Future of Health Care In the US

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From The New England Journal of Medicine, June 4, 1998


(Book :The Future U.S. Healthcare System: Who Will Care for the Poor and Uninsured? by Stuart H. Altman,Uwe E. Reinhardt,Alexandra E. Shields)


There are 43 million uninsured Americans (and millions more underinsured), because the richest country in the world has yet to develop the consensus that would provide every citizen with access to an appropriate range of health care services, regardless of health status or personal income. The problem of the uninsured persists in a country that is enjoying the benefits of one of its most sustained economic expansions and where there is even the prospect of achieving a balanced budget in 1998.

The contributors to this book, one of whom is a physician, present the sobering problem of the uninsured not only as real but also as getting worse. After the 1994 failure of health care reform, a national conference sponsored by the Robert Wood Johnson Foundation was organized to provide a forum to discuss ongoing trends in health care coverage. After the conference, additional papers were solicited to present as complete a picture as possible of the problem and to offer an array of views and recommendations by some of this country's outstanding health economists and policy experts.


The book is organized in five sections. Part I presents the problem and includes a chapter asking if the medically uninsured will always be with us. Part II describes the traditional safety net, which includes health centers, public hospitals, and academic health centers and the strains these organizations are currently experiencing as they are buffeted in a rapidly changing marketplace. Part III explores the changes in hospital ownership, including both investor-owned and not-for-profit organizations. Part IV, in exploring current options for solutions, emphasizes incrementalism. This section includes chapters that present both the positive and the negative features of the increasing state role in addressing the problem. Part V explores more comprehensive solutions, concluding with a philosophical and ethical case for universal health insurance coverage.


Although there is no single chapter devoted to children, a number of the authors note that as of 1994 there were approximately 10 million uninsured children and millions more who were underinsured. As many as 3 million to 3.5 million children were eligible for Medicaid but unenrolled. Some authors come close to predicting the establishment of a program similar to the State Child Health Insurance Program (SCHIP), which was established as part of the 1997 Balanced Budget Act (Title XXI). SCHIP is an example of incrementalism and could provide health insurance for another 3 million to 5 million children. Complete Medicaid enrollment plus SCHIP will still leave 4 million to 6 million children uninsured, since in 1998 the number of uninsured children climbed to 12 million.


Some authors suggest that incrementalism is the American way and that this is perhaps the best this country can do. Since most of the authors by far are economists, readers should not be surprised that relying on incrementalism produces multiple approaches to addressing the issue of the uninsured, some of which are contradictory. The range of views offered adds to the book's value.


Medicare is also discussed in a number of the chapters. Since Medicare, even though it needs financial fine-tuning, is the closest this nation has come to universal coverage, a full discussion would have been helpful. Because of Medicare, people over the age of 65 have access to basic health services without a financial barrier, disparities in the use of health care between high- and low-income Americans have virtually been eliminated, and poverty among those over 65 has been substantially reduced.


There is no in-depth discussion of the health care work force in this book. Therefore, "Who will pay for the poor and the uninsured?" would be a more accurate reflection of the book's content than the subtitle, "Who will care for the poor and the uninsured?"


In summary, as the editors intended, this book is a timely benchmark and contribution to the understanding of why this nation alone in the developed world does not yet provide universal health care coverage. As a result, the future of U.S. health care for all, not just for the poor and uninsured, remains uncertain.

Reviewed by Joel J. Alpert, M.D.


Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.


To heal the wounds of a population that is fatter, older and sicker than ever, it takes more than Band-Aids

By Carla Solberg

Monday, Nov. 26, 2007

On a typical Monday morning at Fairview Southdale's Institute for Wound Healing, the white board in the back hall is filled with the first names of patients who are waiting to see William Omlie, M.D.

A nurse has already removed their dressings, measured and photographed the wounds and, where necessary, placed a temporary bandage to sop up the drainage. Before removing those, Omlie, a vascular surgeon, will slide a bucket up to the edge of the exam table.


Like the patients who bear them, the wounds are all different shapes and sizes. One diminutive, elderly woman has a wound the size of a bar of soap on her calf that looks raw and painful. But she doesn't even flinch as Omlie sets a scalpel, which resembles an X-acto knife, at the edge of the wound and begins to scrape its surface.


"She's tough," he says. She can feel it. Unlike many of Omlie's other patients, her nerves are not impaired.

Omlie's patients — and millions of Americans like them — have created one of health care's fastest-growing markets: wound care. Driven by the surging number of Americans who are diabetic, obese or geriatric, wound care services and products are in high demand.

Wounds can't heal properly without good nutrition, good circulation and a healthy nervous system, three things obese, diabetic or geriatric patients often lack.


Twin Cities wound care clinics proliferating

In the Twin Cities, every major hospital system now operates a wound care clinic that provides wound management on an outpatient basis. Statewide, the number of wound management programs provided by hospitals increased from 34 in 2002 to 60 in 2005, according to the most recent survey data available from the Minnesota Hospital Association. Several more have opened since.

Some hospitals use hyperbaric chambers to speed healing by getting increased oxygen to the wound. During treatment, patients enter a chamber of increased atmospheric pressure and breathe 100 percent oxygen.


Hennepin County Medical Center in Minneapolis and the Mayo Clinic in Rochester both have hyperbaric chambers that are used to treat a variety of ailments, including chronic bone infections, crush injuries, carbon monoxide poisoning, skin grafts and chronic wounds.


"Our business has increased 100 percent over the last seven years," says Jan Derouche, nurse manager of HCMC's hyperbaric medicine department, which draws patients from all over the Midwest. Most have injuries stemming from radiation treatment for cancer, she says, but an increasing number have diabetic ulcers. The diabetic man, in the next room, for example, had no idea that as he strolled the beach in a pair of sandals, he had worn a hole in his big toe about as wide and as deep as a stack of three quarters.


Not all wounds can benefit from hyperbaric treatment, Derouche says. Treatment for those that can is a big commitment. Patients need a two-hour treatment five days a week for six to eight weeks. Some insurers offer coverage for a portion of the cost, which totals $35,000. Without hyperbarics, outpatient treatment, including two weekly visits, runs about $20,000 and can take months or years.

Outpatient wound care fills the service gap between in-home and inpatient care. To qualify for in-home wound care, a patient needs to be immobile. Inpatient treatment is reserved for the most severe wounds. The majority of patients with serious, chronic wounds falls somewhere in between. And their numbers are increasing.



· Nearly 21 million Americans have diabetes. In the United States, a new case is diagnosed every 30 seconds.

· Obesity rates for American adults have doubled since 1980.

· About 60 million adults, or 30 percent of the adult population, are obese, meaning their body mass index is greater than 30.

· Another 60 million are considered overweight, with a BMI of 25 to 29.9.

· Since 1980, overweight rates have doubled for children and tripled for adolescents.

· Since 1990, the number of Americans who are 65 or older has increased 12 percent to 35 million people. That number is expected to double by 2030, as baby boomers begin turning 65 in 2011.

· More than 10 million people 60 or older have diabetes.


By 2009, the wound care market could exceed $11.8 billion, according to Ron Sills, an analyst with Nerac, a research and consulting firm in Tolland, Conn. The market includes: wound vacuums, wound closure strips, staples, skin graft materials and bandages.


One piece of the market where profit margins are extremely low and sometimes nonexistent is the provider end. The doctors and nurses who attend to this messy business don't receive big payments from insurers in exchange for the care they provide.


In fact, Fairview Southdale closed a wound care clinic it ran for 12 years starting in 1989 for financial reasons. But the patients didn't go away. They multiplied. And because their primary care physicians don't have the time to manage their chronic wounds, many of them ended up in the hospital for inpatient treatment which can cost $100,000.


So, in February 2006, Fairview Southdale opened its Institute for Wound Healing. The 16-person staff includes nine nurses, a plastic surgeon, a general surgeon, a vascular surgeon, three podiatrists and an infectious disease specialist.


"We saw 600 new patients in 2006," says Pat Hepner, patient care coordinator and a registered nurse who has been tending wounds since the first clinic opened in 1989.

She, Omlie and the other staff members perform a delicate choreography in the back hall as they enter and exit the exam rooms. On this typical Monday, they are short one person and the waiting room is full.


Carla Solberg reports on local business developments, the health care industry and other topics. She can be reached at carlasolberg [at] msn [dot] com.


Diabetes fifth-leading cause of death -- and rising


By Carla Solberg

Monday, Nov. 26, 2007


Diabetes is a preventable disease with no known cure. It is the fifth-leading cause of death in America and seems determined to storm its way up the rankings.

Raising awareness about it might be the only way Americans can break free of the epidemic grip it has on our country. There are scores of campaigns, locally and nationally, to do just that.

In Minnesota, the HealthEast Foundation chose diabetes care as the recipient of its annual fundraising event in November, says Marsha Hughes, director of diabetes care at HealthEast Care System in St. Paul.


"We've identified a tremendous need here," says Hughes. "We're interested in doing more community-based programs." Offering blood sugar screenings at grocery stores, for example, is one way to get to people before full-blown diabetes gets to them, she says.


Nationwide, the American Diabetes Association launched a huge information campaign in November, dubbing it American Diabetes Month. As the month draws to a close, here are some local and national statistics to consider:


· About 7 percent of Americans have diabetes, and about 5.5 percent of Minnesotans are diabetic.

· Every three minutes, diabetes kills one American and is diagnosed in six others. In Minnesota, the death rate from diabetes increased 50 percent between 1990 and 2000.

· The number of Minnesotans with diabetes increased 45 percent between 1994 and 2003.

· American Indians, African-Americans, Asian Americans and Latino Americans are at a greater risk for developing diabetes than whites.

· If current trends continue, one-third of all Americans and one-half of minorities born in 2000 will develop the disease.

· On average, Americans with diabetes incur medical expenses that are 2.4 times higher than those without the disease.

· Diabetes accounts for 32 percent of all Medicare expenditures.

· In 2002, health care costs for diabetes were $132 billion. By 2020, those costs will approach $192 billion.

· Diabetes care cost Minnesotans $2 billion annually.

· While death rates for stroke, heart disease and cancer have declined since 1987, the death rate from diabetes has increased 45 percent.

· Exercise and a healthy diet can help prevent diabetes.

Sources: Minnesota Department of Health, the American Diabetes Association




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