Underinsured Individuals Research Articles

The Financial And Cost Accounting Implications Of Medical Tourism

It is estimated that the current annual U.S. investment in health care is $2 trillion, roughly 16 percent of the gross domestic product (GDP). Of great concern is the fact that health care costs are rising at two-and-one-half times the rate of inflation in the economy. As a result, the model of health care outsourcing to less developed countries has become increasingly more attractive to individuals who pay out of pocket expenses for health care or who do not want to wait long periods for health care. Medical tourism, introduced in several countries outside the U.S. over a decade ago, is a term coined to represent those underinsured individuals who are willing to pay to travel overseas to save significant amounts of money on the same procedures offered at much greater expense through the U.S. health care system. Because quality of health care around the world varies, concern over substandard care with regard to surgery and other medical procedures is a factor to take into consideration when evaluating medical tourism. This article analyzes the cost implications of medical outsourcing abroad and discusses the financial implications of medical tourism as it relates to the cost of direct care, follow up care, and complications.

Abstract MS3-2: Advances in Breast Cancer Risk Assessment, Screening and Prevention: Adapting the Lessons to an Underserved Latina Population

Abstract Breast cancer (BC) is the most common cancer and the leading cause of cancer death in Latina women. Mutations in BRCA genes are associated with 5% of all BC and a larger proportion of young women with BC. Genetic cancer risk assessment (GCRA) has the potential to identify persons at increased risk for cancer prior to the onset of disease, when early detection or prevention strategies would be most effective. Despite clinical studies documenting the efficacy of cancer risk reduction measures in high-risk individuals, low-income, underinsured or ethnic minority individuals have a disproportionate burden of cancer and limited access to GCRA. City of Hope Cancer Screening & Prevention Program Network outreach clinics were established in two regional indigent healthcare delivery systems. Consultations are facilitated by an experienced bilingual cancer risk counselor/physician team and risk management recommendations are given based on BRCA test results or empiric risk estimates. We observed a high prevalence of deleterious BRCA mutations (25–34%) among Latinas seen in a large network of high-risk clinics from Texas to Northern California, and also identified a unique recurrent large BRCA1 rearrangement of presumed Mestizo origin. We also established that the BRCA1 185delAG detected in several independent Latina families shared a common ancestral origin with Jewish carrier families. The presence of additional recurrent mutations led us to pursue ancestry informed strategies for more cost-effective BRCA analyses in underserved Latina populations. Our clinical studies indicate that underserved patients embrace the opportunity for GCRA services, attend their scheduled consultations, have a high level of participation in follow-up surveys and show a positive impact on cancer screening and prevention behaviors. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr MS3-2.

The “Iowa Get Screened” Colon Cancer Screening Program

To implement a colon cancer screening program for uninsured or underinsured Iowans. All 1995 uninsured patients or patients with Iowa Care insurance aged 50 to 64 years attending the University of Iowa Clinic or the Iowa City Free Medical Clinic were mailed information about the project. Recruitment also took place in person, by having the clinic receptionist hand subjects a research packet, and through community posters. Individuals with colonic symptoms or who were up to date with screening were ineligible. Eligible subjects received a free fecal immunochemical test (FIT), and those with positive FITs were provided with a colonoscopy at no cost to them. Of 449 individuals who completed eligibility forms (23% of the study population), 297 (66%) were eligible and were provided with an FIT. Two-hundred thirty-five (79%) returned a stool sample, with 49 (21%) testing positive. Thirty of the 49 (61%) individuals had a colonoscopy, and 20 individuals had at least 1 polyp biopsied. Thirteen individuals had at least 1 tubular adenoma; 2 had adenomas more than 1 cm in diameter, with no colon cancers identified. Face-to-face recruitment had the highest rate of returned FITs (72%) compared with handing the subject a research packet (3%) or a mailing only (9%) (Chi-square, P < .001). There was high interest in and compliance with colon cancer screening using a FIT among underinsured individuals. Although the FIT positivity rate was higher than expected, many individuals did not complete recommended follow-up colonoscopies. Population-based strategies for offering FIT could significantly increase colon cancer screening among disadvantaged individuals, but programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.

Colorectal Cancer Screening Pilot Program for Underserved Women in Cumberland County, Maine

Over 800 Maine residents will be diagnosed with colorectal cancer (CRC) this year, and nearly 300 will die from the disease. While CRC screening can reduce these rates, it is only among insured populations that screening rates exceed 50%. This project aimed to reduce barriers to, and increase rates of CRC screening among underinsured and uninsured women, ages 50 years and over, residing in Cumberland County, Maine. The existing network of the Maine Breast and Cervical Health Program (MBCHP) was used to reach the target population. A packet containing (1) an offer for no-cost fecal occult blood test (FOBT) screening and CRC-related educational materials, and (2) a stamped, addressed postcard specifying the woman's interest in these resources, was mailed to 300 MBCHP enrollees residing in Cumberland County. Women requesting screening were contacted by phone to further determine eligibility. Ninety-three women (31%) requested FOBT kits and 29 of these women requested educational materials. Ten women were ineligible for screening because of previous colonoscopy. Fifty-two completed FOBT kits (63%) were returned; all were negative. An additional 42 (14%) women requested educational materials only. To reduce the burden of CRC in Maine and nationally, disparate populations must be reached with efficient and effective screening services. Established networks are proven means for reaching uninsured and underinsured individuals with education, screening services, and necessary follow-up care. This project serves as a model for the future development of similar programs statewide and nationally.

Vaccinating Adolescents—New Evidence of Challenges and Opportunities

Vaccinating Adolescents—New Evidence of Challenges and Opportunities

Cost-Efficient Treatment Options for Uninsured or Underinsured Patients For Five Common Conditions

The nurse practitioner's (NP's) role in providing quality care continues to evolve, concurrent with the ever-evolving health care system. With an influx of uninsured and underinsured patients, NPs must not only provide high-quality health care, they must also address cost-efficient treatment options for patients who cannot afford expensive medications. Familiarity with the cost of medications and prescribing cost-efficient medications are valuable tools NPs can use to encourage patient compliance with a specific care regimen, consequently improving the overall health of uninsured or underinsured individuals. Knowledge of patient assistance programs may also assist NPs in decreasing prescription drug costs for patients. Cost-efficient treatment options for upper respiratory infection, migraine headache, eczema, trichomoniasis, and polycystic ovarian syndrome are presented.

Cost‐efficient treatment for uninsured or underinsured patients with hypertension, depression, diabetes mellitus, insomnia, and gastroesophageal reflux

As the number of uninsured and underinsured patients in the United States continues to rise, savvy nurse practitioners (NPs) must balance quality of care with cost of drugs. This article reviews evidence-based treatments in light of prescribing the most cost-efficient medications. Searches of electronic databases including MEDLINE, MEDLINEPlus, EBSCO, PubMed, CINAHL, Clinical Pharmacology, Biomedical Reference Collection--Basic, Health Source--Consumer Edition, Health Source--Nursing/Academic Edition, Ovid, and the Cochrane Library Online. As the role of NP continues to evolve, it is important for NPs to establish themselves as economically conscious healthcare providers, striking a delicate balance between providing quality and cost-efficient care. An NP's familiarity with cost-efficient treatment options for common diagnoses such as hypertension, depression, diabetes mellitus, insomnia, and gastroesophageal reflux disorders can help ease the economic burden uninsured and underinsured patients endure, especially with respect to prescription drugs, and improve compliance with medication regimens. NPs should acquire knowledge on how to best treat uninsured or underinsured patients in the most cost-efficient manner. Knowledge of prescription drug cost is one tool an NP can use to encourage patient compliance, improving the overall health of uninsured or underinsured individuals.

Medical tourism: The trend toward outsourcing medical procedures to foreign countries

The rising costs of medical treatment in the United States are fueling a movement to outsource medical treatment. Estimates of the number of Americans traveling overseas for treatment range from 50,000 to 500,000. Charges for common procedures such as heart bypass can be $11,000 in Thailand compared to $130,000 in the United States. Knee replacement in the United States can cost $40,000 compared to $13,000 in Singapore.A new industry, medical tourism, has been created to advise patients on the appropriate facility in the right country for their condition, handle all travel arrangements, teleconference with physicians, and send medical records. To respond to the growth in medical travel, the Joint Commission (formerly the Joint Commission on Accreditation of Health Care Organizations) initiated the Joint Commission International (JCI) to accredit hospitals worldwide. Although outcome statistics from hospitals outside the United States are rare, first-person reports on quality are numerous. Making surgery possible for uninsured and underinsured individuals or self-insured state, municipal, and private entities is a major benefit of medical tourism. Mitigating against medical travel are the lack of legal remedies in place for malpractice and the possibility that travel itself can impose risk to patients. For example, lengthy air flights where the patient is in a fixed position for hours at a time can cause embolisms. If the trend toward medical tourism continues, continuing education, credentialing, and certification services may be required to help assure patient safety.

The Mercy Circle of Care: An Interdisciplinary, Multi-Institutional Collaboration to Promote Community Health and Professional Education

Background and Purpose.With increasing numbers of uninsured and underinsured individuals within our local communities, physical therapists must participate in creating solutions that improve public health. At the same time, physical therapist professional education programs are exploring methods to

The Promise of Public Housing as a Community-Based Model of Health Care

Providing person in every community across the nation [with] equal access to comprehensive, culturally competent, community-based health is an important goal of the U.S. Department of Health and Human Services (HHS, 2000, p. 16). Yet 43 million Americans lack access to primary health care services (Visser, Thurmond, & Stinson, 1998), and the numbers of uninsured children are rising at an alarming rate because of welfare reform (Sochalski & Villarruel, 1999). Despite advances in medical technology and the delivery of health services for poor people in the United States, infant mortality and morbidity rates approximate those of third-world countries (Cook, Selig, Wedge, & Gohn-Baube, 1999). Successful primary care must be integrated, developed in partnership with patients, and practiced in the context of the family and community (Murphy, 1996). Yet in the age of managed care and the growing centralization of medical care, the creation of comprehensive community-based services for uninsured and underinsured individuals is a challenge, at best. This article reviews the barriers to primary health care in the United States and examines the challenges to successful community-based care. An example of a successful community-based empowerment model of primary health care offered in a public housing development is provided. This program is analyzed in terms of its challenges and successes and how community and empowerment-based principles have been integrated into the planning and implementation of the program. BARRIERS TO PRIMARY HEALTH CARE IN THE UNITED STATES Although HHS's goal is to increase access to health care, Mizrahi (1999) noted that the recent transfer of responsibility for public health care services from the federal government to state and local governments has been accompanied by an abdication of government responsibility to meet human needs by limiting resources and entitlements and lowering expectations about what government can and should provide its citizens. It is not surprising, therefore, that limited financial resources of both patients and community-based programs have become major barriers to obtaining health care (HHS, 2000; Visser et al., 1998). Another important barrier to gaining access to and using primary health care is lack of insurance. As the numbers of uninsured people have grown, employment-related health insurance coverage for workers continues to decline (Rocha, 1997). Only 29 percent of poor workers were covered by employer-related insurance in 1993 (Shapiro & Parrott, 1995). Although many families leaving the welfare roles are still eligible for Medicaid for their children, many are not informed by welfare administrators and are unaware that they are still eligible (Sochalski & Villarruel, 1999). Other barriers to obtaining and using primary health care include lack of transportation and child care, long waiting periods for appointments, distance to the provider, and patient perceptions of provider indifference and insensitivity to their health needs (Cook et al., 1999; Rocha & Kabalka, 1999). Many of these barriers can be alleviated through accessible, low-cost, neighborhood-based health clinics. But the many challenges to successful community-based care must be acknowledged for these programs to thrive. CHALLENGES TO SUCCESSFUL COMMUNITY-BASED HEALTH CARE The growing specialization, centralization, and bureaucracy of institutional primary health care has constrained access to services for many people; yet community-based programs can also be fragmented, lack political support, have budget constraints, and cause public frustration (Halpern, 1991). The professional literature indicates mixed results in providing community-based health care. School-based health care for children has met with some success (Coulam, Irvin, & Calore, 1997; Mosley, 1998). Primary care public housing clinics have experienced low use of services, despite high levels of service needs (Badger, Gagan, & McNiece, 2001). …

Talking to patients about food insecurity.

Food insecurity is highly prevalent in the United States. Even in the best of times, some 10% of the U.S. population self-reports food insecurity in the U.S. annual census instrument, and some 23.3 million Americans use the community-based emergency food system. Unemployed or underemployed individuals, the elderly, single parents, substance abusers, and uninsured or underinsured individuals with medical illnesses are at increased risk for food insecurity. This article discusses clinical approaches to food-insecure individuals. Measurement tools developed to define and document the extent of hunger and food insecurity in the U.S. population are presented as templates for discussion between doctor or dietitian and patient. Information is provided to help clinicians guide patients with food insecurity to appropriate resources.

Uncompensated hospital care. Will it be there if we need it?

The debates over health care system reform continue, but they rarely mention the enduring need for free or reduced-cost hospital care as a safety net for uninsured and underinsured individuals. Policy changes on numerous fronts threaten the ability or willingness of hospitals to provide uncompensated care. These changes include the decline of Hill-Burton funds, the closings or mergers of not-for-profit and public hospitals, the dominance of competitive forces, and the redirection of funds intended for disproportionate share hospitals or uncompensated pools. Federal and state governments lack coordinated approaches toward uncompensated care, and health system reforms may not have the expected effects on reducing hospitals' burden of paying for services to indigents. Furthermore, measurement of uncompensated care is inconsistent. In light of the persistent growth in the number of persons with inadequate health insurance coverage and the central role that uncompensated care will continue to play in ensuring access to care for the poor and uninsured, these policies need to be reexamined. Guidelines for policy based on past experience are presented herein.

Training Physicians to Care For the Underserved: Preventive Medicine Residency-Community Health Center Linkages

The population of uninsured and underinsured individuals in the United States continues to grow, compounding problems of adequate access to medical care. Some of the medical needs of this population are met by community health centers (CHCs). However, CHCs often have difficulty recruiting and retaining physicians, especially those with skills in community medicine. This article describes a general preventive medicine residency program that has been successful in preparing physicians for practice in these settings-what we call training in community-oriented preventive medicine (COPM). At the heart of COPM training are mutually beneficial relationships between CHCs and the residency program. This process has been greatly facilitated through the use of Health Resources and Services Administration (HRSA) federal training grant support to "match" funds provided by CHCs. As of July 1994, 11 residents have entered the COPM track, with eight graduates and three current residents. Thus far, all graduates have remained involved in community-based medical care and preventive medicine activities for medically underserved populations. This training arrangement can serve as a model for other preventive medicine residency programs and for CHCs interested in enhancing physician recruitment and retention. Medical Subject Headings (MeSH): community-oriented preventive medicine, medically uninsured, preventive medicine residency training, community health centers.

Correlates of health insurance coverage: evidence from the Midwest.

The Midwest is often overlooked in national studies of health insurance status. We analyzed the economic and social characteristics of uninsured and underinsured individuals and households in a Midwestern state using both bivariate and multivariate techniques. As in much of the country, economic factors, particularly income and employment, were most significant in accounting for insurance coverage. Unexpectedly, rural and urban residents were equally likely to lack insurance. Results indicate that in rural areas, underinsurance may be a greater problem than uninsurance, and that income-based health insurance is more effective than employer-provided plans in reaching all Americans.

Dynamic Considerations in Psychiatric Crisis Intervention

One of the most challenging tasks for psychiatrists and psychiatric residents is emergency room triage. This task becomes more frequent as more patients depend on the emergency room for psychiatric treatment. Various social and economic pressures account for an increased utilization of psychiatric triage. The government funds that were to provide community care for the ex-patients of state hospitals have never materialized in adequate amounts (1). Many of these patients become dependent transients who in a crisis must use the emergency room as a psychiatric clinic. To keep premiums down, some insurance companies have eliminated their outpatient psychiatric coverage, often limiting their clients to inpatient treatment only. As a result under-insured individuals appear in the emergency room seeking hospitalization instead of more appropriate outpatient care.