HCCD Report Utah 84117

Summary of Responses from Discussion Questions

What does the group perceive as the biggest problem in the health system?

1. Individual Responses
   • Lack of coverage - all should have affordable access.
   • The refusal to apply a lower cost and more effective model of care such as the midwives model of care to broader coverage
   • Lack of access to health promotion groups (i.e., centering type groups)
   • Not enough providers to go around
   • People who don’t take responsibility for their health
   • General attitude that the care provider is responsible, that we aren’t autonomous
   • Insurance Companies – this is a broken system and needs to be replaced
2. Group Summary
   We feel that medical coverage should be universally available to all Americans at affordable rates. We believe that applying the Midwifery Model of Care to the broader health spectrum would result in better outcomes and higher satisfaction.
   Definitions of this model can be found at:
   http://cfmidwifery.org/mmoc/define.aspx
   www.apha.org in the following articles:
   http://www.apha.org/membergroups/newsletters/sectionnewsletters/matern/fall05/2142.htm
   http://www.apha.org/membergroups/newsletters/sectionnewsletters/matern/fall08/lubic.htm
   and http://www.cochrane.org/reviews/en/ab004667.html
   In addition, applying the Centering Pregnancy model (www.centeringpregnancy.org) which is an evidence-based redesign of health care delivery that helps to promote patient education, safety, efficiency, effectiveness, timeliness, culturally appropriate/patient-centered care, and more equitable care, to other health issues like diabetes, menopause, pediatrics, etc., could result in increased patient self-care and more positive outcomes.

   We believe that this would decrease costs by increasing individual health promotional activities and decreasing medical lawsuits – leading to the added benefit of decreasing malpractice insurance costs and increased numbers of providers.

   We feel that insurance companies were designed to spread the costs of catastrophic care for the few among the many. We believe that they have instead taken the money of the many and put it into the pockets of the few – namely the “fat cats” of the insurance companies. This is a broken system and needs to be replaced entirely.

How do attendees choose a doctor or hospital? Where do attendees get information in making that decision? How should public policy promote quality health care providers?

1. Individual Responses
   • Everyone at the meeting expressed difficulty finding care. Care is often dictated by insurance companies who limit providers/facilities
   • Often there is no coverage for alternative and mid-level providers
   • Policy makers should recognize skills of mid-level providers and promote instead of restricting access to them
   • Public policy should provide transparency of provider and facility stats and practices available, for example: websites that give information and ratings from patients/clients. E.g.: UT government website with facilities’ price and safety comparisons: http://www.health.utah.gov/myhealthcare/
     Angie’s list as an example:
     http://www.angieslist.com/AngiesList/Visitor/DynContent.aspx?dc=lp.angieslist2&af=102961
2. Group Summary

   Attendees choose doctors according to who is available on their insurance plans. Policy makers should recognize and promote practitioners such as General Practitioners, Family Practice Doctors, Midwives, Nurse Practitioners, Physician’s Assistants, Chiropractors, Naturopaths, etc., as skilled, competent, and cost-saving (though still worthy of proper compensation) providers. Specialists should be reserved for specialized problems.

   We feel it is unconscionable for insurance companies to decide which providers and facilities their members can utilize.

   We feel there should be more transparency and public availability of provider statistics, outcomes, and frequency of procedures, etc. We would like to see public access to information and client/patient ratings of providers/facilities such as in Angie’s List and the Utah government website.

Have attendees or their family members experienced difficulty paying medical bills? How can policy makers address this problem?

1. Individual Responses
   • There was a unanimous response in the positive about difficulty paying medical bills
   • It was agreed that health care costs are unacceptably high in part due to malpractice insurance, insurance companies’ big profits, CEO salaries, “bait and switch” tactics, and the lack of regulation/responsibility for insurance companies’ underhanded tactics
   • Coverage needs to be provided for pre-existing conditions
   • It was agreed that another reason that health care costs are high is that the general population equates technology with high quality care (the more tests and machines, the better the care). However, “low tech” (called “high touch”) care is often equated with better outcomes at a much lower cost.
   • We recognize that the majority of health care costs are spent in the last moments of life. We know that the fear and taboos surrounding birth and death in our society cause us to fight death at an unparalleled cost. We need a paradigm shift in our approach to these subjects. If we were able to let loved ones die without prolonging life, often at the expense of dignity and financial solvency, it could help lower costs.
2. Group Summary

   There are many avenues to cutting health care costs that would in fact increase the health of the general population. These include:

   • Utilizing mid-level providers in low-tech facilities for low risk procedures
   • Increasing patient education and control of their own health care
   • Increasing support for facilities and providers making ethical choices about cost vs. prolonging life
   • Enforcing accountability for insurance companies – or, better yet, finding a whole new system for health care coverage

In addition to employer-based coverage, would the group like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

1. Individual Responses
   • It was unanimous; nobody wants to buy into a public health plan in its current state. Medicaid/Medicare is poorly run and doesn’t compensate the providers for care that saves money.
   • All also agreed that if the above suggestions were followed to make the Medicaid/Medicare system a working system then they would like the option to purchase a private or public plan
2. Group Summary

   The group agreed that buying into a public health plan that looks anything like Medicaid or Medicare, as they currently operate, is unacceptable. However, if the current system was “fixed”, with a major overhaul or a new plan entirely, then they would like the option to buy in.

Did attendees know how much they or their employer pays for health insurance?
What should employer’s role be in a reformed health care system?

1. Individual Responses:
   • Most attendees agreed that they have a good idea what their employer pays for insurance, we have several self-employed people that know, of course
   • The group agreed that employers probably should not be involved in the system. However, we see advantages to their being involved and don’t see an obvious or easy solution.
   • We see the benefits to being in a group for health coverage
2. Group Response

   We all agreed that there are benefits for being in a group for health care coverage but found no obvious or easy solution about where employers fit into health insurance responsibilities.

Were attendees familiar with the types of preventive services Americans should receive? Had attendees gotten the recommended prevention? If not, how can public policy help?

1. Individual Reponses
   • The attendees felt familiar with the types of preventative services that they should be receiving and felt that there should be many more prevention techniques available and accessible to the general public.
   • The group agreed that there should be incentives for receiving preventative care
   • The group felt that there need to be solutions for people who can’t afford to miss work to receive preventative care
2. Group Summary

   Attendees had gotten some of the recommended prevention. The attendees like PSA’s reminding the public of suggested screenings. The group feels that preventative care should be more accessible through work compensation and incentives for receiving that care.

How can public policy promote healthier lifestyles?

1. Individual Responses
   • Having empowering programs, such as the “Centering Pregnancy” program, a discussion group with a limited group size.
   • Giving rewards for participating in healthy activities, i.e. tax breaks
   • Encouraging citizens to take ownership of their own health
   • We don’t encourage free care. There needs to be an exchange of energy/cost, some individuals are not grateful for care (or utilize self care techniques) that is given to them if they don’t pay for it.
   • Public policy should police marketing to children. With controls on “junk food” for example. European countries have policies about any marketing to children…
2. Group Summary

   Public policy could help promote healthier lifestyles by providing incentives (tax breaks for example) for good health, i.e. bonuses for keeping cholesterol, blood pressure, and weight in check, controlling diabetes, seeking prenatal care, well-baby check-ups, quitting smoking, etc.

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PERSONAL STORY #1

I have a very rare progressive neuromuscular disease. And while having this disease has at times greatly reduced my quality of life, my family and I have been much more adversely affected by private insurance companies and government programs such as Medicaid and SSI. It would be impossible to overstate how devastating it is for families to be unnecessarily heaped upon with added trauma and misery from the very companies and agencies who are actually supposed to be helping.

There are many reasons why working individuals (and hence their families) lose or cannot obtain health insurance, and the irony of our family's being denied health insurance because I actually needed it was not lost on us. And it was at this point that our real suffering began.

Our journey from a being middle-class family to a family subsisting in poverty is a tortured and long story but suffice it to say that it finally came to this terrible choice: either I die, or we qualify for the Medicaid accompanying SSI in order for me to get the medical care I needed. My school teacher husband eventually ended up bagging groceries.

That I was not receiving SSDI instead of SSI was a travesty in itself. It seems that though I had worked many years prior to my marriage and the birth of our children, I was being penalized for deciding to stay home to personally raise our children - too many years had passed since I had worked for an employer for me to qualify for SSDI and Medicare, though I worked plenty as a wife and mother. To further the irony, not wanting to burden a government program, though obviously disabled, I actually delayed applying for disability assistance, thereby unknowingly resigning myself to SSI instead of SSDI.

Receiving SSI is nothing short of an ordeal. Because my husband's income varied month by month, we were constantly receiving what can only be described as threatening letters from SSI, demanding immediate reimbursement for "overpayment." It was as if there was an assumption that SSI recipients were also criminal. My husband spent hours on the telephone every month dealing with this issue, hours that should have been spent tending to our young children or to me, in the hospital more often than not.

And while I was in the hospital, my doctors also spent untold hours fighting Medicaid for my treatment. It makes no sense that Medicaid and insurance providers are empowered to dictate treatment, especially for very rare diseases for which there is little if any protocol, but it happened. My biggest fear was not that the disease would kill me but that Medicaid itself would, by virtue of denying my prescribed treatment.

We have four children. At the time, they were all young. They lived on hand-me-downs, beanie-weenies and the generosity of our neighbors, friends, and our church. Finding transportation for four children, two adults and a wheelchair was always difficult. Paying for repairs on our always-used vehicles was impossible. Every expense was vigorously scrutinized - chewing gum was a luxury. There was no room in our budget for music lessons, or after-school sports programs. We were the well-educated parents of four children consigned to a life of poverty by our own government only because I wanted to live. I have never understood why should anyone be forced into poverty simply to get needed medical care. I have never been able to see why it wouldn't have been preferable for my husband to continue working at his capacity, paying those higher taxes, fully supporting our children in all their needs.

Then suddenly, after 18 years, the disease went into a relative remission. Within six months after the remission began, as soon as I learned to walk again, as soon as I thought I could stay upright for more than just a few hours, I found work. I cannot begin to state how physically difficult this was for me. I also cannot begin to express how emotionally freeing it was to finally "quit" SSI and Medicaid. I managed to work, with accommodation, for nearly three years, despite lingering disease.

Then, without warning, the disease once again began progressing.
When it became apparent that I could no longer work, I applied for SSDI. Of course, as with all people who now go through this process, it took years for the approval. (To be noted is the fact that I was physically much worse when I applied for SSDI than I was when I applied for SSI, which was granted to me immediately.) SSDI denied my claim at two levels. Yet the judge who finally saw me asked me a few unrelated questions, spoke with the state-paid medical expert for a minute, and approved my final appeal right then and there, stating that, in fact, it was obvious that I had been legally considered as having a disability even during all the time I had worked.

That said, I still, six months later, have not been paid the "retroactive lump sum." It seems SSDI's computers cannot communicate with SSI's computers to determine that I have indeed not been receiving SSI all these many years. (And it should be noted that people are now dying, waiting for either approval or their retroactive lump sum. I was fortunate to have had disability insurance through my employer to cover this otherwise horrible gap in income, and my husband's employer agreed to cover even me with his health insurance, thereby giving me medical care during this time.) With this inauspicious beginning, I can barely stand to think about the future battles I will surely have with SSDI and Medicare. It could be said by all this that I am now alive only because of a set of very unusual serendipitous circumstances. I am one of the very few who managed to survive through all this mess of bad things - a rare illness, a greedy and deceitful insurance industry, and a few poorly administered and not well-reasoned government programs. I only managed that feat because of some very good things - my faith in God, some good friends, a few dedicated doctors, and a loving and dear family to support me and help me to find my own sheer determination to live through it all. Take away just one of those good things, and most people would not survive the overwhelming bad.

It is within our power as a nation who supposedly cares about each of its citizens to fix all but one of those bad things. I could live with that - compared with the insurance disaster and the government mess, the disease itself is a piece of cake.

PERSONAL STORY #2

My first birth was an emergency cesarean section, by far a more costly and difficult way to give birth. With my second birth I learned a lot more about the options available and chose to have a VBAC, a Vaginal Birth After Cesarean. I received care by a midwife and chose to give birth in my home, primarily because I would have been required to have unnecessary and potentially harmful interventions. The choices were out of my hands, dictated by hospital policy. The evidence does not suggest that those interventions would improve outcomes, and indeed, I gave birth at home without electronic fetal monitoring, medications or surgery. Care by out of hospital providers saved me lots of money, pain and potential heartache. Instead I had a wonderful and empowering experience.

PERSONAL STORY #3
Two Births: One Insured, One Not

My first child was born at a local university hospital with a wonderful nurse-midwife (CNM). My husband and I had planned a homebirth with a direct-entry midwife (CPM). However, my son was showing signs of distress during labor, and my midwife appropriately transferred me to the hospital for further care. My son was born safely, after a few procedures that could not have been done at home. My son and I stayed at the hospital for the usual 48 hours post-partum. I received great care at this hospital and was pleased with my experience. We had chosen that hospital as our back up to homebirth because my husband worked for that university, and we had good medical insurance coverage at that hospital. Months later, we saw that the total bill was almost $10,000 for my relatively uncomplicated vaginal birth. Fortunately, we only had to pay about $200 in copayments for that hospital stay.

A little over two years later, I was expecting our second child. Again, we planned for a homebirth with our midwife. My husband got an offer for a good job in his field of expertise and changed jobs. This was a great opportunity for our family that came with one unfortunate problem; we lost our great health coverage with his old job. The Cobra coverage was wildly expensive and we could not afford it. No short-term insurance companies would cover me because I was pregnant. We made about $100 more a month than the cut-off for Medicaid. We felt we had no choice except to go without health coverage for the period of three months, which included the time we were expecting our baby to enter the world. This left me uneasy and nervous. We prayed that no harm or accident would come upon any member of our family. We had a toddler at the time that was great at getting into mischief, and it terrified me to think of what would happen to us if we ever needed to take him to the hospital or even to a regular doctor’s visit. Our fee with the midwife was very reasonable, a fraction of the cost of a hospital birth. And her care covered my entire pregnancy, birth and six weeks post-partum care. We did have to take care of her fee without insurance since most insurance companies won’t cover the fees of a direct-entry midwife. Her care was very comprehensive. We knew that homebirth was a safe option. Still, because of our last birth experience, we worried, “What if something happens during this birth and we need to go to the hospital again?” If we had racked up a $10,000 hospital bill (or worse) with no health insurance, it would have negatively affected our finances for years and years to come.

It turns out; I did need to seek the advice of an obstetrician/gynecologist during the last trimester of my pregnancy for some issues that were beyond the scope of my midwife. I had to wait until we got our tax return to go see her because we knew it would cost us $120 for one visit, and that did not even include any laboratory costs. The doctor gave me a vague diagnosis and suggested a few possible solutions, one of which was to see another specialist. I knew I could not afford a specialist visit. I had to buy the $20 medication that she prescribed without any coverage. I had to buy the $100 support garments without any help from an insurance company. We did not make very much money, and this took a toll on our budget. It turned out that the medicine did not even help, and I could not afford a follow-up visit before I gave birth. I had to try to ignore my symptoms and move on.

I gave birth to my daughter in my own home in a beautiful water birth with my midwife, my husband, and my son in attendance. My midwife gave us excellent and knowledgeable care and my daughter and I were both safe and healthy. We did not have to go to the hospital. I am grateful that this birth went smoothly. It is one of the most prized memories and accomplishments of my life. My gynecological condition did not negatively affect my ability to birth, but worsened after giving birth. It is sad to me that the worry of being uninsured cast a stressful shadow during my last six weeks of pregnancy, my daughter’s birth, and the first six weeks of my daughter’s life. Our midwife did all of my post-partum exams and all of my baby’s well-child checks in the six-week post-partum period. This was included in her normal fee. We only had to take our baby to the doctor once when she was ten days old, and we had to pay for that visit out of our pocket.

The problem that persisted during and after my pregnancy was never really solved by the gynecological care I received. I later sought out the care of a naturopath that I trusted, but of course, her very thorough care was not covered by our new insurance. I had to pick and choose which testing and therapies she suggested that I could afford, and wait until I could afford the others. The problem still persists today, and I am convinced that if I had had adequate access to appropriate care, testing and therapy, it would have been healed at this point.

I believe that health care and health insurance are broken in this country. I have experienced it in many aspects of my life; this story only tells of my struggles with insurance and health care for my pregnancies and births. I hope that this new administration will include mid-level providers as important links in our healthcare system to save money and to provide excellent preventative care. I hope that legislation will be passed in all states to legalize the practice of direct-entry midwives and make free-standing birth centers an option for all women. I hope that health insurance companies will see the value in these types of providers and cover them for the people they insure. I hope this new administration will address the need for continuous health coverage for all individuals in this country. I know our health system needs a massive overhaul. I believe in change.

Sincerely,
Anne

PERSONAL STORY #4

When our children were very young we were fortunate to have a dental insurance plan through a company with great insight. In retrospect it seems their philosophy must have been to reduce dental problems thereby reducing the need for expensive dental treatments. The plan was simple, but it required a regular yearly dental check-up. The first year they paid 50% of all dental costs. Each year they paid 10% more until dental care was fully paid at 100% on the sixth year of the plan. If a regular yearly exam was missed the plan started over at 50%.

Our oldest children were babies and preschoolers at the time we started this dental plan. They required little care. My husband and I had taken good care of our teeth prior to this plan, and so the first visit included little more than cleaning and x-rays for us. The children required no work. The dentist didn’t want to charge us for the children but agreed to make charges for regular exams when we explained our dental plan to him.

Seventeen years went by with my husband and I requiring limited dental care and cleanings on our yearly exams. The care for our children grew into yearly x-rays, cleanings and recommended prophylactic treatments such as sealants. Our short dental visits gave time for education by the dentist or hygienist. We gained great insight into our teeth.

Our children are now 35-, 33- and 29-years-old. They all developed the habit of regular dental care, which continues to this day.

Everybody was a winner with this dental coverage. We took control of our dental health by seeking regular care, which rewarded us with less dental needs and no dentist bills. Our children were rewarded with no cavities or need of painful dental treatments and no fear of dentists. The dentist was rewarded with the trust of a happy family who referred others to him. The dental insurer was able to keep more of our premiums in its own pockets. The employer must have found this affordable coverage because they offered it for the duration of my husband’s employment with them.

This as an example of what I see can happen with a good model of health care. Everyone needs to be educated and active in the process. Then everyone is rewarded. Sadly, it seems our current model of care is designed to pour time and money into fixing bad health outcomes which might not occur if choices of education and affordable, preventative care were part of plan.

Susan RN

PERSONAL STORY #5

I would like to speak as a Certified Nurse Midwife, a mid-level provider that provides an exemplary service to a few women and babies (about 100 per year). I provide care to low risk women in the childbearing cycle. I am an independent practitioner that owns my own practice and practices obstetrics in a licensed, free standing birthing center. I give longer visits and more personal care to the women that I see. I see women for an average of 90 minutes for an annual exam and each problem visit is 30 minutes with the practitioner. I utilize this time to educate and provide preventive care that is often neglected in medical practices. I take phone calls without an extra charge and see women and infants throughout the nights and weekends. Although I run my own practice and put in many hours averaging 70 hours a week, I have a modest income. I provide all clients with excellent care, but providing care for Medicaid clients is a great sacrifice financially. As a Certified Nurse Midwife (a mid-level provider) I receive decreased payment as compared to a physician despite the dramatically increased time commitment and excellent outcomes.

This last year I took care of a Medicaid client (pregnant women) that had some congenital problems that were seriously affecting her pregnancy. I spent a total of over 200 hours making sure that she was taken care of, coordinating her care for home health services, physician services, pain control, personal care needs, and emotional care needs. This care saved the Medicaid program 10’s of thousands of dollars by not requiring this patient to be hospitalized throughout her pregnancy. This last statement was made by the Medicaid case manager in charge of her case. The amount that I charged was a modest $1850, making my time worth about $9.25 per hour minus expenses for running my own business. The total amount that I received for those many hours of care that I provided her was $489.51, making my time worth to the United States government $2.45 per hour minus expenses which totals an overall loss of income. This is how my government values me and my services.

It is not hard to understand why many providers limit or eliminate Medicare or Medicaid plans from their business. If our country wants to increase maternal and infant health they do not need to spend more, just spend less more wisely.

We as a nation could try to utilize the recommendations of the American Public Health Association (APHA) to increase utilization of out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers. We know that childbirth is the leading reason for hospitalization in the United States, and that 49 percent of all hospital procedures performed on all individuals aged 18 to 44 were obstetric procedures. In 2004, fully 27% of hospital charges to Medicaid and 16% of charges to private insurance were for birthing women and newborns, the most expensive conditions for both payers. The burden on public budgets, taxpayers and employers is considerable.

A recent Washington State study, using conservative cost estimates, estimates that the state’s licensed midwives program, over two years, resulted in recoveries from Medicaid Fee for Service (FFS) alone at more than $473,000. Cost savings to the health care system (public and private insurance) is estimated at $2.7 million. These estimates demonstrate that even the most modest favorable effect on lowering the c-section rates associated with licensed midwives leads to substantial savings to the health care system, as well as lower medical risk and cost to families. What if our national government implements such a program? How much can we save? Specific to upcoming federal legislation, what if birth centers, where many midwives practice, were added as official mandated Medicaid providers? How much can we save then, both in financial and human costs? Utilizing the APHA recommendations for increasing access to out-of-hospital maternity care services and to the midwifery model of care will dramatically decrease national health care costs.

A recent American Journal of Obstetrics and Gynecology report stated that “Despite spending more of our gross domestic product on health care than any other industrialized country, the United States currently ranks 17th in the world in perinatal mortality rate, outcomes that, according to the World Health Organization, are largely due to obstetric causes.” The first step in maternity care reform centers on recognizing that our problems go beyond the secondary issue of insurance coverage and access to care. As the Globe states, “This is not just about who gets care, but about how they’re cared for. Expanding access to a system that doesn’t work won’t change our embarrassing rankings.”

I believe in expanding access to the Midwives Model of Care, an evidence-based maternity care model that provides mothers with not only medical support, but education, emotional support, psychological support and social support, proven to result in lowering c-sections, preterm birth, low birth weight babies, and birth trauma experienced by mothers. We must improve our maternity model, as demanded by the urgent problems with maternal and infant health. And we should globalize this model to all preventative health care.

References can be found in the following sources:

"Increasing Access To Out-Of-Hospital Maternity Care Services Through State-Regulated and Nationally-Certified Direct-Entry Midwives" ,Formally adopted by the Governing Council of the American Public Health Association (APHA), Wednesday, October 24, 2001

Evidence-Based Maternity Care: What It Is and What It Can Achieve, Carol Sakala and Maureen P. Corry, Co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund, October 2008