Why Some Americans Are Risking It and Skipping Health Insurance

Why Some Americans Are Risking It and Skipping Health Insurance

Preparing Doctors to Meet the Demands of the Nation’s Changing Healthcare System

Prices and deductibles are rising. Networks are shrinking. And even some well-off Americans are questioning what they’re paying for. While the share of Americans without health insurance is near historic lows four years after the Affordable Care Act extended coverage to almost 20 million people, the Trump administration has been rolling back parts of the law. At the same time, the cost for many people to buy a health plan—if they don’t get it from a job or the government—is higher than ever.

In tiny Marion, North Carolina, the Buchanans decided that $1,800 a month was too much to pay for health insurance, and are going without it for the first time in their lives.

In Harahan, one bend of the Mississippi River up from New Orleans, the Owenses looked at their doubling insurance premiums and decided no, as well. “We’re not poor people but we can’t afford health insurance,” Mimi Owens said.

And in a Phoenix suburb, the Bobbies and their son Joey will go uninsured so the family can save money to cover their nine-year-old daughter Sophia, who was born with five heart defects.

Across America there are thousands of people like the Buchanans, the Owenses and the Bobbies making the same hard decision to go without health insurance, despite the benefits. They’re risking it—betting that they’ve got enough savings, enough of a back-up plan, or enough luck to get them through a twisted knee, a cancer, or a car wreck.

Bloomberg is following a dozen of these families this year in an effort to understand the trade-offs when a dollar spent on health insurance can’t be spent on something else. Some are financially comfortable. Others are scraping by.

While the share of Americans without health insurance is near historic lows four years after the Affordable Care Act extended coverage to almost 20 million people, the Trump administration has been rolling back parts of the law. At the same time, the cost for many people to buy a health plan—if they don’t get it from a job or the government—is higher than ever.

No one had to tell the Buchanans about the risk. Dianna, 51, survived a bout with cancer 15 years ago. Keith, 48, has high blood pressure and takes testosterone shots. They live in Marion, North Carolina, and make more than $127,000 a year from the small IT business Keith runs and Dianna’s job as a physical therapy assistant, with some additional income from properties they own. That puts them in the top fifth of households by income.

But their insurance premium was $1,691 a month last year, triple their mortgage payment—and was going up to $1,813 this year. They also had a $5,000 per-person deductible, meaning that having and using their coverage could cost more than $30,000.

What sealed the deal was when Blue Cross and Blue Shield of North Carolina and the major hospital system in Asheville, Mission Health, couldn’t reach an agreement, putting the hospital out of network. Keith Buchanan compared the fight to a cable company battling with a broadcaster over what channels to carry.

“It was just two greed monsters fighting over money,” he said. “They’re both doing well, and the patients are the ones that come up short.”

Blue Cross and the hospital eventually made a deal, but enough was enough for the Buchanans. Instead of insurance, they’re paying $198 a month for membership in a local doctors’ practice. They get unlimited office visits and discounts on medications and lab tests. They also signed up for Liberty Health Share, a Christian group that pools members’ money to help pay for medical costs. Liberty costs $450 a month, including a $150 surcharge based on the couple’s blood pressure and weight.

Three days after dropping their Blue Cross coverage at the start of the year, Keith took a wrong step and injured his knee.

It could have been worse. He got it checked out at an urgent care center, where the visit and an X-ray cost him $511. That’s still less than he was paying in premiums to Blue Cross.

“If we can control our health-care costs for a couple of years, the difference that makes on our household income is phenomenal,” Buchanan said. The couple doesn’t have children.

There’s plenty of evidence that having insurance is a good thing. People with health coverage spend less out of pocket on medical care and are less likely to go bankrupt. They see the doctor more often and get more preventive care. They’re less depressed and tell researchers they feel healthier. Some studies suggest having insurance reduces the likelihood of death.

Despite those benefits, some 27.5 million Americans under age 65 were uninsured in 2016, about 10 percent of that population, according to the Kaiser Family Foundation. The most common reason: the cost was too high. A Gallup poll suggests that, after declining for years, the percentage of adults without coverage has increased slightlysince the end of 2016, when President Donald Trump was elected promised to dismantle Obamacare. Other data show no significant change.

The Affordable Care Act wasn’t just an expansion of insurance coverage. It also rearranged how Americans’ medical costs are distributed, favoring some and asking others to pay more.

People near the poverty line got Medicaid for free, while those making more—up to about $100,000 for a family of four—got subsidies to lower the price of private health plans.

Above that threshold, people pay the entire price. Because the law barred insurance companies from charging sick people more or refusing to cover them entirely, costs for healthy people went up as well. Some insurers have left the market, while others have sharply raised premiums to compensate for actions taken by Congress and the administration to weaken the law.

The Bobbie family remembers the problems that the ACA was intended to solve.

Their daughter Sophia was born with serious heart defects, and the organs inside her tiny abdomen were in all the wrong places. She spent the first two weeks of her life in a neonatal intensive care unit. On her six-month birthday, she had open-heart surgery. At nine months, doctors operated on her stomach.

Sophia qualified for Arizona’s Medicaid program. But when she turned 2, the Bobbies were told they made too much money for her to get low-cost state coverage. Her father Joe Bobbie, who co-owns a Philly steak shop with his brother, reduced his take-home pay so Sophia would still qualify.

She had another heart operation just before she turned 3. In just a few short years, her parents were told, Sophia’s medical costs had come to well over $1 million. Before the ACA, no private insurer was willing to cover Sophia’s pre-existing conditions.

“Every door, every option, everything was just slammed in our face,” Sophia’s mother, Corinne, said.  Medical costs that insurance didn’t cover piled up. The family skipped vacations and nights out, and lost their house and car because they couldn’t make the payments.

Corinne and Joe Bobbie, with their children Sophia and Joey.
Source: The Bobbie Family

Those sacrifices have been tough on the Bobbies, but they’ve let Sophia have a relatively normal life. She takes medication for blood pressure and blood-thinners, and a daily antibiotic because she was born without a spleen. She goes to school, rides horses, and plays piano. A recent tumble from her horse frightened her mom, but Sophia jumped up and climbed right back on.

When Obamacare coverage became available in 2014, the Bobbies, who made about $55,000 last year, bought a policy for Sophia that now costs $217 a month.

Adding Sophia’s seven-year-old little brother Joey, who’s healthy, would have cost another $160 per month, with a $6,000 deductible. So he’s uninsured, and so are Joe and Corinne. The money they save risking their own medical and financial health goes to paying Sophia’s bills.

“Every single decision that you make has to be very carefully calculated so that your finances don’t fall apart,” Corinne Bobbie said.

The Trump administration proposes to make it easier for Americans to buy cheaper health plans, which could open more affordable options for the rest of the Bobbie family. But those less-expensive choices, such as short-term health plans, would lack some of the consumer protections created by the Affordable Care Act that allowed Sophia to get coverage in the first place.

The tax proposal that became law in December will also lift the Affordable Care Act’s requirement that every American have coverage or pay a fine. Economists warn that these changes could further weaken insurance markets, pushing up costs for sick patients like Sophia—and forcing more people into similar choices.

Some states are already trying out the new rules, offering plans that don’t adhere to ACA’s requirements. In Idaho, the state’s Blue Cross insurer attempted to offer a “Freedom Plan” with annual limits on care and questionnaires that would let it charge higher premiums to people who are sick or likely to become so. The Trump administration reluctantly judged that such a plan would violate Obamacare’s rules. But federal officials encouraged Idaho to explore offering similar policies as short-term plans that can offer skimpier benefits and lower prices.

In Harahan, Louisiana, outside New Orleans, Mimi Owens learned this year that her family’s $750-a-month plan with Humana Inc. was being discontinued. A new plan for her two daughters and husband on the ACA market would cost close to $1,600. Their family makes about $147,000 from a small business selling class rings and gowns to schools.

Owens said they go to the doctor “for a sniffle, for a flu,” and have a few regular prescriptions, so they looked into short-term health plans and tried out a Christian health-sharing ministry for a few months. The best solution she’s found so far is paying $130 a month to join a direct-primary-care group, which she calls “the best care we’ve ever had.”

It doesn’t cover the big things, though. An accident like a car crash could wipe out their finances.

“We were raised to have insurance,” Owens said. “This is crazy to us.”

What happens when a patient says, ‘Doc, help me die

What happens when a patient says, ‘Doc, help me die

What happens when a patient says, ‘Doc, help me die’

My 54-year-old patient was alone in the intensive care unit, with no family or friends in his life. He slumped in his bed, gasping, staring up at me. Admitted with lung fibrosis and pneumonia, he had scars and infection aggressively replacing his airways, despite our best treatments.

By E. Wes Ely

This piece is the third part of a CNN Opinion series, “What it’s like to be me,” which explores the personal struggles Americans face at a time of profound social change. E. Wesley Ely is a physician and the Grant. W. Liddle Professor of Medicine and Critical Care at Vanderbilt University, Tennessee Valley VA GRECC, and the founder of the Vanderbilt ICU Delirium and Cognitive Impairment Study Group. The views expressed here are solely his.

My 54-year-old patient was alone in the intensive care unit, with no family or friends in his life. He slumped in his bed, gasping, staring up at me. Admitted with lung fibrosis and pneumonia, he had scars and infection aggressively replacing his airways, despite our best treatments.
E. Wes Ely

 E. Wes Ely
As a newly minted doctor years ago, my mind was usually occupied with beeps and buzzers providing me technical information to help calculate choices about patients’ care. Having developed gray hair over many years at the bedside, my first priority is now more straightforward: to hear the voices of the vulnerable people looking up at me from their bed. That is what I try to do as a physician, including, of course, what they tell me in the silences.
I pulled a chair next to his bed so we could talk at eye level. His face was blank. “I want euthanasia. I’m going to die soon, so what’s the point of living longer? I’m just wasted space.”
I felt nauseated. The illegality of euthanasia was not what ran through my mind. Instead I thought about how Paul had lost his sense of personhood. I thought about how I had chosen to become a doctor in the first place.
Caregiving is a partnership

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I chose medicine as my calling after a childhood spent in the Deep South: Shreveport, Louisiana. My mother taught English there after my father, an engineer, had left her for another woman. I remember it was so hot that my siblings and I would fry eggs on the sidewalk. No joke. On most days, we’d walk to a nearby bayou and catch baby alligators for fun and fill up coolers with crawfish for dinner. That last part is important because we had no money at all. Dad wouldn’t pay anything to Mom, who didn’t make much as a teacher. So I started working at the farm of a man who wanted to marry my mother. I worked 14-hour days from about five in the morning doing square bales of hay until seven at night picking vegetables and running the country store.
While I cherish those years and the formation that grueling work provided, I was determined to do something different with my life. Mom told me that Dad had loved math and science, and she taught literature. So I figured it must come naturally for me to split the difference and do something with people, science and the arts. To me, that meant medicine.
Dr. Wes Ely assessing a patient in the Medical Intensive Care Unit at Vanderbilt.

I remember our first big assignment in sixth grade was to write a research paper on what we would be when we grew up. I rode my beat-up bicycle to the local library and began reading about how to become a physician: What was the process and what would it all mean? I walked out of the library that day having spent most of my time reading a long medical essay about truth. The author insisted that to be a physician, one has constantly to seek truth about the patient’s diagnosis, the best treatment, and the best way to serve each and every person. What I learned from the essay was that truth doesn’t change depending on our ability to stomach it. As I progressed through Jesuit high school and Tulane, this became a common theme in my pursuit of a life as a doctor: “Wrong is wrong even if everybody is wrong. Right is right even if nobody is right.” Numerous people are credited with some version of this quote, from actors to philosophers to theologians. That sense of truth drove my study and training and my realization that each person’s life has value beyond measure.
I knew long before I met Paul that I couldn’t kill another person just because he or she wanted me to, but I still had to find a way to respond to Paul’s request to die.

‘Just don’t abandon me’

My response came in parts over my days with him. First, I explained that, as his physician, I wanted to be with him through the dying process. I told him that I considered us to be in a mutual covenant. We both had a degree of autonomy that had to be respected, but I would never intentionally harm him. “Paul, our covenant includes my limiting your suffering,” I said. “You are the best judge of when you need more meds for pain, anxiety and breathing. All of us will work day and night to end your distress, but we won’t deliberately end your life.”
With our eyes locked, Paul gave his instruction: “Just don’t abandon me.” And we sat there, as partners.
As a physician, there is no better place to be. Perhaps especially amid the uncertainty, we must learn to partner with each person in the bonds of this two-way relationship. He in need of help and me in need of helping.
Paul was receiving excellent palliative care for his physical symptoms, but it wasn’t enough. It never is. Emotional isolation and despair can cast a shadow darker than disease. Physicians fail our patients on a human level. We forget that our patients are more than the sum of their medical conditions, so I asked Paul about other types of therapy — art, music, spirituality, pets, sunshine — that might help him.

‘He who has a “why” to live can bear almost any “how”‘

“I want my music. Can you get me the soundtrack for ‘Lord of the Rings’?” Within minutes we had the songs playing in his room, and his demeanor changed from desolate to alert and engaged. “I love music. It’s always been a motivator, but now … I don’t know.” He shifted in his bed. “My goals are gone.”
Nietzsche’s words came to my mind, “He who has a ‘why’ to live can bear almost any ‘how.'”
Viktor Frankl, as a physician-survivor of Auschwitz, used Nietzsche’s quote four times in his crucial analysis, “Man’s Search for Meaning.” I think this book should be required reading for medical students.
As with many patients, Paul’s story needed unpacking. “Paul, what did you do in life?”
He smiled and shrugged. “I’m a rare beast: a plumber who acts. I do Shakespeare festivals. You know, ‘The quality of mercy is not strained.’ I’ve been mulling over that line. Years ago I didn’t understand it. I do now. Mercy should not be forced. It’s better as a natural infusion, one person to another.”
I described for Paul the many years I spent alongside my single-mom-turned-Shakespeare-director, helping her cue actors. As we talked, I watched his erratic oxygen levels fall and then partially recover, obliging us to take breaks. Sweat would build up on his forehead, and, more than once, I worried that our conversation was too much of a strain. But we were unpacking, and it was essential.

The quality of mercy

That night I asked Christine, a nurse who loves theater, to sit and talk with Paul. Soon their lives were interwoven, too.
“I think I helped Christine,” Paul said the next day. “My own illness made me forget that one of my ‘things’ is seeing when someone is hurting. And Christine is. She came to help me, but it turns out some really personal things in our background are weirdly similar. I told her my way through the worst of it.” He paused, his thoughts far away.
It seemed like a good time to return to his previous request. “Paul, you’ve asked for euthanasia, and you brought up Portia’s line from ‘Merchant of Venice’ about mercy. Can we talk about these things?” He nodded, and closed his eyes.
“We all want to be here with you in your suffering. I want your opinion: I don’t think injecting you with a lethal drug would be truly merciful, but it would, in every sense of the word, be ‘strained.’ It would be a forced and unnatural ‘false’ mercy. Whenever possible, mercy must also be lifting and healing. I don’t want to abandon those key elements in serving you.”
His eyes opened wide. “Doc, talking with you and Christine about life’s best and worst times has helped.” He took a deep breath, and I heard the whoosh of high-flow oxygen into his nostrils. “Things I confided to Christine are helping her sort through her own struggles. She said she’s coming back tonight, and that means the world to me.” Then, unwittingly, Paul paraphrased Nietzsche: “When we met, I was afraid of being a burden and not mattering. Now I feel different. I’m not a believer like others, but I guess I remembered the ‘why’ to live.”
Short of a war zone, there are few settings as raw as an ICU. Yet treasured moments of human transformation come when people like Paul rediscover their “why,” even if just for an hour or a day.

‘I’m glad I didn’t miss this time’

I see many paths toward survival in the ICU, and for non-survivors, myriad paths toward death: sudden, prolonged, stuttering, reluctant, stoical — and these paths are dynamic, not static.
It is a rare patient who asks me for euthanasia, but it is nearly universal that dying patients seek help with suffering. Sitting on their beds brings me right up against their fears, the greatest of which is usually not intolerable pain.
Lack of control is what bothers people the most, and it drives most requests for euthanasia, which is predominantly a first-world phenomenon. As we have gained more and more ability to dictate so many aspects of our lives, looking ahead in uncertainty has become something people are not willing to tolerate. As a physician, I find this is a very important “teachable moment” for most patients: helping them (and me) to live in the moment. Whitewashed along a wall in the home for destitute and dying in Kolkata, these words of Saint Mother Teresa became emblazoned in my mind, and I recalled them for Paul: “Yesterday is gone. Tomorrow has not yet come. We have only today. Let us begin.” He nodded in agreement.
Paul reminded me that the best remedy for angst is human relationship and community.
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The problem with assisted suicide and euthanasia for Paul — and for others — is that it presented him with an illusion of ‘cure,’ when in reality it would have left him devoid of the healing he received.
And alongside the patient, of course, sits the physician. The problem for me with intentionally administering lethal medications to end the life of another person is that it would rob me as a healer. I would be qualitatively changed. If I were ever to assume that I had authority over life to take it deliberately, it would, for me, create an irrevocable cavern of emptiness. The infinite worth of every person outprices autonomy: What you and I want is less important than who we are.
Obviously, the approach I took with Paul won’t be an answer for everyone, yet it is too often left untried. Some will say Paul’s story is merely an uplifting anecdote. Nevertheless, I hope to embrace the lessons I learned at his bedside for most of my patients, and I hope my colleagues do the same.
Caregiving is a partnership

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We are sent to heal even when cure is not possible. What we should be trying to heal is often not physical disease or clinical depression, but a person’s sense of insignificance and hopelessness, which we cannot heal by eliminating the person.
Paul died a week later. By then he realized his life was of value even with a terminal disease. In fact, the last thing he said to me, between gasps, was: “I’m glad I didn’t miss this time. I never saw it coming, Doc. … In losing my breath, I gained it.”
Note: The patient’s name and age have been changed for privacy. These conversations reproduce Paul’s words as accurately as possible from the author’s memory.
The Doctor of the Future

The Doctor of the Future

The Doctor of the Future

When patients go to see Dr. C.T. Lin for a checkup, they don’t see just Dr. Lin. They see Dr. Lin and Becky.

Becky Peterson, the medical assistant who works with Lin, sits down with patients first and asks them about their symptoms and medical history—questions Lin used to ask. When Lin comes in the room, she stays to take notes and cue up orders for tests and services such as physical therapy. When he leaves, she makes sure the patient understands his instructions.

The division of labor lets Lin stay focused on listening to patients and solving problems. “Now I’m just left with the assessment and the plan—the medical decisions—which is really my job,” Lin says in a quiet moment after seeing a patient at the Denver clinic where he works.

When patients go to see Dr. C.T. Lin for a checkup, they don’t see just Dr. Lin. They see Dr. Lin and Becky.

Becky Peterson, the medical assistant who works with Lin, sits down with patients first and asks them about their symptoms and medical history—questions Lin used to ask. When Lin comes in the room, she stays to take notes and cue up orders for tests and services such as physical therapy. When he leaves, she makes sure the patient understands his instructions.

The division of labor lets Lin stay focused on listening to patients and solving problems. “Now I’m just left with the assessment and the plan—the medical decisions—which is really my job,” Lin says in a quiet moment after seeing a patient at the Denver clinic where he works.

For generations, when Americans sought health care, they went to see their family doctor. But these days, they’ll often sit down with a physician assistant or nurse practitioner instead. Or they’ll spend a large part of their visit talking to a non-doctor, like Peterson, who takes care of an increasing number of tasks doctors used to handle.

Driven by efforts to control costs and improve outcomes, it’s one of the biggest shifts in the American health care workforce. Medicine increasingly looks like team sport, with duties and jobs that used to fall to a family doctor now executed by a team, from nurses who sit down with patients to discuss diet and exercise to clinical pharmacists who monitor a patient’s medication. The doctor, in this model, is a kind of quarterback, overseeing care plans, stepping in mostly for the toughest cases and most difficult decisions.

Under some models, the doctor may recede even further into the background, leaving advanced practice nurses or other highly qualified professionals in charge.

It’s no longer true “that you’re a sole cowboy out there, saving the patient on your own,” says Mark Earnest, head of internal medicine at the University of Colorado medical school.

The shifting role of doctors is expected to accelerate in the coming decades, as the number of older Americans increases dramatically, many of them living longer with chronic diseases that need monitoring but not necessarily the expensive attention of a physician at every visit.

This isn’t the job many physicians trained for—or that some want. Even doctors who support team-based care have trouble adjusting to the new workflow. Some don’t like the idea that they aren’t always the ones in charge. Others, sick of the industry pressures, are opting out and setting up independent practices that don’t accept health insurance.

But most doctors will have to adapt. Change is coming, regardless of the fate of the Affordable Care Act or other laws designed to reward health systems for outcomes rather than the number of procedures performed, says Randall Wilson, an associate research director for Jobs for the Future, a nonprofit that advocates for increasing job skills. “People see the writing on the wall,” he says.

New models

Americans spend more on health care than people in other wealthy nations. Yet Americans live shorter lives and are more likely to be obese or hospitalized for chronic conditions, such as asthma or diabetes.

Health care experts have long blamed these lousy results on our fragmented health care system. Americans rely on a mix of specialists and settings for care, but those pieces of the health care system don’t necessarily communicate or coordinate with each other.

They also blame the high costs partly on the fee-for-service payment system, which rewards hospitals, clinics and doctors for the volume of procedures they provide. Health insurers will pay for a patient sit down with a doctor. What they sometimes don’t pay for are other services that help patients stay healthy, such as a visit from a community health or a phone call with a nurse. Yet such services can prevent medical emergencies and save her and her insurer a lot of money on expensive treatments.

New payment models encourage health systems to deploy their workers more efficiently — while also avoiding unnecessary services and costly errors. For instance, Medicare already gives some hospitals a single payment to cover everything that happens to a patient from the moment he enters a hospital for knee replacement surgery to three months after he goes home.

Distributing work across team members can help keep costs down, relieve doctors of the busywork that jams up their day, and make everyone more productive.

At least, that’s the idea. There isn’t yet strong research that proves teams provide better or cheaper care, says Erin Fraher, director of the Carolina Health Workforce Research Center, a national research center at the University of North Carolina. Studies do show that nurse practitioners can deliver care as well as physicians, “but talking about substitution of one provider for another is not team-based care,” she says.

Major physician associations support improving teamwork and collaboration among health care professionals. So do medical school leaders. For some years now, accreditors have required colleges and universities that train doctors, nurses, pharmacists, dentists and public health experts to teach students to work in interprofessional teams.

But when it comes to the question of who is in charge, that’s where friction arises. Many doctors aren’t comfortable with the idea that they don’t always need to be in charge. The American College of Physicians will say a physician must always lead care teams, says Ken Shine, professor of medicine at the Dell Medical School at the University of Texas at Austin, but he disagrees.

“My argument is there are situations where another health professional needs to be directing the team,” Shine says. For instance, a nutritionist could create and manage a care plan for a diabetic patient.

Medical associations have also pushed back against proposals to expand the medical decisions non-doctors are able to do make on their own. Health professionals’ so-called “scope of practice” is governed by laws that vary from state to state. “While some scope expansions may be appropriate, others definitely are not,” the American Medical Association says on its website.

In a statement, the association says it “encourages physician-led health care teams that utilize the unique knowledge and valuable contributions of all clinicians to enhance patient outcomes.” It noted that top hospital systems are using physician-led teams to improve patients’ health while reducing costs.

To be sure, doctors aren’t being displaced anytime soon. But shifting tasks to other professionals reduces the need to train so many of them. According to a study by the Rand Corporation, a nonpartisan think tank, a standard primary care team model requires about 7 doctors per 10,000 patients. Increasing the numbers of nurse practitioners and physician assistants can drop that ratio to six doctors per 10,000, and in clinics run by highly trained nurses (known as nurse-managed health centers) the ratio drops to less than one doctor per 10,000.

Culture Change

Hospital systems like UCHealth, the University of Colorado-affiliated system where Lin and Peterson work, are betting that the future of health care involves a mix of professionals sharing responsibility for patients. Doctors will still run the show, but they’ll have to give up some control.

That culture change makes many doctors uneasy at first. Doctors want to protect their one-one-one relationship with patients. They may not understand what their non-physician colleagues have been trained to do, or are legally able to do. And many worry that change will make them even busier, by forcing them to manage the lower-credentialed professionals around them.

Lin is the chief information officer for UCHealth. As an administrator, he’s always pushing for change—his latest project is a system that releases certain test results to patients in real time. But as a practicing doctor, he also understands that change is hard.

He says that having Peterson in the examination room with him took some getting used to. “Like many doctors, I have a fear of letting go of all the things I traditionally do,” he says. That includes documenting a visit. “I’m getting over it, because I don’t want to be the only one here at 8 o’clock at night, typing.”

Matt Moles, a doctor who practices in the same clinic, says he also initially felt uncomfortable. Sharing the examination room went against his medical training, he says: “We’re trained to trust no one.”

It’s still possible for doctors to have jobs that resemble the Norman Rockwell era of long consultations—if they’re willing to opt out of the mainstream. A small but growing number are setting up or joining practices that, rather than taking health insurance, charge patients a monthly fee—typically around $75— for unlimited visits.

“I personally have the mentality of—leave me alone, I’ll take care of my patients,” says Dr. Cory Carroll, when reached by phone at his family care practice in Fort Collins, Colorado. He’s been a solo practitioner for most of his 25-year career.

Carroll has about 300 patients, a fraction of the patient load of a typical doctor in a big health care system. He sits with patients for over an hour if he has to. He visits them at home. He helps them connect with social services and community organizations. And he can focus on what he loves most: teaching patients to eat a healthier diet.

His practice is proof that it’s still possible for a family doctor to do it all. But he emphasizes that his experience is unusual. “I’m absolutely an outlier,” he says. Less than a quarter of all internal medicine doctors in the U.S. have a solo practice, according to the American Medical Association’s latest survey. And although the model Carroll has embraced is growing, it serves a more affluent slice of the patient population than a major hospital system such as UCHealth.

The team-based future

UCHealth’s leaders are so sure that team-based care is the future that newly built clinics, such as the one in Denver’s Lowry neighborhood at which Lin and Peterson work, are literally built for teamwork. Examination rooms don’t line long hallways; instead, they ring desk space where nurses, physicians and medical assistants sit side-by-side.

But the clinic is still in the early stages of transforming its teams. The best place in Denver to watch a diverse set of health professionals working together is across town, at a facility run by Denver Health, the city’s public safety-net hospital system. The facility includes a primary care clinic, an urgent care center and a pharmacy.

One recent morning, the distant wail of a baby in the waiting room announced the start of another busy day. Doctors, physician assistants, nurse practitioners and medical assistants were already typing away at the computers in their cubicles, trying to get a head start before the first patients were shown in to examination rooms.

“A lot of Denver Health patients are so complex,” explains Dr. Benjamin Feijoo, looking up from his desk. Patients often have multiple health issues, too many to handle in a typical 20-minute visit. “It’s a bit of a crunch,” he says.

So Feijoo turns to his colleagues for help. For instance, if a patient has both a medical and a mental health issue, Feijoo can address the medical problem and then ask a mental health specialist to step into the examination room and tackle the mental health problem.

If a patient needs, say, a crash course on prenatal health, she can meet with a nurse for an hourlong discussion. And if a living situation is compromising a patient’s health—such as unstable housing, or insufficient access to healthy food—the clinic’s social worker will try to find a solution.

The clinic also employs two community health workers, who spread the word about Denver Health in low-income neighborhoods, and a patient navigator, who calls the clinic’s patients when they leave a Denver Health hospital (and, for a subset of patients, other major local hospitals) and helps them schedule a follow-up appointment with their primary care provider.

Denver Health began expanding its care teams in 2012, when it received a $20 million federal grant. The system spent about half the money on hiring staff such as social workers, patient navigators and clinical pharmacists and the rest on software that identifies patients who are spending avoidable time in the hospital, including people who are homeless or have a serious but treatable condition, such as HIV. New, smaller clinics wrap even more services around those patients, allowing them to come in for multi-hour visits.

The new system now saves Denver Health—an integrated system, which includes a health plan—so much money on hospital stays and emergency room visits that it covers the salaries of the additional hires, says Tracy Johnson, the director of health reform initiatives for the system.

Reconfiguring care teams has made financial sense for UCHealth, too. Although the clinic where Lin and Peterson work has roughly twice as many medical assistants today as it had a year ago—plus a social worker and nurse manager—the configuration saves doctors so much time that they’re able to see more patients each day. The extra visits bring in enough money to cover the cost of adding more employees.

“The reason a lot of this happened is physician burnout was significant, especially in primary care,” says Dr. Carmen Lewis, the medical director of the Lowry clinic. The redesigned teams launched earlier this year aim to make doctors’ lives less stressful.

Patients across the UCHealth system don’t seem to mind the change. A few will ask to speak with their doctor in private, but others are more open with the medical assistant than with their doctor. “Sometimes, they don’t feel as judged,” Peterson says.

Lin says that since he’s started working with Peterson, his patients have been better able to keep their blood pressure and diabetes under control. “Patients will forget to tell me that they’re out of prescriptions,” he says—or he’ll be so busy tackling a more immediate problem that he’ll forget to ask.

With a medical assistant methodically asking all the opening questions, crucial details such as prescription renewals no longer slip through the cracks.

Rethinking medical school

Medical school leaders want to make sure the next generation of doctors has the skills and mind-set the jobs of the future will require—such as the ability to lead teams effectively, draw insights from data sets and guide patients through a system full of bewildering treatments, care settings and payment options.

Students traditionally spend the first two years of medical school learning science in classrooms and two years getting hands-on experience at clinical sites. That’s no longer enough, says Susan Skochelak, group vice president for medical education at the American Medical Association.

She says students need to understand “health system science”—everything from how health insurance works to how factors such as income and education affect health. “We had medical students who were graduating, not knowing the difference between Medicare and Medicaid,” she says.

So in 2013 the AMA began issuing grants to medical schools that wanted to do things differently. One program allowed Indiana University to put anonymous patient data into an electronic health record students can use to search for clues to a patient’s health—such as whether he is showing signs of opioid addiction. Another grant allowed Pennsylvania State University to create a new curriculum that requires medical students to work as patient navigators.

“Brand new medical students—they totally get the need for this,” says Robert Pendleton, a professor of internal medicine at the University of Utah and the university hospital system’s chief medical quality officer. At this year’s kickoff for an elective curriculum on data and performance measurement, he says, students packed the auditorium.

And all medical schools are trying to emphasize teamwork. At the University of Colorado medical school, the idea that doctors should treat non-doctors as partners—not subordinates—is impressed on students from Day One, says Harin Parikh, a second-year student.

The medical school shares a campus with education programs for six other health professions. Students hang out on the same quad, grab lunch in the same places, and even take some classes together. In a required first-year class, students from a mix of health fields are split into teams and are asked to plan a response to given scenarios. One day, a nursing student might lead the team; the next, a pharmacy student.

Parikh says the team-based approach makes sense to him. “From a provider perspective, it’s about checks and balances,” he says. When multiple people, with different kinds of expertise, come together around a patient, one may notice something the others don’t.

Reorienting medical schools, like reorienting hospital systems, will take time. Scheduling barriers can make it hard to get students from different health fields in one room, for instance. Some faculty members aren’t prepared to teach a new kind of curriculum. And when students leave school for their clinical training, they work in real-life settings that are all over the spectrum when it comes to teamwork.

“We’re working on an ideal,” says John Luk, assistant dean for interprofessional integration at the Dell Medical School at the University of Texas at Austin. “But the reality is, many of us have not been practicing at the ideal.”

Author: Sophie Quinton is a reporter for Stateline, a nonprofit journalism project funded by the Pew Charitable Trusts.

How Workplaces Are Improving Employee Health — And What Millennials Can Do To Help

How Workplaces Are Improving Employee Health — And What Millennials Can Do To Help

How Workplaces Are Improving Employee Health — And What Millennials Can Do To Help

Employee health has always had a big impact on overall company performance, but we’re only now starting to take more proactive action. Poor employee health can cost businesses upwards of $225.8 billion each year, or $1,685 per employee, which includes lost productivity, time off work due to illness, and additional healthcare costs.

Employee health has always had a big impact on overall company performance, but we’re only now starting to take more proactive action. Poor employee health can cost businesses upwards of $225.8 billion each year, or $1,685 per employee, which includes lost productivity, time off work due to illness, and additional healthcare costs.

This figure doesn’t include the costs of lower morale and less energy and interest in work, which could further decrease productivity and increase employee turnover. What’s more, companies with better employee health benefits also benefit from being more attractive to potential candidates, which makes them better performers.

Fortunately, modern workplaces are starting to realize these detrimental effects and are instituting new policies and features to improve employee health. So what measures are being adopted, and how can millennials entering the workforce contribute to better health-focused office cultures?

How Workplaces Are Improving Employee Health

These are just some of the important—and sometimes subtle—features of modern workplaces attempting to improve employee health:

  1. Better air filtration. Indoor air is full of potentially harmful particles, including spores, pollen, dust, dirt, bacteria, allergens, and chemicals from cleaning products. In an office environment, with dozens of people, the air quality is even worse, and can influence the onset of asthma, allergies, and general feelings of discomfort. Thankfully, the solution is pretty simple–installing a high-quality air filter, choosing the right filters, and changing the filters regularly can dramatically improve the quality of the air — not to mention the productivity of employees sensitive to allergens.
  2. Ergonomic seating. Ergonomic seating may seem like a luxury, but it’s an important installation if you care about your employees’ health. Ergonomic seating relieves pressure from the back and neck, and encourages a healthier posture throughout the workday. Over the course of years, ergonomic seating can prevent a multitude of problems, including back pain, hip pain, and even complications like carpal tunnel syndrome.
  3. Walkable offices. You can also have a substantial impact on your employee health by making your office more walkable. This could mean providing more walking opportunities within the office itself, or by choosing an office location central to a downtown area, to encourage more people to walk to work.
  4. Healthy snacks. Some companies are encouraging employees to lead healthier lifestyles by providing healthy snack options in the breakroom. Employees who forget lunch or need a midday pick-me-up can choose from vegetables, nuts, and fruits, rather than candy bars and junk food in the vending machines. This simple change can introduce one extra healthy meal, per day, in the lives of employees.
  5. Leisure and relaxation areas. Don’t forget, there’s a mental and emotional component to health as well. If employees are constantly stressed, with no available outlet, they’re going to be at risk for high blood pressure, heart disease, and countless other complications. To combat this, businesses are doing more to create and maintain leisure and relaxation areas in their main offices, so employees have a chance to sit back, relax, decompress, or even nap to get through an especially tough workday.

How Millennials Can Help

If you’re the CEO or founder of your own company, you have the power to do just about whatever you want to improve your employees’ health; even if it costs several thousand dollars a year, the benefits you institute will likely end up saving you money by improving morale and productivity in the long run.

But if you aren’t in charge, there are still some things you can do to push for proactive, positive changes in your work environments:

  • Introduce healthier food choices. Instead of buying donuts for the office, buy a basket of fresh fruit. If enough of you make healthy food choices regularly enough, it will encourage the entire office to follow suit.
  • Start a ride to work program. Motivate yourself (and others) to ride to work by starting a ride-to-work program. Simply biking to work can provide you with the day’s cardiovascular exercise and keep you in healthy shape.
  • Encourage incidental exercise. You can inspire yourself and your coworkers to get more incidental exercising by going on walks during lunch, taking the stairs instead of the elevator, or even stretching at your desk.
  • Talk to your bosses. Don’t be afraid to speak up about the benefits of better employee health; talk to your bosses about what you can do as an organization to improve it.

Every small change you make to your office environment can have an impact on you and the people around you. Your investments will return to you many times over—especially if you institute these changes early on in your career.

As more businesses invest more in their employees’ health, public pressure will mount for national, cultural changes, and soon, health-centric workplaces will become the new normal.

Original article: FORBES https://goo.gl/jyf3FW

By: Larry Alton

Is Texting Physician Orders 2G2BT?

Is Texting Physician Orders 2G2BT?

Is Texting Physician Orders 2G2BT?

First it was banned, then it was given the green light. Now, it’s been banned again. What’s the future look like for text messaging PHI in a health care environment?

Text messaging has become so ingrained in our daily lives that it’s hardly a surprise the communication tool has made its way into the medical industry. While text messaging holds promise to improve care processes, it also is a major privacy concern with skeptics concerned about the consequences of physicians and nurses text messaging physician orders and other protected health information (PHI) on a regular basis.

First it was banned, then it was given the green light. Now, it’s been banned again. What’s the future look like for text messaging PHI in a health care environment?

Text messaging has become so ingrained in our daily lives that it’s hardly a surprise the communication tool has made its way into the medical industry. While text messaging holds promise to improve care processes, it also is a major privacy concern with skeptics concerned about the consequences of physicians and nurses text messaging physician orders and other protected health information (PHI) on a regular basis.

While the practice was initially banned in 2011, it was permitted again in May 2016, with the thought that technology had advanced enough to allow for completely secure text messaging. Then, in December 2016, the practice was once again banned, with federal officials saying more time is needed for secure implementation.

Is banning the practice of text messaging PHI the best idea, or are there merely a few hurdles that need to be cleared before it can be implemented?

Why Was Secure Text Messaging Banned?
The use of secure text messaging was banned in 2011 due to a lack of usable security protocols. The text messaging applications were unable to verify the sender or store information as a record.

Additionally, any information from a text message had to be manually entered into the patient’s EHR. Information and care orders being sent by text message are difficult to verify, and there’s the potential for patient information to be compromised or lost, or care orders to be incorrectly received or carried out based on a text message. It also was too difficult to verify that the person sending the orders was indeed the attending physician.

The ban was lifted briefly in 2016 but then reinstated a few months later. The Joint Commission determined that more information was needed before a secure text-messaging program could be successfully implemented.

Secure Text Messaging Challenges
Before regaining the trust of The Joint Commission, the secure text messaging of PHI presents health care organizations with several issues, including the following:

• Identity verification: For the concept to be viable, a mechanism must be in place to verify the identity of both the sender and the recipient to ensure the information is going to the correct person.

• Message encryption: Messages sent on the system must be secured through the highest level of encryption.

• Message archiving: Messages should be archived on the device when possible and in the patient’s EHR.

• Secure facility-specific contact lists: Users should not be able to add or delete contacts.

• Accuracy: Transferring the information from text messages to a patient’s EHR leaves the information open to potential transcription errors. With some industry sources estimating an average of 80% of all medical bills contain errors, accurate information transfer or transcription is essential.

It can also be argued that requiring nurses to manually transfer or transcribe information from a text message adds to their already significant workload, making their busy days and nights that much more difficult. Also, skeptics have raised concerns about potential treatment delays in cases where nurses or other health care professionals must text the physician to clarify an issue.

Matthew Werder, chief technology officer at Hennepin County Medical Center in Minnesota, says the challenges are nothing out of the ordinary. “Because the market is still maturing and new players enter the market regularly, challenges are inevitable, but they are being overcome as the technology features are fine-tuned,” he says. “The good news is that there are numerous options, so while it may take some time to make a good choice, it is actually rather exciting to have so many good options to consider.”

Finding Answers
Once the challenges have been identified, how can they be overcome? Is it possible to create a secure text messaging system that protects patient data while still being functional? According to The Joint Commission, the following is a rundown of problems and their possible solutions:

• Identity verification is one of the easiest questions to answer. Most new commercial smartphones are equipped with fingerprint scanners. Pairing a fingerprint scan with a unique alphanumeric password can both secure the device and be used to verify the sender and/or recipient’s identity. These passwords should be changed on a random but regular basis.

• Message encryption should be included on both the sender’s and recipient’s devices, and wireless transmissions must have the highest level of encryption possible. While encryption can be applied individually, employing a security or encryption specialist may achieve better results.

• A message archive should be kept for a specific amount of time as determined by an administrator. The archive must be kept on record in the patient’s EHR and deleted only after either a specific amount of time or at the administrator’s discretion.

• The contact list should be facility specific and incapable of being edited or altered.

• Patient data transferred from a secure text message to an EHR must be accurate. Some form of quality assurance must be performed before the PHI is submitted to the patient’s EHR. If the facility opts not to use transcriptionists or other HIM professionals, it’s possible to implement technology that can transfer PHI directly from a phone to a patient’s file.

“Any new solution such as secure text messaging requires the application of a comprehensive communications strategy,” Werder says. “I personally underestimated the strength of the richness of the pager culture, which has stood the test of time and remains a highly reliable and cost-effective communication solution. Secure texting—like earlier advances—merits a broad view of the benefits it offers to improve enterprise collaboration. Otherwise, it will face some resistance, as previous advances did, because some will view it as unneeded change. In my experience, the technologies on the market today are very intuitive and require little training. Depending on the institution, various policies may need to be modified to establish the guardrails for effective communication through text messages.”

Privacy Concerns
Text messaging in a health care environment raises security questions, mostly due to the nature of the messages, the majority of which are anonymous and impersonal, and can be sent by anyone with a phone. Even after health care organizations have taken steps to secure the transmission of text messages, security lapses can occur. For example, text messages may be directed to the incorrect party.

“It is important for the health care industry—particularly organizations like The Joint Commission—to recognize that secure, ephemeral, and compliant messaging platforms mitigate modern cyber threats, which are increasing in frequency and complexity,” says Galina Datskovsky, PhD, CRM, FAI, CEO of Vaporstream. “An example of one of these threats is mobile ransomware, a recent trend gaining popularity that targets vulnerable SMS communications, which 95% of health care workers use when they don’t have a secure solution available.

“To address the threats head-on, organizations should not only embrace but also require the implementation of secure messaging platforms to collaborate between care giving teams, physicians, specialists, pharmacists, payers, and the patient, since they are specifically designed to utilize text in a HIPAA-compliant manner. These platforms leverage the convenience of mobile text messaging while ensuring the protection of PHI, personally identifiable information, and internet protocol, and seamlessly integrate with EHR systems to streamline workflows and compliance. Once that hurdle is removed, it is important to simplify rollout and integrate into all existing systems to accelerate adoption and increase participation.”

Secure text messaging would seem to have a place in the near future of health care. For example, in a fast-paced environment, such as an emergency department, a quick text message can be an ideal platform to keep physicians and nurses in touch with each other.

“Secure text messages that are immediately and automatically routed to the correct care team member for the particular clinical situation at hand allow care team members to easily communicate and collaborate without the needless disruption that ‘blind’ phone calls/pages create—forcing physicians and nurses to answer calls even if the correspondence is not urgent in nature,” explains Michelle McCleerey, PhD, MA, MEd, MBA, RN, vice president of product management at PerfectServe.

As more vendors target solutions, the push to allow PHI in text messaging will likely grow much stronger, she says. “Given that there are cloud-based secure messaging vendors that have assumed and overcome the challenges of archiving and documenting PHI from text messages, the benefits of text messaging far outweigh any obstacle it would pose to a health care organization,” McCleerey says. “These types of intelligent messages alleviate the need for care team members to search and struggle for the right individual to contact, prevent the wrong individual from being contacted, and eliminate the patient care time wasted waiting for a return call—all of which significantly delay patient care and degrade the patient experience.”

Moving away from and supplementing traditional communication methods has improved workflow at Hennepin County Medical Center, where staff have found text messaging to be effective for mass alert notifications, patient throughput problem solving, quick questions, and patient status updates. “Secure text messaging brings the opportunity for improved collaboration among caregivers and the extended care team,” Werder says. “Traditionally, communication among nurses, physicians, support staff, and others utilized and still use a plethora of technologies, from pagers to overhead announcements. At Hennepin County, we are fully embracing secure messaging for our health care system to improve collaboration and communication pathways among our care teams.”

Work to Be Done
Throughout the business world, text messaging has become a common, convenient communications tool used to keep colleagues connected throughout the day. While text messaging can be just as useful in a medical setting, steps must be taken to ensure patient information is protected before, during, and after transit.

The Joint Commission is in the process of researching and determining the best way to implement secure text messaging in a health care environment. Once a secure system can be ensured, experts believe it may have a significant impact on patient care. However, until issues concerning data security can be resolved, the prospect of health care professionals exchanging patient data via text remains just out reach.

— Kayla Matthews is a writer contributing to conversations about health, technology, and new developments in science. You can follow her on ProductivityBytes.com or on Twitter @KaylaEMatthews.