Bank Coverage vs. Private Coverage. What you need to know!

So let's get on to a mortgage insurance discussion. Did I say mortgage insurance? Ah yes! Yes, it's a unique name given to normal, ordinary life insurance, couched under a very nice sounding name - which makes a whole lot of difference to people wary of "life insurance." So, they're not buying life insurance-no, no, they're buying mortgage insurance. I wish there were many more such unique names for good old Life Insurance which would persuade people to buy life insurance and protect their loved ones and their estates.

Apparently, people do not want to talk about death; so life insurance is the last topic for discussion unless you get a close call from the Creator, by way of a heart attack or stroke. Mortgage insurance is not mandatory at your bank, or anywhere for that matter. All you have to do is sign a waiver and you're off to the races. The waiver releases the lending institution of its obligations to offer you a plan that would take care of your family in the event you had a premature death.

Let's get back to the statistics. Out of 1,000 people aged 30, 125 will die prior to the conclusion of a 25 year mortgage. And surprisingly, despite having this fantastic name to this very important plan there are thousands of families lacking protection and leaving their dependent families open to the risk of losing their homes. I am certainly glad that due to the plans aggressively marketed by the banks, many families are protected. Or else, there would be thousands of unprotected families who would end up homeless.

If a mortgage is not paid immediately, in the event of your death, it will become a huge liability to the family.

Choices: Let's visit the choices your family would have to make in such a situation.

1. Will the surviving spouse/partner carry on the entire burden of the mortgage and will the bank accept the risk? If two incomes together found it difficult to make both ends meets, how can one income possibly be adequate?

2. The family could sell the house, relocate or rent somewhere else. Will there be a buyer for the house? What about the cost involved in selling the house? Will there be enough money after selling or will the family owe the bank?

3. Sell the house and move in with the relatives. Not the best alternative and how many people have philanthropic, generous relatives willing to take in another family? Not many, I can bet.

4. It's an accepted fact that for most people their house is their most valuable asset and they protect it by way of mortgage insurance.

By the way, I'm sure you have heard this statement from a friend saying that someone they knew had died and that the surviving family does not have any money. You can immediately conclude that those folks did not have insurance and must have probably snubbed many insurance advisors like me. If one truly loves his or her family, a mere $15.00 a month can prevent such an eventuality.

o Why take advice from a bank official, whose experience is not insurance?

Before we discuss the nitty-gritty of the plans marketed by the banks and other lending institutions, let's get one thing straight. Would you go to your dentist if you are ill? Or, would you go to your family doctor? True, both are doctors, but their lines of specialty are totally different. Why, then, would a person take advice from a bank official (whose expertise is banking and NOT insurance) to purchase protection of his/her most valuable asset?

Don't get me wrong-bank officers may be extremely knowledgeable in the financial aspects of banking related issues, but insurance issues are far beyond their scope. They are only doing their duty by offering the mortgage plans available.

Therefore, getting advice and signing an extremely important document which can affect your entire family's financial future is something you have to take really seriously. An Insurance Advisor, on the other hand, is qualified to give you better advice on insurance related issues.

o Plans offered by an Insurance Advisor provide coverage that remains level for the term you select.

Mortgage insurance plans offered by banks relate to your mortgage balance, and obviously as your mortgage drops so does your insurance coverage. In this case, if you are happy about reducing your mortgage, remember that the insurance company is equally happy because this reduces their liability.

Individually acquired plans are tailor made for you personally and so, if you are healthy, you get a better rate. Unfortunately, the plans that banks recommend are group plans. It does not matter how healthy you may be compared to others in the group.

o Plans we offer have premiums guaranteed and cannot be changed by the insurer.

As you might be aware, group plan premiums are generally not guaranteed. Mortgage insurance plans are group plans.

o Individual plans do not reduce their benefits and so the premium remains the same.

Mortgage insurance plans offered by banks relate to your mortgage balance, and as your mortgage drops so does your insurance coverage, as mentioned previously. However, the premiums that the bank charges you remain the same. Does this seem fair?

Most bank plans leave the insurance carrier with loopholes to decline your claim.

o Individual plans will require complete medical check-ups done by qualified medical professionals, at the time of application, which will save your beneficiaries from problems later. It also protects your interests and the interests of your beneficiaries at a later date. Qualified Insurance Advisors will coach you on most medical questions so that your answers are accurate and appropriate.

Most bank plans can be set up with a few condensed medical questions-which leaves your bank's insurance carrier with loopholes to decline your claim.

o Our plans do not require you to pay additional PST. The premium offered is the final figure, no PST surprise.

Premiums quoted by group insurance plans do not include Provincial Sales Tax. Therefore, just like the rest of your regular purchases PST sneaks in silently to add to your total. So, when you shop for a price, please take this into consideration. A PST of 8% could buy you a lot of additional insurance coverage OR reduce your cost significantly.

With our plans, the premium offered is the final figure-no PST surprise.

o The plans offered by an Insurance Advisor insure both spouses separately, and so, insurance is paid on both deaths, for instance in a disaster where both the insured die, two separate death claims in the same amount will be paid, thus doubling the benefit.

Bank mortgage plans are "first to die" plans-i.e. the plans pay and cease when one person of the two insured dies. Obviously you would agree that that's the purpose of this insurance. Sure. However, wouldn't you prefer a better option?

For example: a 45 year old male and a 42 year old female insured for a mortgage of $250,000 "first to die" would pay $49.50 per month. By insuring them separately for two amounts, the cost would be about $52.00 per month. Wouldn't you agree that it's worth an additional $2.00 month to double the coverage, so that the beneficiaries receive $500,000? That's the advice you will receive from a qualified insurance professional.

o The plans an Insurance Advisor offers can generally be converted to a permanent plan, without the necessity for further medical evidence. So if you develop a medical condition which would disqualify you for insurance, this feature would be of great importance in the continuation of your insurance policy, thus protecting your family.

Bank mortgage plans are strictly rental (term) plans and that's about it. You do not have a choice.

o Our plans are traditional life insurance policies, the proceeds of which go to a named beneficiary tax free. The insurance policies are creditor proof, thus totally negating undue expenses such as probate fees.

When insurance proceeds from a bank plan are paid towards a property, those proceeds may be open to probate or creditors.

o With traditional life insurance plans, the choice of coverage amount is always yours and does not require mortgage documentations.

Again, as the coverage of bank plans relates to your mortgage balance, you do not have a choice. For instance, if you wanted an extra amount of coverage to protect your family, you would need to purchase it from elsewhere and unnecessarily end up paying an additional amount of money by way of policy fees.

o With the plans an Insurance Advisor offers, the choice of using the benefit amount anyway you choose is yours, and you can make any changes as and when you need. For instance, when you die, your spouse has the option of whether he/she wishes to pay off the mortgage in its entirety or not, as per the spouse's needs at the time.

With a bank policy the bank is the beneficiary; your family has no choice.

o Our plans are portable. They are not tied to any property. They are based on your life-not your house or any other asset.

When you purchase a mortgage insurance plan from a bank, you are confining the coverage to a particular property; hence, the moving to another property requires another contract.

o Refinancing does not affect the insurance plans that an Insurance Advisor will offer.

Refinancing alters your mortgage balance and so the contract of a bank plan stands void. There will be a rate increase in line with your current age, with additional underwriting. You in fact may not be able to get insurance again as your health conditions may have changed.

o We offer you choices of coverage ranging from 5 to 21 critical illnesses with the flexibility of purchasing the amount of coverage that you can afford. Also, you can claim two benefits separately-i.e. if the insured gets a critical illness and claims, then dies after the claim is paid, the death benefit also gets paid.

Some institutions generally add the critical illness benefit to your life insurance coverage, giving you no choice with regard to the amount you may wish to purchase according to what you can afford. It also does not allow you to claim two benefits-i.e. if you collect a claim on a heart attack which is a critical illness benefit and you survive, then the contract ends. Also, the number of critical illnesses covered is limited.

o A qualified Insurance Advisor can draw out a plan which allows you the option to stop paying premiums and still continue your policy.

Bank mortgage insurance plans are term products which have no cash values, and so, if you stop payments, the policy will immediately lapse.

o Most insurance agents will service you effectively and most of all take care of a claim, personally assisting your family when in dire need. Most Insurance Advisors' actions will definitely speak better than bank TV commercials. They will assist you in the creation of an estate and certainly will meet you one-on-one and at your choice of venue or at your home. Basically you have hired the services of a professional in this line for the rest of the term of the plan you have purchased.

Can you recall any bank making personal contact with you such as sending you a birthday card, a calendar, newsletters, or even making a courtesy call, etc.? The only time you would hear from them is possibly at the time of renewal, which would mean an additional sale for them.

It's worth noting that traditional life insurance policies from an Insurance Advisor offer a discount of approximately 9 per cent if the premium is paid annually, thus reducing the cost significantly. This discount factor does not arise with a bank's mortgage insurance plans, which are generally paid on a monthly or biweekly basis.

Health· Health Insurance· Home Improvement· Insurance· Life Insurance

Life Insurance For Mortgages

Bank Coverage vs. Private Coverage. What you need to know!

So let's get on to a mortgage insurance discussion. Did I say mortgage insurance? Ah yes! Yes, it's a unique name given to normal, ordinary life insurance, couched under a very nice sounding name - which makes a whole lot of difference to people wary of "life insurance." So, they're not buying life insurance-no, no, they're buying mortgage insurance. I wish there were many more such unique names for good old Life Insurance which would persuade people to buy life insurance and protect their loved ones and their estates.

Apparently, people do not want to talk about death; so life insurance is the last topic for discussion unless you get a close call from the Creator, by way of a heart attack or stroke. Mortgage insurance is not mandatory at your bank, or anywhere for that matter. All you have to do is sign a waiver and you're off to the races. The waiver releases the lending institution of its obligations to offer you a plan that would take care of your family in the event you had a premature death.

Let's get back to the statistics. Out of 1,000 people aged 30, 125 will die prior to the conclusion of a 25 year mortgage. And surprisingly, despite having this fantastic name to this very important plan there are thousands of families lacking protection and leaving their dependent families open to the risk of losing their homes. I am certainly glad that due to the plans aggressively marketed by the banks, many families are protected. Or else, there would be thousands of unprotected families who would end up homeless.

If a mortgage is not paid immediately, in the event of your death, it will become a huge liability to the family.

Choices: Let's visit the choices your family would have to make in such a situation.

1. Will the surviving spouse/partner carry on the entire burden of the mortgage and will the bank accept the risk? If two incomes together found it difficult to make both ends meets, how can one income possibly be adequate?

2. The family could sell the house, relocate or rent somewhere else. Will there be a buyer for the house? What about the cost involved in selling the house? Will there be enough money after selling or will the family owe the bank?

3. Sell the house and move in with the relatives. Not the best alternative and how many people have philanthropic, generous relatives willing to take in another family? Not many, I can bet.

4. It's an accepted fact that for most people their house is their most valuable asset and they protect it by way of mortgage insurance.

By the way, I'm sure you have heard this statement from a friend saying that someone they knew had died and that the surviving family does not have any money. You can immediately conclude that those folks did not have insurance and must have probably snubbed many insurance advisors like me. If one truly loves his or her family, a mere $15.00 a month can prevent such an eventuality.

o Why take advice from a bank official, whose experience is not insurance?

Before we discuss the nitty-gritty of the plans marketed by the banks and other lending institutions, let's get one thing straight. Would you go to your dentist if you are ill? Or, would you go to your family doctor? True, both are doctors, but their lines of specialty are totally different. Why, then, would a person take advice from a bank official (whose expertise is banking and NOT insurance) to purchase protection of his/her most valuable asset?

Don't get me wrong-bank officers may be extremely knowledgeable in the financial aspects of banking related issues, but insurance issues are far beyond their scope. They are only doing their duty by offering the mortgage plans available.

Therefore, getting advice and signing an extremely important document which can affect your entire family's financial future is something you have to take really seriously. An Insurance Advisor, on the other hand, is qualified to give you better advice on insurance related issues.

o Plans offered by an Insurance Advisor provide coverage that remains level for the term you select.

Mortgage insurance plans offered by banks relate to your mortgage balance, and obviously as your mortgage drops so does your insurance coverage. In this case, if you are happy about reducing your mortgage, remember that the insurance company is equally happy because this reduces their liability.

Individually acquired plans are tailor made for you personally and so, if you are healthy, you get a better rate. Unfortunately, the plans that banks recommend are group plans. It does not matter how healthy you may be compared to others in the group.

o Plans we offer have premiums guaranteed and cannot be changed by the insurer.

As you might be aware, group plan premiums are generally not guaranteed. Mortgage insurance plans are group plans.

o Individual plans do not reduce their benefits and so the premium remains the same.

Mortgage insurance plans offered by banks relate to your mortgage balance, and as your mortgage drops so does your insurance coverage, as mentioned previously. However, the premiums that the bank charges you remain the same. Does this seem fair?

Most bank plans leave the insurance carrier with loopholes to decline your claim.

o Individual plans will require complete medical check-ups done by qualified medical professionals, at the time of application, which will save your beneficiaries from problems later. It also protects your interests and the interests of your beneficiaries at a later date. Qualified Insurance Advisors will coach you on most medical questions so that your answers are accurate and appropriate.

Most bank plans can be set up with a few condensed medical questions-which leaves your bank's insurance carrier with loopholes to decline your claim.

o Our plans do not require you to pay additional PST. The premium offered is the final figure, no PST surprise.

Premiums quoted by group insurance plans do not include Provincial Sales Tax. Therefore, just like the rest of your regular purchases PST sneaks in silently to add to your total. So, when you shop for a price, please take this into consideration. A PST of 8% could buy you a lot of additional insurance coverage OR reduce your cost significantly.

With our plans, the premium offered is the final figure-no PST surprise.

o The plans offered by an Insurance Advisor insure both spouses separately, and so, insurance is paid on both deaths, for instance in a disaster where both the insured die, two separate death claims in the same amount will be paid, thus doubling the benefit.

Bank mortgage plans are "first to die" plans-i.e. the plans pay and cease when one person of the two insured dies. Obviously you would agree that that's the purpose of this insurance. Sure. However, wouldn't you prefer a better option?

For example: a 45 year old male and a 42 year old female insured for a mortgage of $250,000 "first to die" would pay $49.50 per month. By insuring them separately for two amounts, the cost would be about $52.00 per month. Wouldn't you agree that it's worth an additional $2.00 month to double the coverage, so that the beneficiaries receive $500,000? That's the advice you will receive from a qualified insurance professional.

o The plans an Insurance Advisor offers can generally be converted to a permanent plan, without the necessity for further medical evidence. So if you develop a medical condition which would disqualify you for insurance, this feature would be of great importance in the continuation of your insurance policy, thus protecting your family.

Bank mortgage plans are strictly rental (term) plans and that's about it. You do not have a choice.

o Our plans are traditional life insurance policies, the proceeds of which go to a named beneficiary tax free. The insurance policies are creditor proof, thus totally negating undue expenses such as probate fees.

When insurance proceeds from a bank plan are paid towards a property, those proceeds may be open to probate or creditors.

o With traditional life insurance plans, the choice of coverage amount is always yours and does not require mortgage documentations.

Again, as the coverage of bank plans relates to your mortgage balance, you do not have a choice. For instance, if you wanted an extra amount of coverage to protect your family, you would need to purchase it from elsewhere and unnecessarily end up paying an additional amount of money by way of policy fees.

o With the plans an Insurance Advisor offers, the choice of using the benefit amount anyway you choose is yours, and you can make any changes as and when you need. For instance, when you die, your spouse has the option of whether he/she wishes to pay off the mortgage in its entirety or not, as per the spouse's needs at the time.

With a bank policy the bank is the beneficiary; your family has no choice.

o Our plans are portable. They are not tied to any property. They are based on your life-not your house or any other asset.

When you purchase a mortgage insurance plan from a bank, you are confining the coverage to a particular property; hence, the moving to another property requires another contract.

o Refinancing does not affect the insurance plans that an Insurance Advisor will offer.

Refinancing alters your mortgage balance and so the contract of a bank plan stands void. There will be a rate increase in line with your current age, with additional underwriting. You in fact may not be able to get insurance again as your health conditions may have changed.

o We offer you choices of coverage ranging from 5 to 21 critical illnesses with the flexibility of purchasing the amount of coverage that you can afford. Also, you can claim two benefits separately-i.e. if the insured gets a critical illness and claims, then dies after the claim is paid, the death benefit also gets paid.

Some institutions generally add the critical illness benefit to your life insurance coverage, giving you no choice with regard to the amount you may wish to purchase according to what you can afford. It also does not allow you to claim two benefits-i.e. if you collect a claim on a heart attack which is a critical illness benefit and you survive, then the contract ends. Also, the number of critical illnesses covered is limited.

o A qualified Insurance Advisor can draw out a plan which allows you the option to stop paying premiums and still continue your policy.

Bank mortgage insurance plans are term products which have no cash values, and so, if you stop payments, the policy will immediately lapse.

o Most insurance agents will service you effectively and most of all take care of a claim, personally assisting your family when in dire need. Most Insurance Advisors' actions will definitely speak better than bank TV commercials. They will assist you in the creation of an estate and certainly will meet you one-on-one and at your choice of venue or at your home. Basically you have hired the services of a professional in this line for the rest of the term of the plan you have purchased.

Can you recall any bank making personal contact with you such as sending you a birthday card, a calendar, newsletters, or even making a courtesy call, etc.? The only time you would hear from them is possibly at the time of renewal, which would mean an additional sale for them.

It's worth noting that traditional life insurance policies from an Insurance Advisor offer a discount of approximately 9 per cent if the premium is paid annually, thus reducing the cost significantly. This discount factor does not arise with a bank's mortgage insurance plans, which are generally paid on a monthly or biweekly basis.

Introduction: We're Not #1

I believe Americans need a new way of thinking about health. Look where our current perspectives on the subject have gotten us - we are last among the world's 17 most industrialized nations in all the key indicators of health. It's hard to believe but true: we're last in life expectancy; we have the highest rates of obesity, infant mortality, low birth weights, heart disease, diabetes, chronic lung disease, homicide rates, teen pregnancy and sexually transmitted diseases.

The lead author of the Institute of Medicine, NIH sponsored study that revealed this situation remarked that "Americans get sicker, die sooner and sustain more injuries than people in all other high-income countries." (That's a quote from the report.) Then he added this coup de grace: "We were stunned by the propensity of findings all on the negative side - the scope of the disadvantage covers all ages, from babies to seniors, both sexes, all classes of society. If we fail to act, life spans will continue to shorten and children will face greater rates of illness than those in other nations."

Two Ways to Think of Health

I believe Americans are overly passive about their health. Good health can only be attained and maintained by conscious deeds. These deeds require planning and disciple. Examples include exercising regularly and vigorously, dining in ways that nourish the body without causing problems and otherwise behaving in positive, active ways.

The level of health you will enjoy is clearly affected by your lifestyle choices. Your health status depends to a great extent on whether you invest in your well being or not. If you make little or no such investments, your health will depend on chance, genetics, the aging process and the timeliness of the quality of medical care you receive.

If, on the other hand, you do invest, if you seek, protect and defend an advanced state of well being, the nature of the health status you will have will be dramatically different - and better.

Therefore, we need to distinguish these two kinds of health situations - one passive, one active.

The Institute of Health report that places America last reflects that segment of America that is passive. If the quite small segment of the American population that practices active health were separated, if their health data were compiled and compared, I'm sure we would be #1.

For these and related reasons, I propose we view health in two different ways - by making a distinction between static health - which is how most view and approach their health, and earned health. The latter is what you get when you invest wisely in your own well being.

It's a way of life I call REAL wellness.

Health As Currently Perceived

The WHO definition of health is unrealistic (nobody, not even the most devout wellite, enjoys "complete physical, mental and social well-being," at least not every day). Most think of health in far less exalted ways. Most think they are well if they are not sick. This is pathetic. It equates with not needing immediate medical attention. For the vast majority, this is a "good enough" view of health. Thinking that way is a self-fulfilling prophesy. It means that not healthy is the best you can hope for. This is the static definition of health and it must be reformed and at least accompanied by another, comparison perspective for those Americans willing to do their part. That would be earned health.

I think we need ideas about health that remind people of a key fact, namely, that a passive situation is not as effective, desirable, protective or rewarding as a dynamic earned state of health. We should all be aware that static health, the default setting you get for just existing and doing nothing special to enhance health, can and must be reinforced and boosted.

Employing a term like earned health might remind people that health can be much more than non-illness. The term earned health can signal the availability of a richer level of well being. It can remind everyone that health at its best is more than a static condition. Health is a dynamic state; it gets better with effort, worse if ignored.

Earned health represents a higher health standard. Earned health is more ambitious and more consistent with a REAL wellness mindset and lifestyle than the current norm of health as non-sickness.

The Static/Earned Health Continuum

This continuum is another way of expressing Dr. John Travis' original, simple line drawing model of health along a continuum, with "premature death" on the far left side of his continuum) and an ever-changing dynamic of "high level wellness" at the other, right side extreme. The "0" in the middle represents a neutral point, which could be simple non-sickness.

The Static/Earned Health Continuum

-10 ______________ 0 ______________ +10

Earned health is what happens from the neutral point to the +10 indicator. Everyone moves along an imaginary continuum of this kind every day, because health is dynamic, under constant change. By living wisely with the right behaviors, we fuel a state of health that is better than if we allow health status to be determined by the passage of time (i.e., the aging process, chance, medical interventions, circumstances and events.

This continuum is a simple way of depicting the basic fact that earned health evolves largely due to our own efforts to improve and protect our well being; static health, on the other side is affected by what happens to you.

By the way, Dr. Travis made regular expansions to his original model. You can view the latest edition and read more the continuum here. A related construct that will interest wellness enthusiasts is Dr. Travis Wellness Energy System.

Earned health is not determined or advanced by medical interventions. Static health, that is, health along the continuum from the center to the left of the of the continuum, is so influenced.

The Path to REAL Wellness

To become healthier in an earned sense, it's up to us to act so as to move along the right side of the continuum.

The failure to appreciate the different nature of health, earned from static, partly accounts for why America can have so much medical care and yet not enjoy the best quality of health status. After all, modern medicine is a wonderful thing but there are two problems: people expect too much of it and too little of themselves.

Understanding the difference between static and earned health might encourage people to be less passive - to realize the need for and value of REAL wellness lifestyles.

A Fable

Here is a fable to express the limits of medicine to boost health status versus the power of our own behaviors.

Imagine a country where everyone owns high powered luxury cars - they cost next to nothing and are easily replaced. In this mythical country, everyone gets unlimited free medical care of the highest quality, plus all the medications they need plus there are highly skilled trauma teams set up at every intersection. The thing is, the people in this mythical country can do whatever they like - there are no laws governing auto safety. Everyone drives way over the speed limits, nobody wears seat belts, there are no air bags and no stop signs, traffic signals or rules of the road. One more thing - brakes haven't been invented yet.

Interpretation of the Fable

The greatest advances in the mythical society would not follow from introducing more doctors, hospitals, drugs or trauma teams. Changes in customs and driver behaviors would, on the other hand, go a long way to promote a healthier society.

Changes in lifestyles are also the key to better health outcomes in the real world, our country in particular. We have a great health care system - now we need sensible people making wise lifestyle choices that make life not just healthier but more rewarding, more fulfilling and more attractive. We need to help people understand that health is not only a static phenomenon: Earned health offers so much more.

The philosopher Epicurus (c. 341-270 BCE) offered this bit of wisdom long ago: "It is impossible to live pleasurably without living prudently, honorably, and justly; or to live prudently, honorably, and justly, without living pleasurably."

We all want to live pleasurably. Let's recognize and act on the other qualities that enable us to earn active positive health. Let's embrace REAL wellness lifestyles.

Health

There Are Two Kinds of People in the US - Those Who View Health As Static and Those Who Don't

Introduction: We're Not #1

I believe Americans need a new way of thinking about health. Look where our current perspectives on the subject have gotten us - we are last among the world's 17 most industrialized nations in all the key indicators of health. It's hard to believe but true: we're last in life expectancy; we have the highest rates of obesity, infant mortality, low birth weights, heart disease, diabetes, chronic lung disease, homicide rates, teen pregnancy and sexually transmitted diseases.

The lead author of the Institute of Medicine, NIH sponsored study that revealed this situation remarked that "Americans get sicker, die sooner and sustain more injuries than people in all other high-income countries." (That's a quote from the report.) Then he added this coup de grace: "We were stunned by the propensity of findings all on the negative side - the scope of the disadvantage covers all ages, from babies to seniors, both sexes, all classes of society. If we fail to act, life spans will continue to shorten and children will face greater rates of illness than those in other nations."

Two Ways to Think of Health

I believe Americans are overly passive about their health. Good health can only be attained and maintained by conscious deeds. These deeds require planning and disciple. Examples include exercising regularly and vigorously, dining in ways that nourish the body without causing problems and otherwise behaving in positive, active ways.

The level of health you will enjoy is clearly affected by your lifestyle choices. Your health status depends to a great extent on whether you invest in your well being or not. If you make little or no such investments, your health will depend on chance, genetics, the aging process and the timeliness of the quality of medical care you receive.

If, on the other hand, you do invest, if you seek, protect and defend an advanced state of well being, the nature of the health status you will have will be dramatically different - and better.

Therefore, we need to distinguish these two kinds of health situations - one passive, one active.

The Institute of Health report that places America last reflects that segment of America that is passive. If the quite small segment of the American population that practices active health were separated, if their health data were compiled and compared, I'm sure we would be #1.

For these and related reasons, I propose we view health in two different ways - by making a distinction between static health - which is how most view and approach their health, and earned health. The latter is what you get when you invest wisely in your own well being.

It's a way of life I call REAL wellness.

Health As Currently Perceived

The WHO definition of health is unrealistic (nobody, not even the most devout wellite, enjoys "complete physical, mental and social well-being," at least not every day). Most think of health in far less exalted ways. Most think they are well if they are not sick. This is pathetic. It equates with not needing immediate medical attention. For the vast majority, this is a "good enough" view of health. Thinking that way is a self-fulfilling prophesy. It means that not healthy is the best you can hope for. This is the static definition of health and it must be reformed and at least accompanied by another, comparison perspective for those Americans willing to do their part. That would be earned health.

I think we need ideas about health that remind people of a key fact, namely, that a passive situation is not as effective, desirable, protective or rewarding as a dynamic earned state of health. We should all be aware that static health, the default setting you get for just existing and doing nothing special to enhance health, can and must be reinforced and boosted.

Employing a term like earned health might remind people that health can be much more than non-illness. The term earned health can signal the availability of a richer level of well being. It can remind everyone that health at its best is more than a static condition. Health is a dynamic state; it gets better with effort, worse if ignored.

Earned health represents a higher health standard. Earned health is more ambitious and more consistent with a REAL wellness mindset and lifestyle than the current norm of health as non-sickness.

The Static/Earned Health Continuum

This continuum is another way of expressing Dr. John Travis' original, simple line drawing model of health along a continuum, with "premature death" on the far left side of his continuum) and an ever-changing dynamic of "high level wellness" at the other, right side extreme. The "0" in the middle represents a neutral point, which could be simple non-sickness.

The Static/Earned Health Continuum

-10 ______________ 0 ______________ +10

Earned health is what happens from the neutral point to the +10 indicator. Everyone moves along an imaginary continuum of this kind every day, because health is dynamic, under constant change. By living wisely with the right behaviors, we fuel a state of health that is better than if we allow health status to be determined by the passage of time (i.e., the aging process, chance, medical interventions, circumstances and events.

This continuum is a simple way of depicting the basic fact that earned health evolves largely due to our own efforts to improve and protect our well being; static health, on the other side is affected by what happens to you.

By the way, Dr. Travis made regular expansions to his original model. You can view the latest edition and read more the continuum here. A related construct that will interest wellness enthusiasts is Dr. Travis Wellness Energy System.

Earned health is not determined or advanced by medical interventions. Static health, that is, health along the continuum from the center to the left of the of the continuum, is so influenced.

The Path to REAL Wellness

To become healthier in an earned sense, it's up to us to act so as to move along the right side of the continuum.

The failure to appreciate the different nature of health, earned from static, partly accounts for why America can have so much medical care and yet not enjoy the best quality of health status. After all, modern medicine is a wonderful thing but there are two problems: people expect too much of it and too little of themselves.

Understanding the difference between static and earned health might encourage people to be less passive - to realize the need for and value of REAL wellness lifestyles.

A Fable

Here is a fable to express the limits of medicine to boost health status versus the power of our own behaviors.

Imagine a country where everyone owns high powered luxury cars - they cost next to nothing and are easily replaced. In this mythical country, everyone gets unlimited free medical care of the highest quality, plus all the medications they need plus there are highly skilled trauma teams set up at every intersection. The thing is, the people in this mythical country can do whatever they like - there are no laws governing auto safety. Everyone drives way over the speed limits, nobody wears seat belts, there are no air bags and no stop signs, traffic signals or rules of the road. One more thing - brakes haven't been invented yet.

Interpretation of the Fable

The greatest advances in the mythical society would not follow from introducing more doctors, hospitals, drugs or trauma teams. Changes in customs and driver behaviors would, on the other hand, go a long way to promote a healthier society.

Changes in lifestyles are also the key to better health outcomes in the real world, our country in particular. We have a great health care system - now we need sensible people making wise lifestyle choices that make life not just healthier but more rewarding, more fulfilling and more attractive. We need to help people understand that health is not only a static phenomenon: Earned health offers so much more.

The philosopher Epicurus (c. 341-270 BCE) offered this bit of wisdom long ago: "It is impossible to live pleasurably without living prudently, honorably, and justly; or to live prudently, honorably, and justly, without living pleasurably."

We all want to live pleasurably. Let's recognize and act on the other qualities that enable us to earn active positive health. Let's embrace REAL wellness lifestyles.

While consumers search for affordable health insurance, they have price in their mind as the top priority. A general conception among the consumers is that cheap health plans should not be costly-the cheapest health plan available in the market is their target. However, this approach is not good. Sometimes, paying for a cheap health insurance plan but still not getting the required level of coverage results only in wastage of money.

With the implementation of the affordable care act, the reach of affordable health plans is set to increase. Or at least, this is what is believed to be the objective of healthcare reforms. However, lots of consumers are still in confusion about how things would work. In this article, we will discuss some detailed options that consumers can try while looking to buy affordable health plans.

To get a hand on affordable health insurance plans, consumers need to take of certain things. First among them is about knowing the options in the particular state of the residence. There are lots of state and federal government-run programs that could be suitable for consumers. Knowing the options is pretty important. Next would be to understand the terms and conditions of all the programs and check the eligibility criteria for each one of them. Further, consumers should know their rights after the implementation of healthcare reforms, and something within a few days, they may qualify for a particular program or could be allowed to avail a particular health insurance plan. If consumers take care of these steps, there is no reason why consumers can't land on an affordable health plan that could cater to the medical care needs.

Let's discuss some options related to affordable health insurance plans state-wise:

State-run affordable health insurance programs in California

While considering California, there are three affordable health insurance plans that are run by the state government. Consumers can surely get benefitted by these if they are eligible for the benefits.

• Major Risk Medical Insurance Program (MRMIP)

This program is a very handy one offering limited health benefits to California residents. If consumers are unable to purchase health plans due to a preexisting medical condition, they can see if they qualify for this program and get benefits.

• Healthy Families Program

Healthy Families Program offers Californians with low cost health, dental, and vision coverage. This is mainly geared to children whose parents earn too much to qualify for public assistance. This program is administered by MRMIP.

• Access for Infants and Mothers Program (AIM)

Access for Infants and Mothers Program provides prenatal and preventive care for pregnant women having low income in California. It is administered by a five-person board that has established a comprehensive benefits package that includes both inpatient and outpatient care for program enrollees.

Some facts about affordable health insurance in Florida

While talking about affordable health insurance options in Florida, consumers can think about below mentioned options:

• Floridians who lost employer's group health insurance may qualify for COBRA continuation coverage in Florida. At the same time, Floridians, who lost group health insurance due to involuntary termination of employment occurring between September 1, 2008 and December 31, 2009 may qualify for a federal tax credit. This credit helps in paying COBRA or state continuation coverage premiums for up to nine months.

• Floridians who had been uninsured for 6 months may be eligible to buy a limited health benefit plan through Cover Florida.

• Florida Medicaid program can be tried by Floridians having low or modest household income. Through this program, pregnant women, families with children, medically needy, elderly, and disabled individuals may get help.

• Florida KidCare program can help the Floridian children under the age of 19 years and not eligible for Medicaid and currently uninsured or underinsured.

• A federal tax credit to help pay for new health coverage to Floridians who lost their health coverage but are receiving benefits from the Trade Adjustment Assistance (TAA) Program. This credit is called the Health Coverage Tax Credit (HCTC). At the same time, Floridians who are retirees and are aged 55-65 and are receiving pension benefits from Pension Benefit Guarantee Corporation (PBGC), may qualify for the HCTC.

Some facts about affordable health insurance in Virginia

While talking about affordable health insurance options in Virginia, consumers need to consider their rights:

• Virginians who lost their employer's group health insurance may apply for COBRA or state continuation coverage in Virginia.

• Virginians must note that they have the right to buy individual health plans from either Anthem Blue Cross Blue Shield or CareFirst Blue Cross Blue Shield.

• Virginia Medicaid program helps Virginians having low or modest household income may qualify for free or subsidized health coverage. Through this program, pregnant women, families with children, and elderly and disabled individuals are helped.

• Family Access to Medical Insurance Security (FAMIS) helps Virginian children under the age of 18 years having no health insurance.

• In Virginia, the Every Woman's Life Program offers free breast and cervical cancer screening. Through this program, if women are diagnosed with cancer, they may be eligible for treatment through the Virginia Medicaid Program.

Some facts about affordable health insurance in Texas

While talking about affordable health insurance options in Texas, consumers need to consider their rights:

• Texans who have group insurance in Texas cannot be denied or limited in terms of coverage, nor can be required to pay more, because of the health status. Further, Texans having group health insurance can't have exclusion of pre-existing conditions.

• In Texas, insurers cannot drop Texans off coverage when they get sick. At the same time, Texans who lost their group health insurance but are HIPAA eligible may apply for COBRA or state continuation coverage in Texas.

• Texas Medicaid program helps Texans having low or modest household income may qualify for free or subsidized health coverage. Through this program, pregnant women, families with children, elderly and disabled individuals are helped. At the same time, if a woman is diagnosed with breast or cervical cancer, she may be eligible for medical care through Medicaid.

• The Texas Children's Health Insurance Program (CHIP) offers subsidized health coverage for certain uninsured children. Further children in Texas can stay in their parent's health insurance policy as dependents till the age of 26 years. This clause has been implemented by the healthcare reforms.

• The Texas Breast and Cervical Cancer Control program offers free cancer screening for qualified residents. If a woman is diagnosed with breast or cervical cancer through this program, she may qualify for medical care through Medicaid.

Like this, consumers need to consider state-wise options when they search for affordable health coverage. It goes without saying that shopping around and getting oneself well-equipped with necessary information is pretty much important to make sure consumers have the right kind of health plans.

Health

All About Affordable Health Insurance Plans

While consumers search for affordable health insurance, they have price in their mind as the top priority. A general conception among the consumers is that cheap health plans should not be costly-the cheapest health plan available in the market is their target. However, this approach is not good. Sometimes, paying for a cheap health insurance plan but still not getting the required level of coverage results only in wastage of money.

With the implementation of the affordable care act, the reach of affordable health plans is set to increase. Or at least, this is what is believed to be the objective of healthcare reforms. However, lots of consumers are still in confusion about how things would work. In this article, we will discuss some detailed options that consumers can try while looking to buy affordable health plans.

To get a hand on affordable health insurance plans, consumers need to take of certain things. First among them is about knowing the options in the particular state of the residence. There are lots of state and federal government-run programs that could be suitable for consumers. Knowing the options is pretty important. Next would be to understand the terms and conditions of all the programs and check the eligibility criteria for each one of them. Further, consumers should know their rights after the implementation of healthcare reforms, and something within a few days, they may qualify for a particular program or could be allowed to avail a particular health insurance plan. If consumers take care of these steps, there is no reason why consumers can't land on an affordable health plan that could cater to the medical care needs.

Let's discuss some options related to affordable health insurance plans state-wise:

State-run affordable health insurance programs in California

While considering California, there are three affordable health insurance plans that are run by the state government. Consumers can surely get benefitted by these if they are eligible for the benefits.

• Major Risk Medical Insurance Program (MRMIP)

This program is a very handy one offering limited health benefits to California residents. If consumers are unable to purchase health plans due to a preexisting medical condition, they can see if they qualify for this program and get benefits.

• Healthy Families Program

Healthy Families Program offers Californians with low cost health, dental, and vision coverage. This is mainly geared to children whose parents earn too much to qualify for public assistance. This program is administered by MRMIP.

• Access for Infants and Mothers Program (AIM)

Access for Infants and Mothers Program provides prenatal and preventive care for pregnant women having low income in California. It is administered by a five-person board that has established a comprehensive benefits package that includes both inpatient and outpatient care for program enrollees.

Some facts about affordable health insurance in Florida

While talking about affordable health insurance options in Florida, consumers can think about below mentioned options:

• Floridians who lost employer's group health insurance may qualify for COBRA continuation coverage in Florida. At the same time, Floridians, who lost group health insurance due to involuntary termination of employment occurring between September 1, 2008 and December 31, 2009 may qualify for a federal tax credit. This credit helps in paying COBRA or state continuation coverage premiums for up to nine months.

• Floridians who had been uninsured for 6 months may be eligible to buy a limited health benefit plan through Cover Florida.

• Florida Medicaid program can be tried by Floridians having low or modest household income. Through this program, pregnant women, families with children, medically needy, elderly, and disabled individuals may get help.

• Florida KidCare program can help the Floridian children under the age of 19 years and not eligible for Medicaid and currently uninsured or underinsured.

• A federal tax credit to help pay for new health coverage to Floridians who lost their health coverage but are receiving benefits from the Trade Adjustment Assistance (TAA) Program. This credit is called the Health Coverage Tax Credit (HCTC). At the same time, Floridians who are retirees and are aged 55-65 and are receiving pension benefits from Pension Benefit Guarantee Corporation (PBGC), may qualify for the HCTC.

Some facts about affordable health insurance in Virginia

While talking about affordable health insurance options in Virginia, consumers need to consider their rights:

• Virginians who lost their employer's group health insurance may apply for COBRA or state continuation coverage in Virginia.

• Virginians must note that they have the right to buy individual health plans from either Anthem Blue Cross Blue Shield or CareFirst Blue Cross Blue Shield.

• Virginia Medicaid program helps Virginians having low or modest household income may qualify for free or subsidized health coverage. Through this program, pregnant women, families with children, and elderly and disabled individuals are helped.

• Family Access to Medical Insurance Security (FAMIS) helps Virginian children under the age of 18 years having no health insurance.

• In Virginia, the Every Woman's Life Program offers free breast and cervical cancer screening. Through this program, if women are diagnosed with cancer, they may be eligible for treatment through the Virginia Medicaid Program.

Some facts about affordable health insurance in Texas

While talking about affordable health insurance options in Texas, consumers need to consider their rights:

• Texans who have group insurance in Texas cannot be denied or limited in terms of coverage, nor can be required to pay more, because of the health status. Further, Texans having group health insurance can't have exclusion of pre-existing conditions.

• In Texas, insurers cannot drop Texans off coverage when they get sick. At the same time, Texans who lost their group health insurance but are HIPAA eligible may apply for COBRA or state continuation coverage in Texas.

• Texas Medicaid program helps Texans having low or modest household income may qualify for free or subsidized health coverage. Through this program, pregnant women, families with children, elderly and disabled individuals are helped. At the same time, if a woman is diagnosed with breast or cervical cancer, she may be eligible for medical care through Medicaid.

• The Texas Children's Health Insurance Program (CHIP) offers subsidized health coverage for certain uninsured children. Further children in Texas can stay in their parent's health insurance policy as dependents till the age of 26 years. This clause has been implemented by the healthcare reforms.

• The Texas Breast and Cervical Cancer Control program offers free cancer screening for qualified residents. If a woman is diagnosed with breast or cervical cancer through this program, she may qualify for medical care through Medicaid.

Like this, consumers need to consider state-wise options when they search for affordable health coverage. It goes without saying that shopping around and getting oneself well-equipped with necessary information is pretty much important to make sure consumers have the right kind of health plans.

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient's will or without the patient's knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient's circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient's care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation 'in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient's 'needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient's care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient's care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:

• premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician's leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient's home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient's special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient's care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician's plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency's staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient's needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider's personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care' setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider's service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect "problem" employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient's record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient's record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient's obtaining replacement home health care should be emphasized.

6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient's attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient's case should be thoroughly discussed with the home health provider's risk manager, legal counsel, medical director, and the patient's attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence... [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician's order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional's failure to observe, examine, assess, or monitor a patient's condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient's needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient's complaints and failing to follow a physician's orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse's Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).

Health

Patient Abandonment - Home Health Care

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient's will or without the patient's knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient's circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient's care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation 'in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient's 'needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient's care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient's care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:

• premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician's leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient's home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient's special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient's care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician's plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency's staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient's needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider's personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care' setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider's service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect "problem" employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient's record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient's record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient's obtaining replacement home health care should be emphasized.

6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient's attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient's case should be thoroughly discussed with the home health provider's risk manager, legal counsel, medical director, and the patient's attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence... [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician's order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional's failure to observe, examine, assess, or monitor a patient's condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient's needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient's complaints and failing to follow a physician's orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse's Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).

The Affordable Care Act (ACA) mandates that health insurance companies pay for preventive health visits. However, that term is somewhat deceptive, as consumers may feel they can visit the doctor for just a general checkup, talk about anything, and the visit will be paid 100% with no copay. In fact, some, and perhaps most, health insurance companies only cover the A and B recommendations of the U.S. Preventive Services Task Force. These recommendations cover such topics as providing counseling on smoking cessation, alcohol abuse, obesity, and tests for blood pressure, cholesterol, and diabetes (for at risk patients), and some cancer screening physical exams. BUT if a patient mentions casually that he or she is feeling generally fatigued, the doctor could write down a diagnosis related to that fatigue and effectively transform the "wellness visit" into a "sick visit." The same is true if the patient mentions occasional sleeplessness, upset stomach, stress, headaches, or any other medical condition. In order to get the "free preventive health" visit paid for 100%, the visit needs to be confined to a very narrow group of topics that most people will find vert constrained.

Similarly, the ACA calls for insurance companies to pay for preventive colonoscopy screenings for colon cancer. However, once again there is a catch. If the doctor finds any kind of problem during the colonoscopy and writes down a diagnosis code other than "routine preventive health screening," the insurance company may not, and probably will not, pay for the colonoscopy directly. Instead, the costs would be applied to the annual deductible, which means most patients would get stuck paying for the cost of the screening.

This latter possibility frustrates the intention of the ACA. The law was written to encourage everyone - those at risk as well as those facing no known risk - to get checked. But if people go into the procedure expecting insurance to pay the cost, and then a week later receive a surprise letter indicating they are responsible for the $2,000 - $2,500 cost, it will give people a strong financial disincentive to getting tested.

As an attorney, I wonder how the law could get twisted around to this extent. The purpose of a colonoscopy is determined at the moment an appointment is made, not ex post facto during or after the colonoscopy. If the patient has no symptoms and is simply getting a colonoscopy to screen for colon cancer because the patient has reached age 45 or 50 or 55, then that purpose or intent cannot be negated by subsequent findings of any condition. What if the doctor finds a minor noncancerous infection and notes that on the claim form? Will that diagnosis void the 100% payment for preventive service? If so, it gives patients a strong incentive to tell their GI doctors that they are only to note on the claim form "yes or no" in response to colon cancer and nothing else. Normally, we would want to encourage doctors to share all information with patients, and the patients would want that as well. But securing payment for preventive services requires the doctor code up the entire procedure as routine preventive screening.

The question is how do consumers inform the government of the need for a special coding or otherwise provide guidance on preventive screening based on intent at time of service, not on subsequent findings? I could write my local congressman, but he is a newly elected conservative Republican who opposes health care and everything else proposed by Obama. If I wrote him on the need for clarification of preventive health visits, he would interpret that as a letter advising him to vote against health care reform at every opportunity. I doubt my two conservative Republican senators would be any different. They have stand pat reply letters on health care reform that they send to all constituents who write in regarding health care matters.

To my knowledge, there is no way to make effective suggestions to the Obama administration. Perhaps the only solution is to publicize the problem in articles and raise these issues in discussion forums

There is a clear and absolute need for government to get involved in the health care sector. You seem to forget how upset people were with the non-government, pure private sector-based health care system that left 49 million Americans uninsured. When those facts are mentioned to people abroad, they think of America as having a Third World type health care system. Few Japanese, Canadians, or Europeans would trade their existing health care coverage for what they perceive as the gross inequities in the US Health Care System.

The Affordable Care Act, I agree, completely fails to address the fundamental cost driver of health care. For example, it perpetuates and even exacerbates the tendency of consumers to purchase health services without any regard to price. Efficiency in private markets requires cost-conscious consumers; we don't have that in health care.

I am glad the ACA was passed. It is a step in the right direction. As noted, there are problems with the ACA including the "preventive health visits" to the doctor, which are supposed to be covered 100% by insurance but may not be if any diagnostic code is entered on the claim form.

Congress is so polarized on health care that the only way to get changes is with a groundswell of popular support. I don't think a letter writing campaign is the correct way to reform payment for the "preventive health visits." If enough consumers advise their doctors that this particular visit is to be treated solely as a preventive health visit, and they will not pay for any service in the event the doctor's office miscodes the visit with anything else, then the medical establishment will take notice and use its lobbying arm to make Congress aware of the problem.

COMMENT: Should there not be an agreement up front between both parties on what actions that will be taken if said item is found or said event should be seen or occur? Should their be a box on the pre-surgical form giving the patient the right to denying the doctor to take proper action (deemed by whom?) if they see a need to? Checking this box would save the patient the cost of the procedure, and give them time for a consult. If there is not a box to check, why isn't there one?

There are two separate questions posed by the checkbox election for procedures. First, does a patient have a legal right to check such a box or instruct a physician/surgeon orally or in writing that he does not give consent for that procedure to be performed? The answer to that question is yes.

The second question is does it serve the economic interest of the patient to check that box? For the colonoscopy, in theory the patient would get his or her free preventive screening, but then be told the patient needs to schedule a second colonoscopy for removal of a suspicious polyp. In that case, the patient would eventually have to pay for a colonoscopy out of pocket (unless he had already met his yearly deductible), so there is no clear economic rationale for denying the physician the right to remove the polyp during the screening colonoscopy.

But we are using the much less common colonoscopy example. Instead, let's return to preventive care with a primary care doctor. Should a patient have the right to check a box and say "I want this visit to cover routine preventive care and nothing more"? Certainly. There is way too much discretion afforded physicians to code up whatever they want on claim forms such that two physicians seeing the exact same patient might code up different procedures and diagnostics for the exact same preventive health screening visit.

When I expect to receive a "zero cost to me" preventive screening, I do not imply that I am willing to accept a "bait and switch" change of procedure and payment due to the doctor from me. The "zero cost to me" induces consumers to go to the office visit; it is actually paid for out of the profits earned by the health insurance firms to whom consumers pay monthly premiums. Consumers need to hold doctors financially accountable for their claim billing practices. If you are quoted a "zero price" for a visit, the doctor's office better honor that price, or it amounts to fraud.

It is all too easy to find any little old thing to justify billing a patient for a sick visit instead of a wellness visit. However, it is up to the patient to prevent that kind of profiteering at his or her expense.

It would be wonderful if HHS would give carriers the proper code or specify that other diagnostic codes cannot negate the preventive screening code used for a wellness visit. That is not happening now. DHS has been bombarded with so many questions and suggestions for health care reform that the department has a fortress like mentality. So realistically, consumers cannot expect DHS to address the coding issue for preventive health screenings any time soon. That leaves the full burden to fall on each consumer to ensure the doctor's billing practices match the patient's expectations for a free preventive health office visit.

I investigated the web site http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html and discovered some inconsistencies. For example, the site purports to list the services covered under the "preventive health" coverage benefit, yet it omits the annual physical exam. Also, the site states that colorectal cancer screening are provided for people age 50 or older. However, I have been advised in writing that United Healthcare will cover preventive screening colonoscopies for people under age 50. In essence, that government web page is a good start to learn about preventive health care benefits, but a better source would be each consumer's own health insurance carrier. For those with temporary insurance or who are without any insurance coverage, unfortunately, the preventive health benefit of the ACA will not have any practical consequence.

Where will the money come from for the preventive health screening visit to a primary care doctor as well as the screening colonoscopy? We have to look at different scenarios. If the patient indeed has preventive health screenings with no other medical diagnoses, then the patient will be charged $0 for these services, and they will be paid for by the insurance carrier. The insurance carrier will pay these costs out of its operating income or profits. There is simply no other source for payment. The government has not offered to pay the insurance companies for these services.

If the patient is hit with various medical diagnostic codes during these preventive health screenings, then he or she will pay his customary charge for the primary care doctor's office visit and the contract-negotiated price for the diagnostic colonoscopy. In that scenario, the consumer will be paying most of these costs, although the visit to the primary doc may be limited up to any applicable copay amount.

It is not a big shock or surprise to say preventive health care is going to be borne by health insurance carriers. The extent to which these carriers can pass along costs to consumers through higher rates depends on the degree of competition in their markets. Ehealthinsurance.com advises me that for the vast majority of states, the insurance carriers have NOT been able to shift these costs onto consumers through higher rates. That may change in 2013 or 2014. However, the trend is clearly moving in the direction of more power for consumers, more options and carriers available to supply health insurance in their states, which means greater competition and lower prices.

For additional sections of this article, please see http://www.michaelguth.com

Michael A. S. Guth, Ph.D., J.D., directs Health Economics & Outcomes Research (HEOR) at Risk Management Consulting, a contract research organization based in Oak Ridge, Tennessee, where he has successfully managed the HEOR consulting business for the past ten years. He is also a licensed attorney at law with an active practice of more than 200 clients and has developed expertise on the Affordable Care Act and its implementing regulations. Dr. Guth's principal research focus has been preventing the onset of age-related diseases known collectively as the metabolic syndrome. In the area of diabetes, he is familiar with all of the drugs used to treat the disease and their potential drawbacks. Low thyroid hormones (T3 and T4) may represent one of the most unrecognized and under-treated causes of prediabetes status affecting some 75 million Americans. His current research comprises the optimal design of health care insurance and total health/wellness programs including preventive health strategies and employee health engagement and resiliency. Working as part of a global benefits team, he creates an integrated wellness-benefits strategy and executes programs aimed at changing mid- and high-risk behaviors. He positions wellness and disease-prevention as part of a larger strategy for medical cost containment, and contributes innovative ideas for achieving this desired result. He demonstrates thinking "outside the box" to rein in health care spending costs and reform patient utilization of medical services. A second area of current research is the use of Clomiphene in men for hormone modulation to prevent cardiovascular disease and other consequences of the metabolic syndrome. He is Principal Investigator of a clinical study that compares use of Clomiphene with external sources of testosterone given to men; the study includes safety, efficacy, cost, and value comparisons.

Health

Getting Insurance To Pay For Preventive Health Under The ACA

The Affordable Care Act (ACA) mandates that health insurance companies pay for preventive health visits. However, that term is somewhat deceptive, as consumers may feel they can visit the doctor for just a general checkup, talk about anything, and the visit will be paid 100% with no copay. In fact, some, and perhaps most, health insurance companies only cover the A and B recommendations of the U.S. Preventive Services Task Force. These recommendations cover such topics as providing counseling on smoking cessation, alcohol abuse, obesity, and tests for blood pressure, cholesterol, and diabetes (for at risk patients), and some cancer screening physical exams. BUT if a patient mentions casually that he or she is feeling generally fatigued, the doctor could write down a diagnosis related to that fatigue and effectively transform the "wellness visit" into a "sick visit." The same is true if the patient mentions occasional sleeplessness, upset stomach, stress, headaches, or any other medical condition. In order to get the "free preventive health" visit paid for 100%, the visit needs to be confined to a very narrow group of topics that most people will find vert constrained.

Similarly, the ACA calls for insurance companies to pay for preventive colonoscopy screenings for colon cancer. However, once again there is a catch. If the doctor finds any kind of problem during the colonoscopy and writes down a diagnosis code other than "routine preventive health screening," the insurance company may not, and probably will not, pay for the colonoscopy directly. Instead, the costs would be applied to the annual deductible, which means most patients would get stuck paying for the cost of the screening.

This latter possibility frustrates the intention of the ACA. The law was written to encourage everyone - those at risk as well as those facing no known risk - to get checked. But if people go into the procedure expecting insurance to pay the cost, and then a week later receive a surprise letter indicating they are responsible for the $2,000 - $2,500 cost, it will give people a strong financial disincentive to getting tested.

As an attorney, I wonder how the law could get twisted around to this extent. The purpose of a colonoscopy is determined at the moment an appointment is made, not ex post facto during or after the colonoscopy. If the patient has no symptoms and is simply getting a colonoscopy to screen for colon cancer because the patient has reached age 45 or 50 or 55, then that purpose or intent cannot be negated by subsequent findings of any condition. What if the doctor finds a minor noncancerous infection and notes that on the claim form? Will that diagnosis void the 100% payment for preventive service? If so, it gives patients a strong incentive to tell their GI doctors that they are only to note on the claim form "yes or no" in response to colon cancer and nothing else. Normally, we would want to encourage doctors to share all information with patients, and the patients would want that as well. But securing payment for preventive services requires the doctor code up the entire procedure as routine preventive screening.

The question is how do consumers inform the government of the need for a special coding or otherwise provide guidance on preventive screening based on intent at time of service, not on subsequent findings? I could write my local congressman, but he is a newly elected conservative Republican who opposes health care and everything else proposed by Obama. If I wrote him on the need for clarification of preventive health visits, he would interpret that as a letter advising him to vote against health care reform at every opportunity. I doubt my two conservative Republican senators would be any different. They have stand pat reply letters on health care reform that they send to all constituents who write in regarding health care matters.

To my knowledge, there is no way to make effective suggestions to the Obama administration. Perhaps the only solution is to publicize the problem in articles and raise these issues in discussion forums

There is a clear and absolute need for government to get involved in the health care sector. You seem to forget how upset people were with the non-government, pure private sector-based health care system that left 49 million Americans uninsured. When those facts are mentioned to people abroad, they think of America as having a Third World type health care system. Few Japanese, Canadians, or Europeans would trade their existing health care coverage for what they perceive as the gross inequities in the US Health Care System.

The Affordable Care Act, I agree, completely fails to address the fundamental cost driver of health care. For example, it perpetuates and even exacerbates the tendency of consumers to purchase health services without any regard to price. Efficiency in private markets requires cost-conscious consumers; we don't have that in health care.

I am glad the ACA was passed. It is a step in the right direction. As noted, there are problems with the ACA including the "preventive health visits" to the doctor, which are supposed to be covered 100% by insurance but may not be if any diagnostic code is entered on the claim form.

Congress is so polarized on health care that the only way to get changes is with a groundswell of popular support. I don't think a letter writing campaign is the correct way to reform payment for the "preventive health visits." If enough consumers advise their doctors that this particular visit is to be treated solely as a preventive health visit, and they will not pay for any service in the event the doctor's office miscodes the visit with anything else, then the medical establishment will take notice and use its lobbying arm to make Congress aware of the problem.

COMMENT: Should there not be an agreement up front between both parties on what actions that will be taken if said item is found or said event should be seen or occur? Should their be a box on the pre-surgical form giving the patient the right to denying the doctor to take proper action (deemed by whom?) if they see a need to? Checking this box would save the patient the cost of the procedure, and give them time for a consult. If there is not a box to check, why isn't there one?

There are two separate questions posed by the checkbox election for procedures. First, does a patient have a legal right to check such a box or instruct a physician/surgeon orally or in writing that he does not give consent for that procedure to be performed? The answer to that question is yes.

The second question is does it serve the economic interest of the patient to check that box? For the colonoscopy, in theory the patient would get his or her free preventive screening, but then be told the patient needs to schedule a second colonoscopy for removal of a suspicious polyp. In that case, the patient would eventually have to pay for a colonoscopy out of pocket (unless he had already met his yearly deductible), so there is no clear economic rationale for denying the physician the right to remove the polyp during the screening colonoscopy.

But we are using the much less common colonoscopy example. Instead, let's return to preventive care with a primary care doctor. Should a patient have the right to check a box and say "I want this visit to cover routine preventive care and nothing more"? Certainly. There is way too much discretion afforded physicians to code up whatever they want on claim forms such that two physicians seeing the exact same patient might code up different procedures and diagnostics for the exact same preventive health screening visit.

When I expect to receive a "zero cost to me" preventive screening, I do not imply that I am willing to accept a "bait and switch" change of procedure and payment due to the doctor from me. The "zero cost to me" induces consumers to go to the office visit; it is actually paid for out of the profits earned by the health insurance firms to whom consumers pay monthly premiums. Consumers need to hold doctors financially accountable for their claim billing practices. If you are quoted a "zero price" for a visit, the doctor's office better honor that price, or it amounts to fraud.

It is all too easy to find any little old thing to justify billing a patient for a sick visit instead of a wellness visit. However, it is up to the patient to prevent that kind of profiteering at his or her expense.

It would be wonderful if HHS would give carriers the proper code or specify that other diagnostic codes cannot negate the preventive screening code used for a wellness visit. That is not happening now. DHS has been bombarded with so many questions and suggestions for health care reform that the department has a fortress like mentality. So realistically, consumers cannot expect DHS to address the coding issue for preventive health screenings any time soon. That leaves the full burden to fall on each consumer to ensure the doctor's billing practices match the patient's expectations for a free preventive health office visit.

I investigated the web site http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html and discovered some inconsistencies. For example, the site purports to list the services covered under the "preventive health" coverage benefit, yet it omits the annual physical exam. Also, the site states that colorectal cancer screening are provided for people age 50 or older. However, I have been advised in writing that United Healthcare will cover preventive screening colonoscopies for people under age 50. In essence, that government web page is a good start to learn about preventive health care benefits, but a better source would be each consumer's own health insurance carrier. For those with temporary insurance or who are without any insurance coverage, unfortunately, the preventive health benefit of the ACA will not have any practical consequence.

Where will the money come from for the preventive health screening visit to a primary care doctor as well as the screening colonoscopy? We have to look at different scenarios. If the patient indeed has preventive health screenings with no other medical diagnoses, then the patient will be charged $0 for these services, and they will be paid for by the insurance carrier. The insurance carrier will pay these costs out of its operating income or profits. There is simply no other source for payment. The government has not offered to pay the insurance companies for these services.

If the patient is hit with various medical diagnostic codes during these preventive health screenings, then he or she will pay his customary charge for the primary care doctor's office visit and the contract-negotiated price for the diagnostic colonoscopy. In that scenario, the consumer will be paying most of these costs, although the visit to the primary doc may be limited up to any applicable copay amount.

It is not a big shock or surprise to say preventive health care is going to be borne by health insurance carriers. The extent to which these carriers can pass along costs to consumers through higher rates depends on the degree of competition in their markets. Ehealthinsurance.com advises me that for the vast majority of states, the insurance carriers have NOT been able to shift these costs onto consumers through higher rates. That may change in 2013 or 2014. However, the trend is clearly moving in the direction of more power for consumers, more options and carriers available to supply health insurance in their states, which means greater competition and lower prices.

For additional sections of this article, please see http://www.michaelguth.com

Michael A. S. Guth, Ph.D., J.D., directs Health Economics & Outcomes Research (HEOR) at Risk Management Consulting, a contract research organization based in Oak Ridge, Tennessee, where he has successfully managed the HEOR consulting business for the past ten years. He is also a licensed attorney at law with an active practice of more than 200 clients and has developed expertise on the Affordable Care Act and its implementing regulations. Dr. Guth's principal research focus has been preventing the onset of age-related diseases known collectively as the metabolic syndrome. In the area of diabetes, he is familiar with all of the drugs used to treat the disease and their potential drawbacks. Low thyroid hormones (T3 and T4) may represent one of the most unrecognized and under-treated causes of prediabetes status affecting some 75 million Americans. His current research comprises the optimal design of health care insurance and total health/wellness programs including preventive health strategies and employee health engagement and resiliency. Working as part of a global benefits team, he creates an integrated wellness-benefits strategy and executes programs aimed at changing mid- and high-risk behaviors. He positions wellness and disease-prevention as part of a larger strategy for medical cost containment, and contributes innovative ideas for achieving this desired result. He demonstrates thinking "outside the box" to rein in health care spending costs and reform patient utilization of medical services. A second area of current research is the use of Clomiphene in men for hormone modulation to prevent cardiovascular disease and other consequences of the metabolic syndrome. He is Principal Investigator of a clinical study that compares use of Clomiphene with external sources of testosterone given to men; the study includes safety, efficacy, cost, and value comparisons.

Why are Americans so worked up about health care reform? Statements such as "don't touch my Medicare" or "everyone should have access to state of the art health care irrespective of cost" are in my opinion uninformed and visceral responses that indicate a poor understanding of our health care system's history, its current and future resources and the funding challenges that America faces going forward. While we all wonder how the health care system has reached what some refer to as a crisis stage. Let's try to take some of the emotion out of the debate by briefly examining how health care in this country emerged and how that has formed our thinking and culture about health care. With that as a foundation let's look at the pros and cons of the Obama administration health care reform proposals and let's look at the concepts put forth by the Republicans?

Access to state of the art health care services is something we can all agree would be a good thing for this country. Experiencing a serious illness is one of life's major challenges and to face it without the means to pay for it is positively frightening. But as we shall see, once we know the facts, we will find that achieving this goal will not be easy without our individual contribution.

These are the themes I will touch on to try to make some sense out of what is happening to American health care and the steps we can personally take to make things better.

A recent history of American health care - what has driven the costs so high?

Key elements of the Obama health care plan

The Republican view of health care - free market competition

Universal access to state of the art health care - a worthy goal but not easy to achieve

what can we do?

First, let's get a little historical perspective on American health care. This is not intended to be an exhausted look into that history but it will give us an appreciation of how the health care system and our expectations for it developed. What drove costs higher and higher?

To begin, let's turn to the American civil war. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause ghastly results. Not generally known is that most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail's pace and this caused severe delays in treating the wounded. Secondly, many wounds were subjected to wound care, related surgeries and/or amputations of the affected limbs and this often resulted in the onset of massive infection. So you might survive a battle wound only to die at the hands of medical care providers who although well-intentioned, their interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!

Let's skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a "wait and see" approach. Medicine could handle bone fractures and increasingly attempt risky surgeries (now largely performed in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.

This very basic review of American medical history helps us to understand that until quite recently (around the 1950's) we had virtually no technologies with which to treat serious or even minor ailments. Here is a critical point we need to understand; "nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in such a scenario costs are curtailed. The simple fact is that there was little for doctors to offer and therefore virtually nothing to drive health care spending. A second factor holding down costs was that medical treatments that were provided were paid for out-of-pocket, meaning by way of an individuals personal resources. There was no such thing as health insurance and certainly not health insurance paid by an employer. Except for the very destitute who were lucky to find their way into a charity hospital, health care costs were the responsibility of the individual.

What does health care insurance have to do with health care costs? Its impact on health care costs has been, and remains to this day, absolutely enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight a great pool of money became available to pay for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. More Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare and Medicaid (1965). In addition funding became available for expanded veterans health care benefits. Finding a cure for almost anything has consequently become very lucrative. This is also the primary reason for the vast array of treatments we have available today.

I do not wish to convey that medical innovations are a bad thing. Think of the tens of millions of lives that have been saved, extended, enhanced and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor's offer and most of us demand and get access to the latest available health care technology in the form of pharmaceuticals, medical devices, diagnostic tools and surgical procedures. So the result is that there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). Add an insatiable and unrealistic public demand for access and treatment and we have the "perfect storm" for higher and higher health care costs. And by and large the storm is only intensifying.

At this point, let's turn to the key questions that will lead us into a review and hopefully a better understanding of the health care reform proposals in the news today. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? When we add politics and an election year to the debate, information to help us answer these questions become critical. We need to spend some effort in understanding health care and sorting out how we think about it. Properly armed we can more intelligently determine whether certain health care proposals might solve or worsen some of these problems. What can be done about the challenges? How can we as individuals contribute to the solutions?

The Obama health care plan is complex for sure - I have never seen a health care plan that isn't. But through a variety of programs his plan attempts to deal with a) increasing the number of American that are covered by adequate insurance (almost 50 million are not), and b) managing costs in such a manner that quality and our access to health care is not adversely affected. Republicans seek to achieve these same basic and broad goals, but their approach is proposed as being more market driven than government driven. Let's look at what the Obama plan does to accomplish the two objectives above. Remember, by the way, that his plan was passed by congress, and begins to seriously kick-in starting in 2014. So this is the direction we are currently taking as we attempt to reform health care.

Through insurance exchanges and an expansion of Medicaid,the Obama plan dramatically expands the number of Americans that will be covered by health insurance.

To cover the cost of this expansion the plan requires everyone to have health insurance with a penalty to be paid if we don't comply. It will purportedly send money to the states to cover those individuals added to state-based Medicaid programs.

To cover the added costs there were a number of new taxes introduced, one being a 2.5% tax on new medical technologies and another increases taxes on interest and dividend income for wealthier Americans.

The Obama plan also uses concepts such as evidence-based medicine, accountable care organizations, comparative effectiveness research and reduced reimbursement to health care providers (doctors and hospitals) to control costs.

The insurance mandate covered by points 1 and 2 above is a worthy goal and most industrialized countries outside of the U.S. provide "free" (paid for by rather high individual and corporate taxes) health care to most if not all of their citizens. It is important to note, however, that there are a number of restrictions for which many Americans would be culturally unprepared. Here is the primary controversial aspect of the Obama plan, the insurance mandate. The U.S. Supreme Court recently decided to hear arguments as to the constitutionality of the health insurance mandate as a result of a petition by 26 states attorney's general that congress exceeded its authority under the commerce clause of the U.S. constitution by passing this element of the plan. The problem is that if the Supreme Court should rule against the mandate, it is generally believed that the Obama plan as we know it is doomed. This is because its major goal of providing health insurance to all would be severely limited if not terminated altogether by such a decision.

As you would guess, the taxes covered by point 3 above are rather unpopular with those entities and individuals that have to pay them. Medical device companies, pharmaceutical companies, hospitals, doctors and insurance companies all had to "give up" something that would either create new revenue or would reduce costs within their spheres of control. As an example, Stryker Corporation, a large medical device company, recently announced at least a 1,000 employee reduction in part to cover these new fees. This is being experienced by other medical device companies and pharmaceutical companies as well. The reduction in good paying jobs in these sectors and in the hospital sector may rise as former cost structures will have to be dealt with in order to accommodate the reduced rate of reimbursement to hospitals. Over the next ten years some estimates put the cost reductions to hospitals and physicians at half a trillion dollars and this will flow directly to and affect the companies that supply hospitals and doctors with the latest medical technologies. None of this is to say that efficiencies will not be realized by these changes or that other jobs will in turn be created but this will represent painful change for a while. It helps us to understand that health care reform does have an effect both positive and negative.

Finally, the Obama plan seeks to change the way medical decisions are made. While clinical and basic research underpins almost everything done in medicine today, doctors are creatures of habit like the rest of us and their training and day-to-day experiences dictate to a great extent how they go about diagnosing and treating our conditions. Enter the concept of evidence-based medicine and comparative effectiveness research. Both of these seek to develop and utilize data bases from electronic health records and other sources to give better and more timely information and feedback to physicians as to the outcomes and costs of the treatments they are providing. There is great waste in health care today, estimated at perhaps a third of an over 2 trillion dollar health care spend annually. Imagine the savings that are possible from a reduction in unnecessary test and procedures that do not compare favorably with health care interventions that are better documented as effective. Now the Republicans and others don't generally like these ideas as they tend to characterize them as "big government control" of your and my health care. But to be fair, regardless of their political persuasions, most people who understand health care at all, know that better data for the purposes described above will be crucial to getting health care efficiencies, patient safety and costs headed in the right direction.

A brief review of how Republicans and more conservative individuals think about health care reform. I believe they would agree that costs must come under control and that more, not fewer Americans should have access to health care regardless of their ability to pay. But the main difference is that these folks see market forces and competition as the way to creating the cost reductions and efficiencies we need. There are a number of ideas with regard to driving more competition among health insurance companies and health care providers (doctors and hospitals) so that the consumer would begin to drive cost down by the choices we make. This works in many sectors of our economy but this formula has shown that improvements are illusive when applied to health care. Primarily the problem is that health care choices are difficult even for those who understand it and are connected. The general population, however, is not so informed and besides we have all been brought up to "go to the doctor" when we feel it is necessary and we also have a cultural heritage that has engendered within most of us the feeling that health care is something that is just there and there really isn't any reason not to access it for whatever the reason and worse we all feel that there is nothing we can do to affect its costs to insure its availability to those with serious problems.

OK, this article was not intended to be an exhaustive study as I needed to keep it short in an attempt to hold my audience's attention and to leave some room for discussing what we can do contribute mightily to solving some of the problems. First we must understand that the dollars available for health care are not limitless. Any changes that are put in place to provide better insurance coverage and access to care will cost more. And somehow we have to find the revenues to pay for these changes. At the same time we have to pay less for medical treatments and procedures and do something to restrict the availability of unproven or poorly documented treatments as we are the highest cost health care system in the world and don't necessarily have the best results in terms of longevity or avoiding chronic diseases much earlier than necessary.

I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens - health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don't need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.

Let's go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don't exercise but we offer a lot of excuses. We don't eat right but we offer a lot of excuses. We smoke and/or we drink alcohol to excess and we offer a lot of excuses as to why we can't do anything about managing these known to be destructive personal health habits. We don't take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because "health care is there" and somehow we think we have no responsibility for reducing our demand on it.

It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.

There are a huge number of free web sites available that can steer us to a more healthful life style. A soon as you can, "Google" "preventive health care strategies", look up your local hospital's web site and you will find more than enough help to get you started. Finally, there is a lot to think about here and I have tried to outline the challenges but also the very powerful effect we could have on preserving the best of America's health care system now and into the future. I am anxious to hear from you and until then - take charge and increase your chances for good health while making sure that health care is there when we need it.

Health

Health Care Reform - Why Are People So Worked Up?

Why are Americans so worked up about health care reform? Statements such as "don't touch my Medicare" or "everyone should have access to state of the art health care irrespective of cost" are in my opinion uninformed and visceral responses that indicate a poor understanding of our health care system's history, its current and future resources and the funding challenges that America faces going forward. While we all wonder how the health care system has reached what some refer to as a crisis stage. Let's try to take some of the emotion out of the debate by briefly examining how health care in this country emerged and how that has formed our thinking and culture about health care. With that as a foundation let's look at the pros and cons of the Obama administration health care reform proposals and let's look at the concepts put forth by the Republicans?

Access to state of the art health care services is something we can all agree would be a good thing for this country. Experiencing a serious illness is one of life's major challenges and to face it without the means to pay for it is positively frightening. But as we shall see, once we know the facts, we will find that achieving this goal will not be easy without our individual contribution.

These are the themes I will touch on to try to make some sense out of what is happening to American health care and the steps we can personally take to make things better.

A recent history of American health care - what has driven the costs so high?

Key elements of the Obama health care plan

The Republican view of health care - free market competition

Universal access to state of the art health care - a worthy goal but not easy to achieve

what can we do?

First, let's get a little historical perspective on American health care. This is not intended to be an exhausted look into that history but it will give us an appreciation of how the health care system and our expectations for it developed. What drove costs higher and higher?

To begin, let's turn to the American civil war. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause ghastly results. Not generally known is that most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail's pace and this caused severe delays in treating the wounded. Secondly, many wounds were subjected to wound care, related surgeries and/or amputations of the affected limbs and this often resulted in the onset of massive infection. So you might survive a battle wound only to die at the hands of medical care providers who although well-intentioned, their interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!

Let's skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a "wait and see" approach. Medicine could handle bone fractures and increasingly attempt risky surgeries (now largely performed in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.

This very basic review of American medical history helps us to understand that until quite recently (around the 1950's) we had virtually no technologies with which to treat serious or even minor ailments. Here is a critical point we need to understand; "nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in such a scenario costs are curtailed. The simple fact is that there was little for doctors to offer and therefore virtually nothing to drive health care spending. A second factor holding down costs was that medical treatments that were provided were paid for out-of-pocket, meaning by way of an individuals personal resources. There was no such thing as health insurance and certainly not health insurance paid by an employer. Except for the very destitute who were lucky to find their way into a charity hospital, health care costs were the responsibility of the individual.

What does health care insurance have to do with health care costs? Its impact on health care costs has been, and remains to this day, absolutely enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight a great pool of money became available to pay for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. More Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare and Medicaid (1965). In addition funding became available for expanded veterans health care benefits. Finding a cure for almost anything has consequently become very lucrative. This is also the primary reason for the vast array of treatments we have available today.

I do not wish to convey that medical innovations are a bad thing. Think of the tens of millions of lives that have been saved, extended, enhanced and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor's offer and most of us demand and get access to the latest available health care technology in the form of pharmaceuticals, medical devices, diagnostic tools and surgical procedures. So the result is that there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). Add an insatiable and unrealistic public demand for access and treatment and we have the "perfect storm" for higher and higher health care costs. And by and large the storm is only intensifying.

At this point, let's turn to the key questions that will lead us into a review and hopefully a better understanding of the health care reform proposals in the news today. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? When we add politics and an election year to the debate, information to help us answer these questions become critical. We need to spend some effort in understanding health care and sorting out how we think about it. Properly armed we can more intelligently determine whether certain health care proposals might solve or worsen some of these problems. What can be done about the challenges? How can we as individuals contribute to the solutions?

The Obama health care plan is complex for sure - I have never seen a health care plan that isn't. But through a variety of programs his plan attempts to deal with a) increasing the number of American that are covered by adequate insurance (almost 50 million are not), and b) managing costs in such a manner that quality and our access to health care is not adversely affected. Republicans seek to achieve these same basic and broad goals, but their approach is proposed as being more market driven than government driven. Let's look at what the Obama plan does to accomplish the two objectives above. Remember, by the way, that his plan was passed by congress, and begins to seriously kick-in starting in 2014. So this is the direction we are currently taking as we attempt to reform health care.

Through insurance exchanges and an expansion of Medicaid,the Obama plan dramatically expands the number of Americans that will be covered by health insurance.

To cover the cost of this expansion the plan requires everyone to have health insurance with a penalty to be paid if we don't comply. It will purportedly send money to the states to cover those individuals added to state-based Medicaid programs.

To cover the added costs there were a number of new taxes introduced, one being a 2.5% tax on new medical technologies and another increases taxes on interest and dividend income for wealthier Americans.

The Obama plan also uses concepts such as evidence-based medicine, accountable care organizations, comparative effectiveness research and reduced reimbursement to health care providers (doctors and hospitals) to control costs.

The insurance mandate covered by points 1 and 2 above is a worthy goal and most industrialized countries outside of the U.S. provide "free" (paid for by rather high individual and corporate taxes) health care to most if not all of their citizens. It is important to note, however, that there are a number of restrictions for which many Americans would be culturally unprepared. Here is the primary controversial aspect of the Obama plan, the insurance mandate. The U.S. Supreme Court recently decided to hear arguments as to the constitutionality of the health insurance mandate as a result of a petition by 26 states attorney's general that congress exceeded its authority under the commerce clause of the U.S. constitution by passing this element of the plan. The problem is that if the Supreme Court should rule against the mandate, it is generally believed that the Obama plan as we know it is doomed. This is because its major goal of providing health insurance to all would be severely limited if not terminated altogether by such a decision.

As you would guess, the taxes covered by point 3 above are rather unpopular with those entities and individuals that have to pay them. Medical device companies, pharmaceutical companies, hospitals, doctors and insurance companies all had to "give up" something that would either create new revenue or would reduce costs within their spheres of control. As an example, Stryker Corporation, a large medical device company, recently announced at least a 1,000 employee reduction in part to cover these new fees. This is being experienced by other medical device companies and pharmaceutical companies as well. The reduction in good paying jobs in these sectors and in the hospital sector may rise as former cost structures will have to be dealt with in order to accommodate the reduced rate of reimbursement to hospitals. Over the next ten years some estimates put the cost reductions to hospitals and physicians at half a trillion dollars and this will flow directly to and affect the companies that supply hospitals and doctors with the latest medical technologies. None of this is to say that efficiencies will not be realized by these changes or that other jobs will in turn be created but this will represent painful change for a while. It helps us to understand that health care reform does have an effect both positive and negative.

Finally, the Obama plan seeks to change the way medical decisions are made. While clinical and basic research underpins almost everything done in medicine today, doctors are creatures of habit like the rest of us and their training and day-to-day experiences dictate to a great extent how they go about diagnosing and treating our conditions. Enter the concept of evidence-based medicine and comparative effectiveness research. Both of these seek to develop and utilize data bases from electronic health records and other sources to give better and more timely information and feedback to physicians as to the outcomes and costs of the treatments they are providing. There is great waste in health care today, estimated at perhaps a third of an over 2 trillion dollar health care spend annually. Imagine the savings that are possible from a reduction in unnecessary test and procedures that do not compare favorably with health care interventions that are better documented as effective. Now the Republicans and others don't generally like these ideas as they tend to characterize them as "big government control" of your and my health care. But to be fair, regardless of their political persuasions, most people who understand health care at all, know that better data for the purposes described above will be crucial to getting health care efficiencies, patient safety and costs headed in the right direction.

A brief review of how Republicans and more conservative individuals think about health care reform. I believe they would agree that costs must come under control and that more, not fewer Americans should have access to health care regardless of their ability to pay. But the main difference is that these folks see market forces and competition as the way to creating the cost reductions and efficiencies we need. There are a number of ideas with regard to driving more competition among health insurance companies and health care providers (doctors and hospitals) so that the consumer would begin to drive cost down by the choices we make. This works in many sectors of our economy but this formula has shown that improvements are illusive when applied to health care. Primarily the problem is that health care choices are difficult even for those who understand it and are connected. The general population, however, is not so informed and besides we have all been brought up to "go to the doctor" when we feel it is necessary and we also have a cultural heritage that has engendered within most of us the feeling that health care is something that is just there and there really isn't any reason not to access it for whatever the reason and worse we all feel that there is nothing we can do to affect its costs to insure its availability to those with serious problems.

OK, this article was not intended to be an exhaustive study as I needed to keep it short in an attempt to hold my audience's attention and to leave some room for discussing what we can do contribute mightily to solving some of the problems. First we must understand that the dollars available for health care are not limitless. Any changes that are put in place to provide better insurance coverage and access to care will cost more. And somehow we have to find the revenues to pay for these changes. At the same time we have to pay less for medical treatments and procedures and do something to restrict the availability of unproven or poorly documented treatments as we are the highest cost health care system in the world and don't necessarily have the best results in terms of longevity or avoiding chronic diseases much earlier than necessary.

I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens - health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don't need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.

Let's go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don't exercise but we offer a lot of excuses. We don't eat right but we offer a lot of excuses. We smoke and/or we drink alcohol to excess and we offer a lot of excuses as to why we can't do anything about managing these known to be destructive personal health habits. We don't take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because "health care is there" and somehow we think we have no responsibility for reducing our demand on it.

It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.

There are a huge number of free web sites available that can steer us to a more healthful life style. A soon as you can, "Google" "preventive health care strategies", look up your local hospital's web site and you will find more than enough help to get you started. Finally, there is a lot to think about here and I have tried to outline the challenges but also the very powerful effect we could have on preserving the best of America's health care system now and into the future. I am anxious to hear from you and until then - take charge and increase your chances for good health while making sure that health care is there when we need it.

Defining a Health Information Exchange

The United States is facing the largest shortage of healthcare practitioners in our country's history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.

This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, "Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective."

United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the "art of medicine" is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.

History of Health Information Exchanges

Major urban centers in Canada and Australia were the first to successfully implement HIE's. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it's third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.

In the United States one of the earliest HIE's started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.

In Tennessee Regional Health Information Organizations (RHIO's) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark's HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children's Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.

Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE's. These communities' health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the department of Health and Human Services in September 2011.

A healthcare model for Nashville to emulate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.

Regulatory Aspects of Health Information Exchanges and Healthcare Reform

The department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions and Tennessee is part of Region IV headquartered out of Atlanta. The Regional Director, Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.

The National Health Information Network (NHIN) is a division of HHS that guides the standards of exchange and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities and state HIE's (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity and finally timely public health alerts through agencies like the CDC based on this information.12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act of 2009. HITECH's goals are to invest dollars in community, regional and state health information exchanges to build effective networks which are connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling 548 million dollars.

History of Health Information Partnership TN (HIPTN)

In Tennessee the Health Information Exchange has been slower to progress than places like Maine and Indiana based in part on the diversity of our state. The delta has a vastly different patient population and health network than that of middle Tennessee, which differs from eastern Tennessee's Appalachian region. In August of 2009 the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time with an operations council formed in December. HIP TN's first initiatives involved connecting the work through Carespark in northeast Tennessee's s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010 four workgroups were established to focus on areas like technology, clinical, privacy and security and sustainability.

By May of 2010 data sharing agreements were in place and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP) which was sent out to over forty vendors. In July 2010 a fifth workgroup,the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved after a release of Program Information Notice (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations and a contract was signed with the chosen vendor Axolotl on September 30th, 2010. At that time a production goal of July 15th, 2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN's CEO. Keith brings twenty six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth and several entrepreneurial efforts. HIP TN's mission is to improve access to health information through a statewide collaborative process and provide the infrastructure for security in that exchange. The vision for HIP TN is to be recognized as a state and national leader who support measurable improvements in clinical quality and efficiency to patients, providers and payors with secure HIE. Robert S. Gordon, the board chair for HIPTN states the vision well, "We share the view that while technology is a critical tool, the primary focus is not technology itself, but improving health". HIP TN is a non profit, 501(c)3, that is solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012. Carespark, one of the original regional health exchange networks voted to cease operations on July 11, 2011 based on lack of financial support for it's new infrastructure. The data sharing agreements included 38 health organizations, nine communities and 250 volunteers.16 Carespark's closure clarifies the need to build a network that is not solely reliant on public grants to fund it's efforts, which we will discuss in the final section of this paper.

Current Status of Healthcare Information Exchange and HIPTN

Ten grants were awarded in 2011 by the HIE challenge grant supplement. These included initiatives in eight states and serve as communities we can look to for guidance as HIP TN evolves. As previously mentioned one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems who serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for it's Docs for Docs program and the manner in which collaboration has taken place since it's conception in 2004. Kathleen Sebelius, Secretary of HHS commented, "The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts in an effective manner from its history of building long standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care." Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.

A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA's conversion to electronic records in early 2000 occurred as a result of the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population. OHPA established a cross functional work team to improve their practices in the areas of facilities, personnel, communication, technology and external influences. Noteworthy was chosen as the EMR vendor based on user friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days OHPA had 100% compliance and use of their EMR system.

The Future of HIP TN and HIE in Tennessee

Tennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be full scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and the systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data repository for all patients information that can be accessed from anywhere and contains a full history of the patients medical record, lab tests, physician network and medicine list. To entice providers to enroll in the statewide HIE tangible value to their practice has to be shown with better safer care. In a 2011 HIMSS editor's report Richard Lang states that instead of a top down approach "A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE's and then connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development."22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main point of contact for the patient.

One piece of the puzzle often overlooked is the patient investment in a functional EHR. In order to bring together all the pieces of the HIE puzzle patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR's like Memitech's 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post in patient therapies to reduce readmissions.

The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) who assist providers with educational initiatives in areas like HIT, ICD9 to ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability it is critical that Tennessee build a network of private funding so that what happened with Carespark won't happen to HIP TN. The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding and of those independent HIE's, break even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going so to speak, the sustainable fuel, as observed in the case of Carespark, has to come from value that can be monetized. KLAS research reports that 54% of public HIE's were concerned about future sustainability while only 35% of private HIE's shared this concern.

Hospital Implications of HIP TN (A Call to Action)

From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with other state HIE's. To get a realistic idea of the benefits and costs associated with health information integration. we can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction. Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit and $17.41 per patient/year due to redundant lab tests which amounts to $52 million for a population of 3 million patients. In Grand Junction Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in the first year of operation and uses a subscription fee for all the organizations who interact with them. In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty of twenty five objectives in the first phase (2011-2012) and adopting and implement an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.

Perhaps the most compelling argument to building a functional Health Information Exchange is patient and community safety. The Healthbridge reduction in disease outbreak detection of 3-5 days is a perfect example of this safety benefit. Imagine the implications in the case of a rampant virus like avian or swine flu. The goal is to avoid a repeat of the 1918 influenza outbreak and ultimately save the lives of our most at risk. Rick Krohn of Healthsense makes the case for a socially responsible HIE that serves those who are chronically ill, uninsured and homeless. As the taxpayers ultimately bear the societal burden for our country's healthcare coverage, the need to reduce redundancies, increase efficiency and provide healthcare worthy of the United States is imperative. Right now our healthcare is in the Critical Care Unit it's time to stabilize it through operational excellence starting with our hospital. Let's rebuild the Tower of Babel and enhance communication to provide our patients the healthcare they deserve!

Health

Rebuilding the Tower of Babel - A CEO's Perspective on Health Information Exchanges

Defining a Health Information Exchange

The United States is facing the largest shortage of healthcare practitioners in our country's history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.

This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, "Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective."

United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the "art of medicine" is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.

History of Health Information Exchanges

Major urban centers in Canada and Australia were the first to successfully implement HIE's. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it's third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.

In the United States one of the earliest HIE's started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.

In Tennessee Regional Health Information Organizations (RHIO's) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark's HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children's Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.

Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE's. These communities' health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the department of Health and Human Services in September 2011.

A healthcare model for Nashville to emulate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.

Regulatory Aspects of Health Information Exchanges and Healthcare Reform

The department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions and Tennessee is part of Region IV headquartered out of Atlanta. The Regional Director, Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.

The National Health Information Network (NHIN) is a division of HHS that guides the standards of exchange and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities and state HIE's (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity and finally timely public health alerts through agencies like the CDC based on this information.12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act of 2009. HITECH's goals are to invest dollars in community, regional and state health information exchanges to build effective networks which are connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling 548 million dollars.

History of Health Information Partnership TN (HIPTN)

In Tennessee the Health Information Exchange has been slower to progress than places like Maine and Indiana based in part on the diversity of our state. The delta has a vastly different patient population and health network than that of middle Tennessee, which differs from eastern Tennessee's Appalachian region. In August of 2009 the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time with an operations council formed in December. HIP TN's first initiatives involved connecting the work through Carespark in northeast Tennessee's s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010 four workgroups were established to focus on areas like technology, clinical, privacy and security and sustainability.

By May of 2010 data sharing agreements were in place and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP) which was sent out to over forty vendors. In July 2010 a fifth workgroup,the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved after a release of Program Information Notice (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations and a contract was signed with the chosen vendor Axolotl on September 30th, 2010. At that time a production goal of July 15th, 2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN's CEO. Keith brings twenty six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth and several entrepreneurial efforts. HIP TN's mission is to improve access to health information through a statewide collaborative process and provide the infrastructure for security in that exchange. The vision for HIP TN is to be recognized as a state and national leader who support measurable improvements in clinical quality and efficiency to patients, providers and payors with secure HIE. Robert S. Gordon, the board chair for HIPTN states the vision well, "We share the view that while technology is a critical tool, the primary focus is not technology itself, but improving health". HIP TN is a non profit, 501(c)3, that is solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012. Carespark, one of the original regional health exchange networks voted to cease operations on July 11, 2011 based on lack of financial support for it's new infrastructure. The data sharing agreements included 38 health organizations, nine communities and 250 volunteers.16 Carespark's closure clarifies the need to build a network that is not solely reliant on public grants to fund it's efforts, which we will discuss in the final section of this paper.

Current Status of Healthcare Information Exchange and HIPTN

Ten grants were awarded in 2011 by the HIE challenge grant supplement. These included initiatives in eight states and serve as communities we can look to for guidance as HIP TN evolves. As previously mentioned one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems who serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for it's Docs for Docs program and the manner in which collaboration has taken place since it's conception in 2004. Kathleen Sebelius, Secretary of HHS commented, "The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts in an effective manner from its history of building long standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care." Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.

A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA's conversion to electronic records in early 2000 occurred as a result of the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population. OHPA established a cross functional work team to improve their practices in the areas of facilities, personnel, communication, technology and external influences. Noteworthy was chosen as the EMR vendor based on user friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days OHPA had 100% compliance and use of their EMR system.

The Future of HIP TN and HIE in Tennessee

Tennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be full scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and the systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data repository for all patients information that can be accessed from anywhere and contains a full history of the patients medical record, lab tests, physician network and medicine list. To entice providers to enroll in the statewide HIE tangible value to their practice has to be shown with better safer care. In a 2011 HIMSS editor's report Richard Lang states that instead of a top down approach "A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE's and then connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development."22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main point of contact for the patient.

One piece of the puzzle often overlooked is the patient investment in a functional EHR. In order to bring together all the pieces of the HIE puzzle patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR's like Memitech's 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post in patient therapies to reduce readmissions.

The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) who assist providers with educational initiatives in areas like HIT, ICD9 to ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability it is critical that Tennessee build a network of private funding so that what happened with Carespark won't happen to HIP TN. The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding and of those independent HIE's, break even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going so to speak, the sustainable fuel, as observed in the case of Carespark, has to come from value that can be monetized. KLAS research reports that 54% of public HIE's were concerned about future sustainability while only 35% of private HIE's shared this concern.

Hospital Implications of HIP TN (A Call to Action)

From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with other state HIE's. To get a realistic idea of the benefits and costs associated with health information integration. we can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction. Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit and $17.41 per patient/year due to redundant lab tests which amounts to $52 million for a population of 3 million patients. In Grand Junction Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in the first year of operation and uses a subscription fee for all the organizations who interact with them. In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty of twenty five objectives in the first phase (2011-2012) and adopting and implement an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.

Perhaps the most compelling argument to building a functional Health Information Exchange is patient and community safety. The Healthbridge reduction in disease outbreak detection of 3-5 days is a perfect example of this safety benefit. Imagine the implications in the case of a rampant virus like avian or swine flu. The goal is to avoid a repeat of the 1918 influenza outbreak and ultimately save the lives of our most at risk. Rick Krohn of Healthsense makes the case for a socially responsible HIE that serves those who are chronically ill, uninsured and homeless. As the taxpayers ultimately bear the societal burden for our country's healthcare coverage, the need to reduce redundancies, increase efficiency and provide healthcare worthy of the United States is imperative. Right now our healthcare is in the Critical Care Unit it's time to stabilize it through operational excellence starting with our hospital. Let's rebuild the Tower of Babel and enhance communication to provide our patients the healthcare they deserve!