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Objectives. We describe the lifetime prevalence and associated health-related concerns of family homelessness among fifth-grade students.
Methods. We used a population-based, cross-sectional survey of 5147 fifth-grade students in 3 US cities to analyze parent-reported measures of family homelessness, child health status, health care access and use, and emotional, developmental, and behavioral health and child-reported measures of health-related quality of life and exposure to violence.
Results. Seven percent of parents reported that they and their child had experienced homelessness (i.e., staying in shelters, cars, or on the street). Black children and children in the poorest families had the highest prevalence of homelessness (11%). In adjusted analyses, most general health measures were similar for children who had and had not been homeless. Children who had ever experienced homelessness were more likely to have an emotional, behavioral, or developmental problem (odds ratio [OR]=1.7; 95% confidence interval [CI]=1.1, 2.6; P=.01), to have received mental health care (OR=2.2; 95% CI=1.6, 3.2; P<.001), and to have witnessed serious violence with a knife (OR=1.6; 95% CI=1.1, 2.3; P=.007) than were children who were never homeless.
Conclusions. Family homelessness affects a substantial minority of fifth-grade children and may have an impact on their emotional, developmental, and behavioral health. (Am J Public Health. 2009;99:1446-1452. doi:10.2105/AJPH. 2008.147785)

An estimated 23% of homeless persons in the United States are children younger than 18 years.1 Of individuals who have experienced an episode of homelessness and used a homelessness assistance program over the course of a year, an estimated 38% are children living with parents.2 Families defined as homeless may be literally homeless (spending the night in emergency shelters, abandoned buildings, cars, on the street, and so on) or precariously housed (at imminent risk of literal homelessness).3,4 Data available on the prevalence of literal homelessness (henceforth referred to as “homelessness”) are generally based on emergency shelter use, requests for emergency shelter use, and nighttime counts of those living on the streets.5 The prevalence of homelessness in US cities ranges from a 1-day prevalence of 0.3% to a 3-year prevalence of 3% (prevalence rates increase as the period of time increases because of rapid turnover among the homeless).4,6-8

Population-based studies have estimated the prevalence of episodic homelessness among adults.9-11 One random-digit-dialing survey of US adults found a 7% lifetime prevalence of homelessness.9 A Philadelphia population-based study linked emergency shelter intake records to all adult women with a recorded live birth over a 2-year period and reported 11% homelessness between 3 years before and 4 years after the birth.10 Unlike studies of currently homeless people, these population-based estimates include individuals who have a history of homelessness.6,8 There are no population-based data that estimate the lifetime prevalence of family homelessness among children.

Studies of children in sheltered, homeless families have shown that many have poor health status, high rates of asthma, high rates of emergency department visits, delays in obtaining preventive care, and high rates of emotional, developmental, and behavioral problems.7,12-17 In most studies, health and health-related outcomes were worse for children in sheltered, homeless families compared with children in the general population. In most studies, homeless children also had worse outcomes compared with low-income housed children, although in a few studies the 2 groups had similar outcomes.18 In a study of 82 families using shelters and transitional housing in King County, Washington, 59% of children had no usual health care provider; these children experienced rates of emergency department visits higher than that of the national rate for children. 13 In another study of 220 homeless families in shelters in Worcester, Massachusetts, homeless children were more likely to be reported in poor to fair health and made more frequent emergency department and outpatient visits than did low-income housed children.12 Other studies have found high rates of developmental delay and emotional or behavioral problems among sheltered children.13,14,19,20

Most data on the health status and needs of homeless children compare currently homeless children and their families residing in emergency shelters with low-income housed children or the general population.12-14 Many poor families may experience1or more episodes of homelessness over a period of time, but most studies have only examined currently homeless children.3,21 No published studies to date have described the lifetime prevalence of homelessness and the associated health and health-related problems of a school-aged, nonsheltered, population-based sample of children. We aimed to describe (1) the lifetime prevalence and characteristics of family homelessness among fifth-grade students and (2) the health and health-related concerns of these students.

METHODS

We analyzed data from Healthy Passages, a Centers for Disease Control and Prevention (CDC)-funded, multisite study of 5147 fifthgrade students that focused on risk factors, protective factors, health behaviors, and health outcomes.22 Interviews for the study were conducted from 2004 through 2006.

Sample

The study population consisted of fifth-grade students enrolled in regular classrooms in public schools with a minimum enrollment of 25 fifth-grade students. The eligible schools were located in 3 areas: (1) 10 contiguous public school districts in and around Birmingham, Alabama; (2) 25 contiguous public school districts in Los Angeles County, California; and (3) the largest public school district in Houston, Texas. This study population represented over 99% of all fifth-grade students in regular public school classrooms in the study districts. We selected a random sample of schools, using probabilities that were a function of how closely a school’s racial/ethnic mix corresponded to the site targets for race/ethnicity. This sampling procedure (described in detail elsewhere22) was used to ensure adequate sample sizes of Hispanic, non-Hispanic Black, and non-Hispanic White children.

A total of 118 schools with 11532 enrolled fifth-grade students were selected with this procedure. Each student’s primary caregiver or parent (henceforth referred to as “parent”) received a letter requesting permission to be contacted by study personnel. Of the 11532 parents, 6663 who either agreed to be contacted or who were unsure were invited to participate in the study; 77% of them (5147) completed an interview. Interviews were conducted at the parent’s home, the study center, or another location chosen by the parent. Prior to the interview, parents gave informed consent for their participation and their child’s participation, and the child also gave assent.

Measures

Each parent-child dyad completed a computer-assisted personal interview and an audio computer-assisted self-interview in English or Spanish. The computer-assisted personal interview is a form of personal interviewing that allows the respondent to answer questions directly into a computer, aided by an interviewer. The audio computer-assisted selfinterview is a modified form of the computerassisted personal interview that is used for more sensitive survey items; respondents hear sensitive questions through headphones and privately respond on the computer. To describe the prevalence of homelessness, we focused on literal homelessness, excluding the precariously housed (parents staying with family or friends to avoid becoming literally homeless).3,9 We excluded this group because these data do not always identify those who are staying with family or friends for other reasons, such as to provide care to an aging parent.7

Parent-reported homelessness and demographics. To assess homelessness, we asked parents, “Have you ever had to stay in one of the following places with your child?” They could choose multiple locations from a list that included emergency shelters, abandoned buildings, public parks, and other nonresidential locations. They also reported the total amount of time they had had to stay in those locations. We also collected sociodemographic data, including parents’ age, household income, and level of education, and children’s age, race/ethnicity, and insurance status.

Some interviews took place after Hurricane Katrina hit the US Gulf Coast in August 2005. Because over 100000 Katrina survivors were relocated to Houston, we examined the data for any increase in homelessness after August 29, 2005, that could be attributed to Katrina.

Parent-reported child health and health care measures. We asked parents to rate their child’s current state of health as excellent, very good, good, fair, or poor. Child health status was dichotomized into good health (excellent, very good, and good) and poor health (fair and poor) to examine differences in homelessness between children in good versus poor health. To assess physical health, we asked parents (1) if their child had had a well-child visit in the past 12 months; (2) if their child had had an emergency department visit in the past 12 months; (3) their child’s usual location for preventive care; (4) their child’s health insurance type, if any; and (5) if their child was injured seriously enough over the past 12 months that he or she was seen by a doctor or a dentist, seen in the emergency department, or admitted to a hospital. For emotional, developmental, and behavioral measures and mental health-related measures, we asked parents if their child (1) had any kind of emotional, developmental, or behavioral problem for which he or she needed or got treatment or (2) had ever received care for emotional, behavioral, or drug or alcohol problems.

Other parent-reported measures. Parents also completed the Brief Symptom Inventory (BSI-18), a validated tool to identify psychological distress in adults.23 This18-item scale contains 3 subscales for depression, anxiety, and somatization; all items are summed and reported as standardized T scores derived from community samples to provide a global severity index. We used published cutoff values validated in previous community samples to identify parents with a level of psychological distress considered to require psychosocial intervention.24

Children’s interviews. Children completed the Pediatric Health-Related Quality of Life Inventory 4.0, a validated tool used to measure health-related quality of life for children aged 2 to 18 years.25 The total score for this 36-item tool measures physical, emotional, social, and school functioning. We dichotomized the total scores to identify children at risk for impaired health-related quality of life, defined previously as a score 1 standard deviation or more below the population mean.26,27 Finally, each child reported whether, in the past 12 months, he or she (1) had been personally threatened or injured with a knife or a gun or (2) had seen someone else so threatened or injured.

Statistical Methods

All analyses employed design and nonresponse weights and accounted for the variance effects of both weights and the clustering of children within sites using Stata version 10 SE (Stata Corp, College Station, TX).28-30 We calculated lifetime prevalence of homelessness in the overall sample and used bivariate analyses to compare the characteristics of ever-homeless and never-homeless children. To examine the racial/ethnic differences in homelessness more closely, we used multiple logistic regression, with homelessness as the dependent variable and other characteristics as covariates.

We also compared ever-homeless and never-homeless children on a variety of health measures, using logistic regression for dichotomous outcomes, ordinal logistic regression for ordered outcomes, and multinomial logistic regression for the unordered multicategory outcomes. We used multivariate versions of these tests to compare never-homeless and ever-homeless children while we controlled for covariates. Parent-reported child covariates were age (8-10 years vs 11-14 years; 93% of children were aged10-11years), gender, race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, other race/ethnicity), health status, and whether insured. Parent covariates included age, education (less than high school, high school graduate or general equivalency diploma [GED], some college or 2-year degree, and 4-year college graduate), household income, household composition (2-parent household, single-parent household, other composition), presence of psychological distress, and language of parent interview (English, Spanish). In these regression models, health and health-related outcomes were the dependent variables and homelessness was the independent variable.

RESULTS

Of 5147 children, 5024 parents answered the questions on homelessness; 7% had experienced homelessness. The prevalence of homelessness was similar across the 3 cities (Table 1). Prevalence was highest among Black children (11%), children from households with incomes under $20000 (11%), and children whose parents had an education level of high school completion (11%). More children were ever homeless in single-parent households (10%) than in 2-parent households (5%). Parents of ever-homeless children were more likely to report psychological distress than were parents of never-homeless children (24% vs 17%; P=.01). There were no differences in the prevalence of homelessness before and after Hurricane Katrina, for Houston or the sample as a whole (data not shown).

In a more detailed examination of the association between child race/ethnicity and a history of homelessness, we used unadjusted regression analyses to conduct comparisons with respect to a reference category (White children). The unadjusted odds of homelessness for Black children (odds ratio [OR]=4.7; 95% confidence interval [CI]=2.7, 8.4; P<.001), Hispanic children (OR=3.1; 95% CI=1.7, 5.5; P=.001), and other children (OR=3.2; 95% CI=1.6, 6.1; P=.001) were greater than for White children. In adjusted analysis, the odds of homelessness remained greater for Black and other children, but not for Hispanic children when compared with White children (data not shown).

Places and Duration of Homelessness

Ever-homeless families reported having to stay in a variety of nonresidential locations, including shelters and transitional housing. Forty percent of ever-homeless families spent at least 6 months homeless (Table 2). Twentyeight percent of ever-homeless families also reported having to stay with family or friends, whereas 14% of the total sample reported only having to stay with family or friends, which, by our definition, made them precariously housed, not homeless (data not shown).

General Health-Related Measures

Table 3 presents differences in general health-related measures between ever-homeless and never-homeless children. In unadjusted regression analyses, ever-homeless children were more likely to have a reported impaired health-related quality of life, to be insured by Medicaid or be uninsured, and to use a clinic or health center as their usual source of preventive care or to have no usual source of care. They were also more likely to have experienced a serious injury in the past12 months. These differences in insurance type, health-related quality of life, and usual location for preventive care were fully accounted for by covariates in multiple and multinomial logistic regression (data not shown). However, after we controlled for covariates, ever-homeless children were more likely to have had a serious injury in the past 12 months (OR=1.5; 95% CI=1.1, 2.1; P=.03).

Emotional, Developmental, and Behavioral Problems and Violence Exposure

Children in ever-homeless families experienced more emotional, developmental, and behavioral problems than did those in neverhomeless families (Table 4). In bivariate and multivariate analyses, ever-homeless children were more likely than were never-homeless children to have a parent-reported emotional, developmental, or behavioral problem (OR=1.7; 95% CI=1.1, 2.6; P=.01), to have ever received care for an emotional, behavioral, or substance abuse problem (OR=2.2; 95% CI=1.6, 3.2; P<.001), and to have witnessed serious violence involving a knife (OR=1.6; 95% CI=1.1, 2.3; P=.007) or a gun (OR=1.5; 95% CI=1.0, 2.1; P =.03) in the past 12 months.

DISCUSSION

The lifetime prevalence of homelessness among fifth-grade students and their families was 7%. Among Black children and children in the poorest households, the prevalence of homelessness was 11%. After control for sociodemographic factors, indicators of general child health were similar for ever-homeless and never-homeless children, whereas indicators of emotional, developmental, and behavioral health were not. Ever-homeless children were significantly more likely to have a parentreported emotional, developmental, or behavioral problem and to have received mental health-related services than were never-homeless children. This association, however, should not be interpreted as causal, because we do not know the temporal relationship between the emotional, developmental, and behavioral problems and the episodes of homelessness.

Although there are no other populationbased studies that describe the lifetime prevalence of homelessness among children, our 7% prevalence is similar to other related estimates and studies. Researchers at the Urban Institute used estimates of the number of homeless persons using homelessness assistance programs in an average week in 1996 to calculate a series of projections for homelessness. They projected that 9% of low-income children experienced family homelessness over a 12-month period.2 Our finding of a 7% lifetime prevalence of homelessness for children is also similar to findings from earlier populationbased studies of adult homelessness. Webb et al., in their study of perinatal women in Philadelphia, reported an 11% prevalence of homelessness during the 3 years before and 4 years after the birth of the child,10 similar to the 9% we found for parents aged 18 to 34 years. That study also showed that Black women experienced more homelessness than did White and Hispanic women.10

In another study of public shelter use in New York and Philadelphia, less than 1% of White children had spent time in a shelter in the previous 3 years, compared with 7% of Black children.8 A random-digit-dialing study of US adults, however, did not find a significant difference in the prevalence of homelessness by race/ethnicity, but it did find that Black adults experienced homelessness of longer duration than did White adults.9 This same study found that most adults with a history of homelessness had been homeless for 4 weeks or more during their lifetime, which is similar to our finding that a majority of families reported cumulative homelessness of over 1month. Although we know the total duration of homelessness experienced by the fifth-grade students with their families, we do not have information on the number of episodes of homelessness experienced or the duration of each.

Although some data suggest that health and health-related outcomes are worse for homeless, sheltered children than for lowincome housed children or the general population of US children, to our knowledge, no previous studies have examined this association among a population-based sample of children. 12-14,19,20 Our study provides the first description of the association between a history of family homelessness and health-related measures among a population-based sample of school-aged children. We found that children with a history of homelessness were more likely to report impaired health-related quality of life; however, this difference was not significant after control for sociodemographic factors. Similarly, differences in usual source of care and insurance were explained by sociodemographics. One possible explanation for the differences between our findings and those of other studies that used convenience samples is that shelterbased convenience samples overrepresent families with longer durations or more-frequent episodes of homelessness.9 Children in these families may differ in health and health care use from children in families that use shelters less frequently or who are not currently homeless. These measures may be worse for children during the actual period of homelessness and improve once families secure a place to live.

Even after we controlled for sociodemographic factors, we found that ever-homeless children were more likely to have emotional, developmental, and behavioral problems. Some studies of sheltered, homeless children have described high rates of emotional, developmental, and behavioral problems.14,15 These findings may be related to the stress that episodes of homelessness place on families, or even to the experience of homelessness (or the conditions that led to it). For instance, we found that ever-homeless children were more likely to have witnessed serious violence and were more likely to have had a serious injury in the past 12 months, even when we controlled for a variety of covariates. The experience of homelessness may itself expose children to stressors that in turn affect their behavioral and emotional development.

It is also possible that the children’s emotional, developmental, and behavioral problems are related to their parents’ mental health. Findings from studies of currently sheltered mothers vary; some have found no differences in the rates of psychological distress, depression, and posttraumatic stress disorder between homeless mothers and low-income housed mothers, but others have found higher rates of these mental health problems among homeless mothers than among low-income housed mothers or the general female US population. 19,31-33 We found a positive association between parental psychological distress and homelessness; however, when we controlled for parental psychological distress in multivariate analysis, ever-homeless children were still more likely to have emotional, developmental, and behavioral problems than were never-homeless children.

We found that ever-homeless children were more likely to have received care for an emotional, behavioral, or substance abuse problem, which may seem counterintuitive. Although we do not have data to explain this finding, we can hypothesize that children may have increased access to some social and health services as a result of accessing homelessness services. It is also possible that children with a history of homelessness have more severe symptoms, which increases the likelihood of receiving mental health services. Increasing access to mental health care is probably only a part of the solution for these families; addressing the housing instability itself will likely be an important part of reducing this mental health disparity.

There are limitations to this study. First, our sample was limited to 3 sites and may not generalize to the US population. Nevertheless, these sites contain urban, suburban, and rural schools in 3 different US regions. Second, there could be nonresponse bias caused by parental nonparticipation; however, our nonresponse weighting likely addressed much of this concern, and it is unlikely that any remaining bias overestimated the prevalence of homelessness. Third, we do not know if the episodes of homelessness occurred before, after, or during many of our outcomes of interest. For example, although ever-homeless children were more likely to have experienced a serious injury in the previous 12 months, the injury may not have coincided with the episodes of homelessness. Fourth, we did not count precariously housed families as homeless. By only considering literal homelessness, we may be underestimating the true prevalence of homelessness that would be captured by the broader definition.

Our findings have important clinical and policy implications. First, we found that a small but significant proportion of fifth-grade students experienced homelessness with their families, with a prevalence as high as 11% in some subpopulations. Our results suggest that in a school of 500 students, 35 of them would have a history of family homelessness, and in a classroom of 28 students, 2 students would have been homeless at some point in their lives. It is critical that health professionals who care for children consider the living environments and limited resources of families that may affect numerous aspects of care, including prescription and over-the-counter medication choice, timing and location for followup visits, and parents’ ability to adhere to recommendations.34 In addition, pediatricians and other health professionals may need to have some knowledge of local resources for families who are homeless or precariously housed.

Second, we found a positive association between a history of family homelessness and emotional, developmental, and behavioral problems. The experience of homelessness may contribute to emotional, developmental, and behavioral problems among school-aged children. In addition to ensuring access to appropriate health services, efforts to help families maintain stable living arrangements may be an important part of providing comprehensive primary care. Finally, a majority of ever-homeless families in our study relied on emergency shelters and transitional housing. Many major urban areas, however, may not have the capacity to provide shelter for them. In 2006, emergency shelters in 20 of 23 surveyed major US cities reported having to turn away homeless families because of a lack of resources.35 Policies on homelessness should ensure that states have the necessary funds to meet the emergency housing needs of poor families

[Reference] » View reference page with links

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Policy and Health Issues in the News

CMS Proposes Rule to Adjust Fee Schedule, Increase Payments for Primary Care

Family physicians could see a Medicare payment increase of 8 percent in 2010, pending approval of a proposed rule from the Centers for Medicare and Medicaid Services (CMS). Under the rule, CMS would adjust the relative values of several Current Procedural Terminology (CPT) codes, which determine the level of payment physicians receive for providing medical, surgical, and diagnostic services. CMS has suggested ceasing payments for most consultation codes and using the savings to increase payments for evaluation and management codes. Additionally, the agency would use more recent data to calculate practice expense relative values, which would lead to higher payments for primary care services. The proposed rule also would eliminate physician-administered drugs from the sustainable growth rate formula. This would make it less expensive to permanently fix the current formula, and create a long-term solution to Medicare physician payment problems. The CMS proposal was published in the July 13, 2009, Federal Register. The final rule is expected to be published on November? 1, 2009, and would take effect on January 1, 2010. For more information, visit http://www.aafp.org/news-now/ government-medicine/20090708cms-cpt-rule.html.

ACIP Members Express Preference for Combination vs. Component Vaccines

The Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) produced several provisional recommendations during a recent meeting. If adopted, final recommendations will appear in future issues of Morbidity and Mortality Weekly Report. Committee members approved a recommendation stating that combination vaccines are generally preferred over separate injections of equivalent component vaccines. However, physicians should also consider patient preference, the potential for adverse events, vaccine storage costs and availability, and the likelihood of patient compliance. The committee made one exception regarding the combined measles, mumps, rubella, and varicella (MMRV) vaccine. Compared with a separate varicella vaccine, the MMRV vaccine has been associated with one more febrile seizure per 2,000 children immunized. Because of this, committee members said children one to three years of age may receive the MMRV vaccine or the MMR vaccine plus a separate varicella vaccine. The committee also voted on vaccine recommendations for postexposure rabies, meningitis, polio, and Japanese encephalitis; and received a briefing on a 13-valent pneumococcal vaccine for children. The new vaccine, which is expected to be licensed by the U.S. Food and Drug Administration, will cover six more serotypes than the current recommended vaccine. For more information, visit http://www.aafp.org/news-now/clinical-care-research/20090708acip-rndup.html.

House Testimony Underscores Importance of Primary Care in Health Reform

Any potential health reform legislation must emphasize the critical role primary care plays in the U.S. health care system, according to American Academy of Family Physicians (AAFP) President Ted Epperly, MD, of Boise, Idaho. During separate testimonies before the House Ways and Means Committee and a House Energy and Commerce health care subcommittee, Epperly described the importance of primary care in providing long-term, high-quality, cost-effective care for the whole person. Epperly also praised the House’s recent draft of a health care reform bill that includes a 5 percent bonus for primary care services and as much as a 10 percent bonus for primary care services provided in a health professional shortage area. To qualify for the bonus, at least 50 percent of a physician’s services must be primary care. Epperly estimates that 68 percent of family physicians would qualify. He also recommended that Congress grant “deemed status” to subspecialties that are, by definition, primary care. This would ensure that only physicians who provide coordinated and comprehensive care receive the bonus. For more information, visit http://www.aafp.org/news-now/government-medicine/20090702epperly-house-test.html.

IOM Publishes Report of Comparative Effectiveness Research Priorities

The Institute of Medicine (IOM) has published a report identifying 100 health-related topics that should receive attention from the recent federal investment in comparative effectiveness research. The report is intended to provide independent guidance to Congress and the secretary of the U.S. Department of Health and Human Services (HHS) on how to spend $400 million that is allotted for research under the American Recovery and Reinvestment Act. The 100 topics are divided into quartiles, which are presented in descending order of importance. The first quartile includes suggestions for care coordination programs, such as the patient-centered medical home and chronic disease management. According to the IOM, comparative effectiveness research weighs the benefits and harms of various ways to prevent, diagnose, treat, or monitor clinical conditions to determine which work best for patients in different settings and circumstances. For more information, visit http://www.aafp.org/news-now/government-medicine/20090707iom-cer-report.html or the IOM report at http://www.nephronline.com/uploaded/reports/cer%20priorities%20list.pdf.

Medical Societies Urge HHS to Include All Preventive Vaccines Under Medicare Part B

The AAFP has joined several medical subspecialty organizations in urging HHS to include all recommended preventive vaccines under Medicare Part B. Currently, some vaccines are only available through Medicare Part D, which is designed as a retail pharmacy benefit. This forces patients to purchase Part D vaccines in their physician’s office, which is considered an out-of-network provider, and then file a claim for reimbursement from their Part D plan. Because of this inconvenience, some patients choose to purchase vaccines from an in-network pharmacy and bring the product to their physician’s office for administration. This practice is considered dangerous because many vaccines must be frozen or refrigerated until just before use, and physicians cannot verify whether the vaccine has been stored properly. For more information, visit http://www.aafp.org/news-now/government-medicine/20090707vaccine-partb- consolidate.html.

AARP Tool Calculates Patients’ Drug Costs, Provides List of Cheaper Medications

A new online tool from the AARP is available to help Medicare Part D beneficiaries avoid a gap in their prescription drug coverage. Known as the “doughnut hole,” the gap occurs after patients have exceeded their basic Medicare Part D coverage but before they reach the catastrophic coverage threshold. To use the calculator, patients provide their zip code, Medicare Part D plan, and current medications. First, the tool calculates patients’ monthly out-of-pocket medication expenses to determine whether their prescription costs will push them into the coverage gap. The tool then searches online drug information databases and peer-reviewed journal articles to develop a list of what AARP calls lower-priced but therapeutically similar medications. Patients may print out personalized letters with the list of medications to discuss with their physicians. The AAFP’s Practice Support Division has reviewed the tool and cautions physicians that the list of medications is based solely on economic reasons without consideration of the patient’s medical history. For more information, visit http://www.aafp.org/news-now/ practice-management/20090708donut-hole-tool.html or the AARP tool at http://doughnuthole.aarp.org/.

Payment Expert Links Medical Home to Lower Costs, Fewer Hospital Readmissions

Patient-centered medical homes should take responsibility for reducing hospital readmissions, according to Harold Miller, president and CEO of the Network for Regional Healthcare Improvement and executive director of the Center for Healthcare Quality and Payment Reform. Speaking at a forum on payment reform sponsored by the Robert Wood Johnson Foundation, Miller said that improving the delivery of primary care services and reducing hospital readmissions will create a clear case for funding the medical home model. Miller explained that the majority of preventable readmissions involve patients with chronic conditions, making chronic disease a major driver of health care costs. He pointed to studies showing that simple interventions in the medical home model, such as patient education, self-management support, and immunizations, can lead to reductions in admissions and readmissions. Miller also addressed the need for a physician payment model that provides incentives for controlling health care costs. For more information, visit http://www.aafp.org/news-now/practice-management/20090624miller-forum.html.

AMA Delegates Reject Call for More Research on Vaccines and Autism

The American Medical Association (AMA) House of Delegates recently rejected a proposal to review the most recent research on vaccines and autism. The proposal was included in a resolution submitted by the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and the American Academy of Psychiatry and the Law. In its concluding report, the AMA reference committee asserted that the relationship between vaccines and autism has already been studied extensively, and there is sufficient research demonstrating that the two are not linked. The resolution also recommended that the AMA reaffirm its support for universal vaccination and continue to support research into the etiology and treatment of autism. Delegates overwhelmingly agreed to accept these resolves. For more information, visit http://www.aafp.org/news-now/health-of-the-public/20090626ama-vaccines.html.

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Shortly after visiting U.S. troops in Iraq in April, President Barack Obama ad- dressed an authence of wounded veterans to announce the government’s progress in its effort to streamline the military’s health- care system by transitioning to electronic health records of active-duty troops and vet- erans, part of the Joint Virtual Lifetime Electronic Initiative between the Department of Defense and the Department of Veterans Affairs. The president said the plan should help reduce the current six-month backlog in disability claims at the VA and lower other bureaucratic hurdles veterans now face.

“The Department of Defense and the Department of Veterans Affairs have taken a first step towards creating one unified lifetime electronic health record for members of our armed services that will contain their administrative and medical information-from the day they enlist to the day that they are laid to rest,” the president said. “Currently, there is no comprehensive system in place that allows for a streamlined transition of health records between DoD and the VA. And that’s why I’m asking both departments to work together to define and build a seamless system of integration with a simple goal: When a member of the Armed Forces separate from the military, he or she will no longer have to walk paperwork from a DoD duty station to a local VA health center; their electronic records will transition along with them and remain with them forever.”

The president said his proposed budget includes the largest single-year increase in VA funding in three decades and supports an unprecedented effort to address posttraumatic stress disorder. In addition to the 33,000 wounded in the wars the nation is currently fighting, demand for VA medical services continues to rise from the millions of veterans from World War II, Korea, Vietnam and the first Gulf War.

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This issue is mostly about the best parts of the healthcare system. Of course, there’s another side to the story. We’re publishing our annual ranking of America’s Best Hospitals at a moment when America’s entire health industry is under the microscope. President Obama has decided that now is the opportunity to change the way the country gets its healthcare. He has opened up a trunkful of arguments, most notably about cost, effectiveness, and fairness. The debate will be with us for months to come, if not longer.

Our hospital rankings have long provided some important benchmarks at the top end of the quality spectrum. We looked in depth at nearly 5,000 of the nation’s hospitals and selected the top performers in key specialties, as well as those rare few that do many things with excellence. We have also continued the separate rankings of children’s hospitals that we began two years ago.

Besides the numbers, we look at some of the people and technologies that are improving medical care. The surgical robot on the cover is just one example of what we’re starting to see in regular use. Laser surgery, body scans, and indestructible replacement parts for aging bodies are all becoming common. Many of the improvements have to do with communication, long a shortcoming in medical institutions. Patient data can be sent where they are needed more quickly. Doctors and equipment can be tracked in hospital hallways. Telemedicine, which allows specialists to diagnose patients far away, is gaining critical mass. Big investments by the best hospitals are cutting error rates and improving patient outcomes.

We also know, as we’ve reported for years, that technology alone won’t solve our problems. For every “best hospital” there are plenty of not-so-good hospitals. And even the best are criticized for often being among the costliest. After all, the cost of a life is what so much of this debate comes down to–and why it’s so difficult to resolve. Healthcare is infinitely perfectible and therefore infinitely costly. How do you put a limit on it? Should you? Does someone at some point have to say, “No, that’s all the care you are entitled to?” And who would that person be?

Of course, there are other factors. Our aging population creates unforeseen challenges, to say nothing of our gross national obesity epidemic. Medicare has changed the nature of doctors’ practices, while malpractice suits have imposed stiff costs on them. Many Americans lack health insurance, though the reasons aren’t always simple.

I’d like to hear your thoughts on the healthcare debate. What is on your list of the best ways to make the system more effective and efficient?

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In the 1980s, if you had a heart attack and got to the hospital, you had about a 60 percent chance of living a year. Today, it is over 90 percent. We have been able to transform the health of the American public because of the rapid development of new medicines and technology. These innovations have come at a cost: They are responsible for as much as two thirds of the annual spending increases in healthcare. We’d like to get back to the costs of 1980, but nobody is willing to go back to 1980 medicine. Americans want the most advanced diagnostic tests, drugs, and surgeries–and doctors want the freedom to prescribe them.

Cost is the central dilemma facing the ambitious plans of President Obama–and the nation–to introduce a universal new system that won’t break the already fractured bank. We have to find the hundreds of billions of dollars (dare we say trillions?) to cover the nearly 50 million people who lack insurance. The president was vague about how he will foot the previously estimated $1.6 trillion bill over the next decade. But our entire political leadership has been set back by the recent Congressional Budget Office estimate, as reported by the Washington Post, that it would cost $1 trillion over the next decade just to cover 16 million uninsured. In effect, this means it would exceed $3 trillion to cover all the uninsured. This has thrown the political calculations about costs into turmoil, particularly since the president has promised that his healthcare program will be deficit neutral.

A costly burden. Obama has been leaving too much to the lawmakers of Congress. The danger is that Congress will pass a bill that isn’t fully paid for and will make the fiscal hole we are in even greater. Then the president will sign the bill with the usual cliché that political compromise is called for, leaving the country with a hugely expensive entitlement program whose cost will burden the nation for generations. Who can forget the Medicare prescription drug bill that saw Congress and the Bush administration work together to impose a massive entitlement without addressing problems in the Medicare system or finding a way to pay for it?

We have come a long way from the days when the cry of “socialized medicine,” led by the medical profession and the insurance industry, scuppered every sensible reform, beginning with President Truman’s. Now the American Medical Association gave Obama a standing ovation even when he said our system is a model that has taken the pursuit of medicine “from a profession–a calling–to a business.” We trust the medical profession to guide us, but he touched a nerve: A dollar saved in costs is a dollar’s loss of income for the profession. Hospitals and doctors account for 62 percent of the soaring costs, and they have shown little interest in taking a hit on their income.

We’d rather trust the doctor than some bureaucrat in a government or insurance office, but it is imperative that the system we devise relates costs to results. Americans receive more costly medical services than people in comparable economies–without noticeable benefit. And there is striking evidence of waste. Costs vary significantly across regions and among hospitals and doctors within regions, and even for those diagnosed with similar conditions. Medicare spending in 2006 varied more than threefold across U.S. regions, mostly because of the volume and intensity of care provided for similar patients. And expenditures in the final six months of life are nearly twice as high for Medicare patients at the top academic hospitals, again with no discernibly better outcome.

Dartmouth researchers conclude that the more costly areas and institutions providing a lot more test services and intensive hospital care don’t have better results for their patients than lower-cost centers; indeed, the patients can suffer from overtreatment. The researchers estimate that up to 30 percent of Medicare spending is wasted on needless care for patients who have little incentive to use less care or shop for lower-cost public services because they don’t pay their medical bills, while providers, doctors, hospitals, and drug companies have no interest in limiting care.

If this, in fact, is the case, then the highest-spending areas could be smoothed down to the lowest-spending areas, theoretically saving as much as $700 billion a year.

How to do that? Some favor government intervention. Instead of having employers shop around for insurance for their workers, we could have the government provide the insurance or at least offer insurance in competition with insurers. This “public choice” would resemble the program that covers federal workers. Having a powerful single player to counter the vested interests, and thus contain costs, is seen as the attraction. The industry is fighting public choice, arguing that a government scheme would enjoy unfair advantages and huge pricing power.

One thing we should do is modify the open-ended fee-for-service system offered by private insurance, Medicare, and Medicaid. It simply encourages everyone involved, consumers and providers, to use more resources than necessary. A typical patient goes to the doctor and has no idea of what anything costs, except that he pays about 15 percent of the bill. The doctor gets paid for everything he does, so he, too, has an incentive to perform costly and sometimes unnecessary procedures–especially when a doctor who omits a test is at risk of a considerable award for damages if a lawyer can convince a jury it amounted to negligence. This is just a small part of an out-of-control medical malpractice system that greatly increases the cost of care. (Yet the Obama administration seems to be taking a pass on this.)

A matter of choice. We just have to have a system that puts more responsibility on the individual and encourages cost-consciousness through higher deductibles and copayments. This is one of the reasons there is no enthusiasm in Congress for a free, comprehensive, centralized system almost entirely funded by tax revenues like the British “single-payer” National Health Service.

The biggest available pool of money to pay for the healthcare reform package is the tax exclusion granted on employer-provided health insurance for 60 percent of Americans. This harks back to when wage controls were introduced during and after World War II and firms offered benefits instead of pay increases. The main benefit was health insurance, which employers bought with pretax dollars. It is not only costly but also inequitable. Self-insured individuals have to pay for similar health insurance with after-tax dollars rather than pretax dollars that companies use, and higher-paid, higher-taxed workers enjoy a comparably larger benefit. This encourages individuals to use healthcare they would not if they had to buy it with after-tax dollars.

Sens. Ron Wyden, a Democrat from Oregon, and Bob Bennett, a Utah Republican, make a strong case for their Healthy Americans Act, which would convert the tax exclusion into a tax benefit for individuals and families so they can shop around and purchase coverage on their own–and would make insurance more portable.

But now politics come into it. Can the exemption be rescinded in the face of strong union opposition? Even a partial cap would be helpful. For example, excluding tax benefits above the current average cost of $13,000 per family would generate $1.1 trillion in additional tax revenues over the next decade. This would still produce significant revenue while avoiding the destabilizing effects of totally eliminating this exclusion. It would also create incentives for firms and insurance companies to redesign their policies so the costs stay below the cap. Safeway has shown it is practical. By giving employees a monetary incentive to judge the value of health spending, Safeway’s costs have stayed flat with no diminution in patient satisfaction, by comparison with a ruinous nearly 40 percent increase at other companies.

In fact, the tax exemption is anachronistic, for employer-based coverage makes workers afraid to change jobs in an economy where flexibility is essential. The chairman of the Senate Finance Committee, Max Baucus of Montana, is apparently open to at least capping the exemption. Congress must simply redirect as much of the vast subsidies now prevalent in a job-based health insurance system as possible.

To inject responsibility into our runaway system, we should insist on an individual mandate for every American to have coverage. Without such a mandate, too many healthy people choose not to pay for insurance, which leaves less money to cover the sick. It can also save money because billions of dollars are spent today on the uninsured who get late and expensive care in emergency rooms. But this means the federal government would have to subsidize people who couldn’t afford it themselves, upping federal costs.

Increased individual responsibility for medical decisions is a key. When people aren’t exposed to the true cost of their care, although it might be paid in forgone wages and higher taxes for public programs, they simply consume more. Increasing cost sharing would discipline the health spending curve. Today, with 84 cents out of every medical dollar spent by someone other than the patient, the insured has little incentive to make cost-conscious decisions.

Who is going to make the hard choices? The president should give more of a lead. Legislators are not good at making the difficult decisions that governing responsibly often requires. They rarely seem capable of asking the voters to sacrifice anything by way of taxes or entitlements or services. We cannot just have public rhetoric from the Obama administration that implies that the problems have been resolved when they haven’t and then enables the White House to claim credit for a legislative success. Rhetoric cannot substitute for real policy.

It would be a disaster to exacerbate federal deficits by placing an increasingly unsustainable burden of additional healthcare entitlements onto the national budget.

The independent Congressional Budget Office must publicly assert that any new health program

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Robert Sakowich’s life is an ongoing calculation, a struggle to wrangle his blood sugar into the safe range. Diagnosed with type 1 diabetes in 1987, the former Polaroid technician, 59, makes every choice–about when and what to eat, when to exercise, how much insulin to inject, and how many glucose tablets to take–with an eye toward hitting “the magic number.” If he misses? Blood sugar spikes make him irritable, and dangerous dips put him into “panic mode,” complete with blurred vision, slurred speech, and the threat of a diabetic coma. Finding himself in this state in the past, the lifelong bachelor from Watertown, Mass., would quickly down some orange juice and phone a neighbor to request a callback in an hour “to make sure I’m still here.” Today, Sakowich enjoys much-improved blood-sugar control, thanks to a woman named Rima, whose last name he doesn’t know and whom he has never met.

Rima is one of a new breed of health professionals–a health coach–tasked with training and cheerleading clients into a state of wellness. The registered nurse, whose full name is Rima Mathewson, works for Health Dialog, a Boston-based company that provides coaching as a benefit through companies and insurance plans to some 24 million people. Health Dialog coaches, 85 percent of whom are registered nurses, have access to insurance claims data so they know, for example, if a client has recently had open heart surgery or hasn’t had a checkup lately to monitor hypertension. Mathewson first called Sakowich after he switched insurance plans in 2007, and she has proved an invaluable source, he says, of practical information and prodding. In a pinch, eight Life Savers should bring too-low blood sugar back into range, for example, or it’s time for an eye exam to identify any diabetes-induced damage. “My primary-care physician doesn’t call me. Specialists? They don’t call,” he says. But Rima, he says, will call “as often as I like.”

Some experts think this kind of personalized attention might go a long way toward managing the health system’s ills, too. Approximately 75 percent of the total U.S. healthcare expense–more than $2 trillion in 2006–is attributable to chronic disease. Yet research has shown that just over half of people with chronic conditions actually get recommended preventive care–aspirin therapy after a heart attack, say. By doing a good job of guiding people like Sakowich, argues Ken Thorpe, a healthcare policy expert who is executive director of the Partnership to Fight Chronic Disease, “you keep people out of the hospital and reduce readmission rates.” As the $1 billion earmarked for prevention in February’s Recovery Act is spent, Thorpe believes, all manner of programs and businesses will sprout up to help people mind their doctor, quit smoking, get active, lose weight.

Wild West. Already there’s a considerable spectrum of offerings, from the Health Dialog model to services of solo entrepreneurs with little or no background in health. “The coaching industry is still the Wild West,” says Sean Slovensky, president and CEO of Cincinnati-based Hummingbird Coaching Services. Hummingbird is hired both by companies (including Google and Adecco Group) that extend the services to employees and by individuals who search online for a weight-loss coach, for example. Such individual coaching costs about $35 to $45 per month. “We are busier now than we were when the economy was good,” Slovensky says.

Hummingbird’s coaching approach is based on the tenets of positive psychology, identifying personal strengths–a high capacity for self-control, resilience, or compassion, for example–and recruiting them to help the cause. The majority of Hummingbird coaches have a master’s in counseling, though some are exercise physiologists or nurses, says Slovensky. On average, Hummingbird clients interact with their coaches four or five times per month by phone, E-mail, instant messaging, or cellphone texts–but not in person. Robin Hardman, a Hummingbird coach in Ontario, Canada, has tackled a range of goals, from helping pregnant women eat more healthfully to getting clients trim and fit enough to go off cholesterol or hypertension medications. The ultimate reward, she says, is watching people reach “ah-ha moments when they realize they have a choice.”

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Americans adore technology. We love our iPods, our Kindles, our TiVos, our Xboxes, and our smartphones. So it’s no surprise that our high-tech infatuation extends to our medical system, where we zap prostate cancer in multimillion-dollar proton-beam therapy centers, implant defibrillators in chests to shock hearts back to life, use robots to perform surgery, and take detailed pictures of every part of our bodies using constantly advancing imaging technology.

The trouble is, we really can’t afford it. Experts say that spending on new health technology–not just fancy machines but also drugs, devices, and procedures–makes up as much as two thirds of the more than 6 percent annual increase in healthcare costs (this year’s costs: $2.5 trillion). “It’s one of the key reasons why U.S. healthcare is so expensive,” says Winifred Hayes, founder and CEO of Hayes Inc., a health technology research and consulting firm. The problem isn’t usually the technology itself but rather its use in certain patients where it hasn’t been shown to help more than cheaper options do–or at all.

Several forces are driving this excess use of high-tech medicine. The most commonly cited: “technology creep.” First, a device, say, gets approved for a high-risk population in which there’s a proven benefit. But its use then expands to lower-risk groups, changing the calculus of clinical and financial risk and reward. “I don’t think we have a lot of technologies that aren’t useful,” says Paul Ginsburg, president of the Center for Studying Health System Change. “Our issue is that some of them are valuable but applied too broadly.”

Take the implantable cardioverter-defibrillator, a battery-operated device that is surgically implanted in the chest. “These were first used for people who had survived” cardiac arrest, explains Rita Redberg, a cardiologist at the University of California-San Francisco. “Now they’re being used for primary prevention”–that is, in people who face some risk of cardiac arrest but haven’t experienced it.

Overstated benefits. A paper published last year in the Journal of the American College of Cardiology suggested the benefits of ICDs have been overestimated and the risks probably understated. In primary prevention trials, about 90 percent of ICDs will never save a life, but recipients still get exposed to risks such as infection and unnecessary shocks, says Roderick Tung, a cardiologist at the University of California-Los Angeles. And at $30,000 each, ICDs are cost-effective only in patients most likely to suffer cardiac arrest, research shows.

Technology creep is also at work in imaging, where the number of CT and MRI scans charged to Medicare increased more than 15 percent annually between 2000 and 2004. Consider CT angiograms, which use multiple X-ray images to form a picture of blockages in arteries and can cost more than $1,000. The most accepted use is to evaluate patients in the ER with chest pain, says Redberg, but some physicians use them to screen people with no symptoms. Yet there’s no solid evidence they prolong or improve the quality of life or that they’re cost-effective, according to Steven Nissen, chair of cardiology at the Cleveland Clinic.

The odd economics of health also abet the spread of technology. Healthcare providers are paid for each procedure or service rather than for improving the total health of patients, which means there’s an incentive to offer more tests and treatments. Hospitals, meantime, compete to attract doctors and patients in part by buying advanced tools, whether or not they’re needed in the community. “Say Hospital A has a PET scanner and an MRI. If Hospital B in the same locale doesn’t have them, Hospital B loses in reputation and volume,” says Melanie Nallicheri, a partner and member of the global health team at management consultancy Booz & Co.

Once a piece of expensive equipment is in place, it will be used. Proton-beam therapy, a kind of radiation requiring an investment of as much as $150 million, has soared in popularity in recent years. “With the current regulations . . . you can use it for any malignancy that needs radiation,” says Theodore Lawrence, chair of radiation oncology at the University of Michigan Medical School. It’s being offered for pediatric cancers and certain rare tumors, which Lawrence feels is appropriate, but mostly for prostate cancer, for which it has never been compared in a head-to-head trial against conventional radiation treatments.

Some technologies are advertised directly to consumers before they’ve been evaluated by the kind of clinical trials that demonstrate whether they’re appropriate for widespread use. The American Cancer Society recommends that most women have mammograms–the regular or digital kind–starting at age 40. Only women with a 20 percent or higher lifetime risk of breast cancer are advised to get an MRI also. And no public-health group recommends screening with ultrasound. But there’s a perception even among women of average risk, says Connie Lehman, direc-tor of breast imaging at Seattle Cancer Care Alliance, that a high-tech test is superior to a mammogram. “If they’re going to go in [to be screened], they want an ultrasound or an MRI,” she says. Ads encouraging women to have more advanced tests have helped sow that perception, she says.

Avoiding lawsuits. Defensive medicine is another factor pushing the heavy use of technology. Obstetricians get sued at a particularly high rate, which is one of the reasons childbirth now involves so many aggressive procedures and tests, says Maureen Corry, executive director of Childbirth Connection, a nonprofit organization that promotes evidence-based maternity care. Just one example of an overused intervention not supported by evidence: constant electronic fetal monitoring during labor. “When you look at all the systematic reviews and all the randomized controlled trials, it has no benefit compared to intermittent monitoring,” says Corry. And it has downsides: a lot of false alarms that lead to more unnecessary care, and a less comfortable labor, since it means women lie flat on their backs. Despite all that, says Corry, constant monitoring is standard practice.

“I understand some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable,” President Obama recently told members of the American Medical Association. He went on to say physicians must be supported in their choices not to order that test.

Reversing the trend toward excessive care, some economists argue, requires a fundamental realignment of our current fee-for-service system toward a system more like the Mayo Clinic’s, which rewards the quality, not quantity, of care. Technology creep might be ameliorated by other changes, such as a higher bar for approval of devices and technology, says Dana Goldman, director of health economics at the Rand Corp. Currently, a device, for example, can reach the market if it’s similar to an already-approved device, whether or not it’s proven to produce better outcomes for patients. More practically, the current system could stand, but patients might pay more depending on whether treatments have been shown to significantly improve health, says Goldman. One sign there may be changes on the payment front: Medicare–whose coverage decisions are often followed by private insurers–recently said it would not pay for CT, or “virtual,” colonoscopies, saying the evidence was inadequate. (Comparative-effectiveness research attempts to provide data on which to base these judgments.)

Hospitals and doctors can also question their own habits. “What we’re really doing is asking people to reflect on their own practice and ask whether what they do makes sense,” says Julie Bynum, a geriatrician at Dartmouth Medical School. At Massachusetts General Hospital in Boston, researchers studied whether a simple software program would help cut the number of outpatient CT and MRI scans and ultrasounds ordered. When a doctor ordered a test, she’d get a score reflecting the level of evidence supporting its use in that particular circumstance. Control still remained in the doctor’s hands, says James Thrall, radiologist-in-chief at MGH, but the annual growth in CT scans declined by 11 percent.

Patients, too, can play a role. There are some sources of comparative information for patients. The Blue Cross and Blue Shield Association conducts effectiveness reviews of technology through its Technology Evaluation Center, all of which are available on its website. The Cochrane Collaboration also publishes effectiveness reviews. And you can start by talking with your doctor when faced with a test, procedure, or anything else. “If you have a physician who isn’t willing to give you a good reason why to do something, you’ve got a problem,” says Bynum. The latest technology or test may be exactly what you need–or there may be a more effective and less pricey alternative. “Technology is great,” says Redberg. “But all technology is not great for all people.”

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Take the headache out of dealing with doctors and insurance companies. These time-saving strategies will get you on the fast track.

QUICK AND EASY are two words not usually associated with health care. Just trying to get a convenient doctor’s appointment can be an ordeal (hello, endless loops of Muzak while on hold for the receptionist). But it’s possible to save time and hassle when dealing with physicians, pharmacies, and even insurance companies–plus get great care to boot–by being a little savvy. The trick isn’t to act like a squeaky wheel. (In fact, complaining to the front desk about how long you have been waiting may actually land you at the back of the line.) “The key to quicker service is knowing how to navigate the systems,” says James King, M.D., board chair of the American Academy of Family Physicians. Here, learn smart tactics for resolving your most frustrating health-care woes.

THE PROBLEM

You can’t afford to waste hours in the waiting room.

TIME-SAVING SOLUTIONS

See an open-access doctor.

Some physicians have started offering their patients same-day appointments instead of scheduling weeks or months in advance. This discourages double booking and unclogs wait time, says Davis Liu, the author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System (Stetho Publishing, $25) and a physician in Sacramento, California, who uses this system in his practice.

Fill out forms beforehand.

Ask the office to fax or e-mail any forms a few days before your visit. Bring them with you to the appointment, completed.

Avoid the busiest times.

Nab the first appointment of the day. “We tend to start on schedule,” says King, “but get behind because it’s impossible to predict how much time each patient will need.” Another good option? The first appointment after lunch. Days to avoid: Mondays, Fridays, and the days before and after holidays.

Call ahead.

Most receptionists are happy to tell you if the doctor is on time and, if not, how much later you should arrive. And if you do get stuck in a packed waiting room, it’s OK to ask if you have time to run an errand without losing your place.

THE PROBLEM

You have a question for your doctor but don’t have an appointment.

TIME-SAVING SOLUTIONS

Speak to your doctor’s nurse or the physician’s assistant.

You’re more likely to get one on the phone quickly. He or she may be able to answer a routine question for you or relay it to the doctor and call back with a response. Be sure to give instructions that it’s OK to leave a message on your voice mail or with a person answering your phone, advises Liu. Privacy laws prevent doctors’ offices from leaving messages with others unless authorized.

Ask if you can e-mail.

Some doctors like to correspond with patients via computer, while others prefer not to out of concerns for patient privacy or fears that an emergency will be missed. The receptionist can tell you if this is a good way to contact your doctor and, if so, approximately how long it will take for her to get back to you.

THE PROBLEM

Staying on top of insurance-claim forms is exhausting.

TIME-SAVING SOLUTIONS

Create a master sheet for each family member.

Fill in a blank form with all the basic information (name, address, birth date) and make several copies. Then, when you need to file a claim, just sign and date a copy and attach the doctor’s portion. Many insurance companies will even allow you to submit claims by fax, so you don’t have to search for an envelope or find time to go to the post office.

Be sure your claim is complete.

Missing details can cause the insurance company to bounce a form back to you. Check that your doctor’s statement includes his tax-identification number. “When a physician leaves this off, it may slow processing of the claim,” says Mary McElrath-Jones, a spokesperson for United Healthcare. And make sure the billed amount is itemized if there were multiple charges.

Enlist tracking software.

Often, even after careful reading, your insurance company’s explanation-of-benefits letter may not explain much at all. A product that helps: Quicken Medical Expense Manager ($50 for Windows only, quickenmedical.com). With a little information from you, it will check your reimbursements, deductibles, and flexible-spending account. And if you’ve been shorted, it will create a customized dispute letter for the insurance company.

THE PROBLEM

You need to fill a prescription and don’t want to wait at the pharmacy.

TIME-SAVING SOLUTIONS

Make sure the pharmacy has your current insurance information.

“Incorrect data is the biggest time drain at pharmacies,” says Kristen Binaso, a registered pharmacist and a spokesperson for the American Pharmacists Association. “If you wait until pickup time to inform the pharmacist that you have a new insurance card, it could add an extra 15 to 20 minutes per prescription.”

Ask if your doctor e-prescribes.

Many doctors are subscribing to services that transmit prescriptions from a computer or a PDA to a pharmacy, cutting down on time and errors. Or ask your doctor to call the prescription into the pharmacy directly.

THE PROBLEM

You have an uncomfortable ailment, and your doctor can’t fit you in for a week.

TIME-SAVING SOLUTIONS

See the nurse or the physician’s assistant.

These professionals work under the guidance of the doctor and can treat simple problems. Some are even able to write prescriptions.

Head to a walk-in clinic.

No appointment is necessary at convenient-care clinics, which are popping up in retail stores and pharmacies across the country. They are generally staffed by nurse-practitioners and may be open every day. Most visits take 15 minutes or less and are typically covered by insurance. “These clinics are ideal for minor problems, checkups, and adult vaccinations,” says King. “But you should always go to your own physician for continuing care of a serious or chronic condition.” To find a clinic, log on to ccaclinics.org or call your local pharmacy.

THE PROBLEM

You need to go to the ER and get treatment stat.

TIME-SAVING SOLUTIONS

Call your primary-care doctor before you go.

She can call the emergency room to let them know you’re coming, explain what kind of care you’ll need, and order tests ahead of time. “Of course, if it’s a true emergency, don’t waste time tracking down your doctor,” says King. “Call 911 immediately.”

Be prepared.

Every ER’s triage system ensures that the sickest are treated fastest, and there’s no way around it. “But having certain information can speed your treatment once you are seen,” says Nicholas Jouriles, M.D., president of the American College of Emergency Physicians. First, always carry your insurance card. Also keep a card in your wallet that lists all your doctors’ contact info and all your current medications, vitamins, herbal supplements, and dosages. “If you can, take along the herbal-supplement bottles,” says Jouriles. “I like to check the ingredients to safeguard against drug interactions.” In addition, bring a personal-health record with all your medical info. This will save time and help prevent treatment errors. Create a free one at medem.com (click on “For Patients,” then “Create an iHealthRecord”). Once complete, it can be printed out and saved online.

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As the discussion regarding health care reform moves through Congress and is debated in the public forum, a new policy statement from the Society for Adolescent Medicine (SAM) urges all parties to include adolescent and young adult health issues in the dialogue.

Says Dr. Mary-Ann Shafer, President of SAM, “Many aspects of health care reform that are needed for adults and for younger children will also help adolescents. But adolescents require special attention and services to promote healthy development and a safe transition to adulthood.”

According to the statement, “Adolescence provides a unique opportunity to prevent health conditions and behaviors with lifelong implications for individual young people and for society… Many adolescents experiment with ‘adult’ behaviors and are increasingly independent in personal habits. These behaviors and habits — such as tobacco and alcohol use, other substance use and abuse, diet, exercise, sexual behavior and driving — have significant implications for health.”

“Unfortunately,” says Dr. Shafer, “adolescents lack health insurance at higher rates than younger children, and young adults have the lowest rate of insurance over the lifespan. We are at a point in the health care reform discussion that promises great opportunities. Innovative proposals have been introduced, and SAM recognizes that many of the ideas on the table will have significant implications for this age group. The visibility for adolescent and young adult health issues must be raised because their needs are compelling.”

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U.S. Department of Health & Human Services (HHS) Secretary Kathleen Sebelius released the first in a series of health care “success story” reports that document innovative programs and initiatives that can serve as models for American health care reform. The inaugural report highlights the Michigan Health & Hospital Association (MHA) Keystone Center for Patient Safety & Quality Intensive Care Unit (MHA Keystone: ICU) project that — through voluntary efforts of Michigan hospitals — helped dramatically reduce the number of health care-associated infections in Michigan ICUs, saving more than 1,500 lives and $200 million over 18 months (see also Blue Cross Blue Shield of Michigan).

“We know there are tremendous examples of efficient, high-quality health care in America today. Our challenge is spreading these good examples across the country,” said Sebelius. “Our reports will showcase success stories like the Michigan Keystone ICU Project and highlight how health reform can improve the quality of care for all Americans.”

“When we enact health reform, we can improve quality, help control costs and ensure success stories like the Michigan Keystone ICU Project become the rule, not the exception,” added Sebelius.

The press release in its entirety can be found at: http://www.hhs.gov/news.

“The Michigan hospitals that participate in the MHA Keystone Center programs have achieved significant, measurable patient safety improvements — lives have been saved and errors have been reduced,” said Spencer Johnson, president of the MHA. “We are pleased to see the success of the MHA Keystone Center hospitals serve as a beacon for other hospitals across the nation. We look forward to sharing best practices and future learnings from other MHA Keystone Center collaboratives already in progress.”

Recently, Blue Cross Blue Shield of Michigan (BCBSM) announced an expansion of its commitment to patient safety and health care quality activities through a $6 million, five-year investment in activities by the MHA Keystone Center. This investment from BCBSM was the second of its kind to MHA Keystone Center in less than four years.

“Statewide collaborations under the banner of the MHA Keystone Center have been instrumental in Michigan’s growing national reputation as a destination for world class health care,” said BCBSM President & CEO Daniel J. Loepp. “The partnership between Blue Cross Blue Shield of Michigan, the MHA Keystone Center and Michigan hospitals is the best example of how collaboration between health plans, hospitals, doctors and other medical professionals can positively affect patient outcomes.”

The MHA Keystone: ICU project improves safety and reduces medical errors in hospital ICUs by reducing central line-associated bloodstream infections and ventilator-associated pneumonia and enhancing communication and culture among clinicians. In four years, the project resulted in nearly

1,800 lives saved, 129,000 excess hospital days prevented and $247 million in medical costs avoided.(1)