Policy. The cost of record processing and billing is currently a sink hole for health care dollars. This is an area where significant savings could be achieved. Insurance and entitlement programs need to form a task force to universalize the billing format. Every system presently has its own way of doing things. This leads to confusion and unnecessary cost. Where possible, systems should be designed to interlock from a service viewpoint. The processing systems must interlock as well. Even small modifications cooperatively adopted can be fruitful. Meetings need to be held at local, state and national levels where involved parties can interact. There should be carrots for those who cooperate and a stick for those who don’t.

Action Plan (local): Create a forum for health care providers and third party payers to discuss ways to make the process of billing more efficient.

Action Plan (state): Create a forum for health care providers and third party payers to discuss ways to make the process of billing more efficient.

Action Plan (national): Create a forum for health care providers and third party payers to discuss ways to make the process of billing more efficient.

Malpractice Insurance. Every patient has the right to health care meeting local, state and national standards of quality. Substandard care is not acceptable and where it results in harm, the patient should have legal recourse. That said, physicians deserve protection from all lawsuits where the local, state and national standards of care have been met. Malpractice lawsuits are driving competent physicians from practice and this must stop. To this end, action must be taken, at local, state and national levels, to prevent frivolous lawsuits and ensure that malpractice premiums are reasonable. This issue does not only impact physicians, it has and is impeding citizens of this country from obtaining the care they need.

Action Plan (local): Educate the public about the urgent need to provide relief for our physicians from the soaring cost of malpractice insurance.

Action Plan (state): Missouri has passed tort reform laws and still malpractice premiums have gone up. This should be investigated by a congressional committee. More action must be taken to prevent frivolous law suits. The potential for a coverage pool, especially for physicians working in community clinics, should be explored.

Action Plan (national): Insurance companies need more oversight to prevent price gouging. This is a critical issue because it is driving gifted doctors out of practice. Any “universal” plan must address this issue.

Defensive Medicine. One of the unseen costs of our litigious society is forcing doctors to perform tests which are likely unneeded so they are “covered” in the event of a lawsuit. Our physicians function best in an environment where they don’t have to be looking over their shoulder. It is to everyone’s benefit to provide conditions under which only valid legal action is pursued.

Quality of Care

Americans expect the quality of care to be the finest available. Traditionally, we have the ability to “shop” for doctors and chose the ones we feel are the best. Cost can be a factor and the nature of the doctor-patient relationship is changing. Today insurance companies exercise significant influence over how medicine is practiced. Their emphasis on profit often creates what are perceived as deficits in the quality of care.

The Evolving Doctor-Patient Relationship.  In today’s information laden world, we are seeing a shift from the physician as a “God-like” figure and patients with little understanding obediently do as directed, to a doctor-patient partnership where the patient assumes significant responsibility for his/her own well being. One of the factors that has contributed to this change is the direct marketing of prescription pharmaceuticals to the general public. We are shown that everyone can be wondrously devoid of any symptoms and are repeatedly told to suggest medications to our doctors. The next visit may be contingent on the physician’s compliance. People wind up with medication that they don’t need which may cause side effects that must be dealt with in their own right. This new paradigm offers both potential and problems. The buy in to personal responsibility on the part of the patient lowers cost and decreases the strain on the health care system. If the general population gets good information and acts on it, we will be healthier and everyone will benefit. Today’s doctors are taught to explain the choices and let the patients make the decisions. In practice, this often means physicians are expected to explain what various insurance policies will and won’t cover and, if possible, how to “get around the system”. In some circumstances, the best treatment is not economically feasible. These instances expose the myth of equal care for all. We would rather think that the matter of life and death rests only on how far medical science has progressed, not on the socioeconomic status of the patient.  

Action Plan (local): Prepare doctors for the “new medicine”. Develop training programs for new types of medical professionals which will be needed. Educate the public. Provide programs to allow the public to access high quality medical information.

Action Plan (state): Develop licensure programs for new types of medical professionals. Educate the public. Provide programs to allow the public to access high quality medical information.

Action Plan (national): Support discussion on where medicine is going and how best to get there.

Integrative Care. We generally do a wonderful job with emergency medicine, but don’t do as well with chronic disease. Integrative medicine clinics have been developed at many of the nation’s top medical schools to employ a broader range of care skills. These may include manipulation, mind-body medicine, acupuncture, dietary management, yoga/ T’ai Chi, massage and music therapy. These services are often not covered by third party providers although they are well received by patients and free physicians from roles they often do not have time to fulfill. Studies done by The Mind-Body Wellness Center in Meadville, Pennsylvania have demonstrated that such programs actually reduce the overall cost of care. It is important that we seek to combine all of the most effective approaches to health care in an evidence-based manner. These additional techniques should serve as an adjunct, not alternative, to mainstream medicine.

Action Plan (local): Offer seminars in an academic framework on integrative medicine. Develop a web-based compendium of integrative services available in our community which will serve as a resource for our local physicians.

Action Plan (state): Encourage third party coverage of integrative care.

Action Plan (national): Increase funding for outcomes based research on integrative medicine. Encourage third party coverage of integrative care.

 

This report was compiled by

Edwin S. Purcell, Ph.D.

Associate Professor of Anatomy

A.T. Still University

800 West Jefferson Street

Kirksville, Missouri 63501

660.626.2217

epurcell@atsu.edu

 

I wish to thank the following for their contributions:

Adrian Anast

Bryant Blansit, M.L.S.

Kendall Brune

Lloyd Cleaver, D.O.

Norine Eitel

Michael French

Janet Head, EdD., R.N.

John Heard, Ph.D.

Lloyd Kinder

Travis McKenzie

Larry Olsen

Stephanie Powelson, R.N.

Frederick Shaffer, Ph.D.

Joseph Shepard

Philip Slocum, D.O.

Jennifer Tuttle

Margaret Wilson, D.O.

Kirkville Daily Express

If I have forgotten anyone, I am sincerely sorry.

Appendix

Coverage by the Kirksville Daily Express:

http://www.kirksvilledailyexpress.com/news/x1277295881/A-T-Still-professor-hosts-public-health-care-discussion

 

A specific example of the problems we face:

comment: When I left work to continue my education (medical school), I also left behind the insurance benefits that my employment offered for my family. I knew that because of the demands of medical school that I wouldn't be able to find employment that would work with my schedule and offer benefits. I began looking for insurance coverage comparable to that which I already had my family on. The best quote that I got was for $850 a month and did not include maternity coverage.  Mind you, my wife and I are both extremely healthy and in our mid 20's and both our daughters are perfectly healthy with no history of health concerns. This would mean that health insurance would end up costing 50% more a month than rent ($500).  We explored other options which included a catastrophe only plan that was around $300 a month. After hundreds of hours of searching and talking with insurance agents, I had to resign my pride and accept that not only the best option, but the only option for my!
 family, was medicaid. I was devastated and I wanted to pay for insurance coverage but the only practical option available ($300 for catastrophe only) was like giving away $12,000 during the 4 years that I would be in school. Isn't there a better option for my family? Must we either be wealthy or extremely poor to be able to have health coverage? Should health coverage really cost more than rent or a mortgage?

 

Commentary on many of the issues raised in Physician Practice Options:

http://www.mdoptions.com/common/pdfs/PPO101599.pdf

  

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