Containing the Health Costs of the Uninsured - Essay Example

Containing the Health Costs of the Uninsured Health care costs are rising at rate that is exceeding the s' ability to make up the shortfall. These rising costs are also impacted by the rising number of uninsured and the reduction in employer sponsored healthcare policies. Texas has been especially affected by the rising rates of uninsured where the number of uninsured has hit 24.5% (Friedenzohn 2007 p.8). This is 50% above the national average and the highest in the nation. Several states around the country have taken action to contain the costs and limit the expenditures on healthcare. This must be accomplished while maintaining the same level of care. There are five major areas that Texas needs to address to reduce the costs to the state of caring for the uninsured. These areas are prescription drug coverage, technology, managed care, reducing the number of uninsured, and innovative programs. 1. Prescription Drug Coverage There are several aspects of the prescription drug program that need to be reviewed. Currently Texas has a local health care system where the counties are responsible for the healthcare of its residents. Care often falls to charity or safety net hospitals (Uninsured in Texas n.d. p.4). There needs to be more focus on regional and statewide cooperation involving the purchase of prescription drugs. This would provide a centralized point of purchase, which would aid in the negotiating power of the state on drug prices from the pharmaceutical companies. In addition to lower price there needs to be some forms of cost control on the use of prescription drugs. There should be a review of the formulary for drug availability that would exclude some drugs from coverage. These would include cosmetic, hair loss, and investigational drugs. Drugs with a high potential for abuse such as amphetamines and barbiturates should also come under review. These exclusions would have to be accomplished within the current federal guidelines. Generic drug use should also be encouraged. This can be done through physician agreements or through pharmacy contracts. This could be done by mandating the generic substitution or offering an incentive for offering and providing the generic substitute. Educational programs that promote the use of generic substitutes through pharmacies would also be helpful. This would also help reduce public resistance to low cost generic drugs. A preferred drug list of the lowest cost drugs should be utilized to pre-authorize a particular drug. Prior authorization would be necessry for any drug not on the list. Several other state programs have used this approach with some success. It may be seen as a burden to physicians and pharmacists and should be introduced in a step program beginning with non-emergency treatments such as anorexants and anti-ulcer reflux medications (Kaiser Commission 2002 p.9). Emergency supplies for short-term treatment could still be provided without prior authorization. There should also be a 'failed first policy' on prescription drugs. If a new more expensive drug is available, it should not be used until the older and less expensive substitute has been proven ineffective. Fail first programs may not be appropriate for rapidly evolving medications such as used for the treatment of mental illness (Fail-first policies 2003). This program would need to be strictly monitored and have a physician right to supersede it. 2. Technology Improved technology has the potential to save billions of dollars in health care costs. Texas needs to adopt the most recent innovations in medical technology. Shared medical records across a network would aide physicians and emergency rooms in reducing redundant tests and procedures. It also has the capacity to make the most recent knowledge and diagnosis available across the network in a virtual care coordination system. The creation of a cross care coordinated network would be a valuable tool for the uninsured as well as offering health care providers easy access to medical records. A system of community based care centers and clinics could be linked. This would incorporate Texas's complex system of local health care outlets into a single virtual unit, connecting outpatient clinics, hospital-supported community ambulatory centers, and clinics supported by community organizations such as churches, non-profits and community centers (Task force on access to health care in Texas 2006 p.178). Electronic health records would also save time and increase efficiency than paper records. In addition, it would decrease redundant procedures, evaluations, tests, and can provide information to multiple providers across a single platform. "For uninsured patients who often go to several emergency rooms, multiple clinics, or other providers, the EHR can decrease costs of care" (Task force on access to health care in Texas 2006 p.178). 3. Managed Care Electronic health records would also facilitate greater managed care for a variety of long term illnesses can improve the quality of care as well as be a cost saving method. Patients with high blood pressure diabetes are ideal candidates to enter into a managed care program. "Patients in the virtual care coordination system would be enrolled in programs designed to improve their health management, increase their function and minimize their need for hospitalization" (Task force on access to health care in Texas 2006 p.178). The managed care system could also be utilized to provide immunization status and reminders of prescription needs and future appointments. 4. Reducing the Number of Uninsured Texas has the largest percentage of uninsured in the nation. This is due in part to the large number of small business employers in Texas. States in the Northeast, such as Maine, Massachusetts, and Vermont have extended reforms to subsidize coverage for families with incomes up to three times of the federal poverty level (Friedenzohn 2007 p.13). These states have also tailored their programs to reflect the local priorities and instituted reforms that are able to maximize coverage for their distinct population. Employers with 11 or more full-time employees should be required to make a fair contribution toward health care. The state should subsidize a portion based on the employee's annual income. Many of these workers are seasonal and cyclical and there needs to be some accommodation in the program for lapses in coverage. Employers who do not participate can have an option of contributing to a state fund that will be used to privately insure workers in these industries. These insurance policies could be structured under a purchasing pool program much like that used in Montana. Insure Montana "provides a monthly assistance payment for both the employer's and the employee's portion of the health insurance premium" (Friedenzohn 2007 p.22). Under this program, the employer pays must pays a percentage of an employee's policy. Each employee also receives a monthly payment towards their contribution based on their level of income. It is important to note that in Texas, 2 out of 3 uninsured are employed either in a full time or part time capacity (What has happened and what work remains 2005). Though these are low-income positions, there is an opportunity to bring them under a subsidized health insurance plan. 5. Innovative Program Approaches 5.1 Wellness Programs A regimen of wellness programs could save the state considerable dollars by eliminating illness before it begins. Smoking cessation is among the top priorities for promoting good health. Weight gain, particularly among children, is another key concern. Legislation similar to Massachusetts ban on sweetened beverages in school vending machines should be considered. Child well care should be promoted as a means of prevention and alleviating future health care costs. 5.2 EMTALA Emergency Medical Treatment and Active Labor Act (EMTALA) laws require emergency rooms to evaluate every patient who enters them for treatment and mandates that they provide any necessary immediate treatment (EMTALA Overview 2006). The laws were designed to prevent hospitals from dumping patients back into the system at another hospital. This transfers the increased costs and is against the EMTALA laws. Some modification of the EMATALA laws may make the more effective According to the Code Red Report, " Unfortunately, EMTALA has produced a different kind of "dumping." Some physicians do not wish to provide any care to uninsured individuals and routinely refer them to the emergency room for care, thereby transferring responsibility for the patient" (p.158). This places a burden on expensive emergency room treatment that is already over crowded by uninsured patients. 5.3 Emergency Room Management The emergency room is often the first point of contact for the uninsured. There needs to be a program of community clinics that are accessible for patients that do not require emergency treatment. In addition, a pro-active approach of community outreach that can get the patients the needed medical care before it reaches the emergency stage is vital. 6. Additional Programs A quality assurance fee of 3% should be levied on hospital and emergency room revenues. This could generate as much as $1.1 billion. Combined with federal matching funds this could add $2,8 billion to the state general fund to be used for healthcare (Task force on access to health care in Texas 2006 p.173). Increasing funding for medical internships and forgiving student debt for doctors deserving in a public hospital could greatly add to the workforce in the health care industry. Student debt and the low number of residencies have made it difficult to fill these positions. Conclusion Texas is in a position that something must be done to contain the rising cost of the uninsured. A prescription drug program that reviews and regulates the drugs authorized could be effective. Information technology should be utilized to provide a more efficient delivery and monitoring system. Involving the uninsured through education, wellness, and outreach could reduce future spending. EMTALA should be rewritten to prevent physician dumping into the high cost emergency rooms. References EMTALA Overview (2006, April 17). Retrieved March 5, 2007, from http://www.cms.hhs.gov/EMTALA/ Fail-first policies to limit access to medications (2003, February 21). Retrieved March 2, 2007, from http://www.nami.org/Template.cfmSection=policy_research_institute&Template=/ContentManagement/ContentDisplay.cfm&ContentID=6775 Friedenzohn, I. (Ed.). (2007). State of the States. Washington, DC: Academy Health. Retrieved March 2, 2007, from http://www.nonprofithealthcare.org/documentView.aspdocID=690&sid= Kaiser Commission. (2002). Medicaide and the uninsured. L. Elam (Ed.), . Washington, DC: Kaiser Family Foundation. Task force on access to health care in Texas: Challenges of the uninsured and underinsured (2006). Retrieved March 5, 2007, from http://www.coderedtexas.org/ Uninsured in Texas: A call to care (n.d.). Retrieved March 2, 2007, from http://www.chatexas.org/archive/UninsuredinTx_Final.pdf What has happened and what work remains (2005). Retrieved March 5, 2007, from http://www.cppp.org/files/3/HlthCare_FINAL.pdf Read More