Healthcare Archives - Read. Think. Act.

Community Healthcare in Virginia – Dr. Basim Khan of Neighborhood Health

(Feb 19, 2018) Catherine Read talks with Dr. Basim Khan, Executive Director of Neighborhood Health, a Federally Qualified Health Center (FQHC) located in Northern Virginia. Neighborhood Health was started in an apartment complex by nurses from the Alexandria Health Department back in 1997, becoming an FQHC in 2004. In their first year as a clinic, they saw 1,500 patients and in their 20th year they saw 18,000 patients through their 12 clinics located in Alexandria, Arlington and Fairfax County.

Neighborhood Health provides an integrated medical home to community residents regardless of their ability to pay. Their goal is high quality healthcare that is affordable and accessible to everyone in the community. Their clinics provide Family Practice/Internal Medicine, Pediatrics, Women’s Health, Behavioral Health Counseling and include health screenings, cancer screenings, on-site lab services, immunizations, mental health screenings, dental services and a pharmacy program. They provide language interpreters (sometimes via phone), offer sliding scales to patients who may have high deductibles for their health insurance plan, and provide medications to patients less expensively than through retail pharmacies. Community health centers provide primary healthcare to over 300,000 people in Virginia and to 27 million patients in the U.S. Providing high quality primary care delivers better health outcomes for patients and helps to drive down overall costs.

Dr. Kahn talks about how Neighborhood Health strives to serve as a patient advocate in a really “complicated health system.” In talking about issues of equity and social determinants of health, he points out that our healthcare and social services spending in this country is comparable to other developed nations, but we spend far more on healthcare and far less on social safety net services. Social determinants of health include factors such as education levels, income, the zip codes we live in, the type of housing and employment we have, and our access to adequate healthy food. Working to provide better equity in healthcare outcomes includes Neighborhood Health’s strong partnerships with other local agencies, non-profits and service providers. They work closely with local Community Services Boards to help patients get mental health services and case management when needed. They work with Departments of Health and Human Services that also provide employment assistance, and help with issues of aging and disability. This is the “community” in community health services that treat the whole patient through providing social services that impact health outcomes.

Neighborhood Health continues to expand their services, meeting patients where they are in the community. They currently work with Alexandria City Schools to provide dental care to low income students in 8 elementary school through a mobile bus that provides the services right on school grounds. That includes routine cleanings, x-rays, and fillings as needed. Catherine Read pointed out that this is an example of the type of partnership that is at the core of the Community School model – a model of education we don’t currently have in Virginia. Providing needed services to students through the school impacts educational and health outcomes for many students who lack access to things as basic as food, clothing, dental and healthcare, school supplies and tutoring.

Dr. Khan addresses public health issues such as the opioid crisis and how the trend of medicalizing so many issues has resulted in the over prescribing of pain medications. The epidemic of chronic diseases such as hypertension, diabetes and cancer are tied to social determinants, yet we seem to lack the political will to prioritize key things that need to be addressed, such as affordable housing, which impact health.

In the last segment, Medicaid Expansion in Virginia is addressed and what the impact would be on the patients Neighborhood Health serves. The most immediate impact would be the ability to refer patients to local specialists instead of having the University of Virginia as the only option. There are substantive discussions taking place during the 2018 Legislative Session in Richmond that have both parties negotiating terms that now include a “work requirement” proffered by the Trump Administration as an option states can elect to mandate. At the time of broadcast, Medicaid Expansion was still very much up in the air with the future outcome very uncertain.

For more information about Neighborhood Health visit www.NeighborhoodHealthVA.org, follow them on Twitter @NeighborhoodHth or on Facebook, or call their main number for assistance at 703-535-5568.

by William Zuhl

Legacy Planning with Bettina Lawton – Your Need to Know

Catherine Read has a conversation with Bettina Lawton (Esq.) of Lawton Legacy Planning about legal planning. Bettina Lawton is a licensed legal professional who specializes in legal planning for a client’s eventual death or incapacitation. She deals with people from all walks of life, from single adults to married couples with children to seniors of all financial statuses and helps them plan how to meet their objectives in the event of death or incapacitation.

While indisputably important, many people have difficulty talking about, and planning for their eventual incapacitation or death. Over 60% of Americans have no will, or other similar document. According to Bettina Lawton, it is critical that people find a qualified person they can work with in order to make a plan, as even a will alone is not enough. Wills only go into effect after the person has died, so they make no differences in cases where the client is incapacitated or otherwise unable to take care of themselves or others. It is especially important in cases where children are involved, as a failure to have a designated guardian can see children placed into the foster care system when their parents are otherwise unable to take care of them. In Virginia, parents can designate whom they wish to take their children using a Standby Guardianship, which grants their chosen caretakers 30 days of authority, which gives time for the courts to work without sending children into foster care.

Beyond just having a will in the first place, it is also important to make sure your will is up to date. Laws change over time so what you currently have may have unintended consequences if it is not updated. For example, in July of last year Virginia adopted a fiduciary access to digital assets act, which allows a person to designate a beneficiary to access their digital assets, like photos hosted online. Bettina Lawton recommends reviewing your will and other legal plans every three to five years. Generally, only minor changes will be needed, but they can add up to a big difference to the final result.

When planning, it is important to keep in mind the location of your assets. Real estate passes ownership based on the laws of the location it is in, not necessarily the laws of the jurisdiction where the owner lived. Two properties in two different locations are subject to two different laws. This is why Bettina Lawton recommends outside properties be placed in a revocable trust, which changes real estate assets into trust assets and simplifies the process. In Virginia the law now allows for transfer on death deeds, which allows owners to designate a beneficiary who will receive ownership of the deed in the event of the original owners death, allowing property to transfer without going into an estate.

In addition to a will, people should also be planning for what happens if they are unable to make medical decisions. A person retains their legal right to make decisions up until two medical professionals agree that someone is unable to make a choice themselves (either due to inability to speak or inability to understand their situation). People need to make an advanced medical directive to designate who can make medical decisions on their behalf. While the state does designate a list of people who can make the decision in the event you have not made plans, it can be very hard on the person who is called upon to make the decision, and they might make a decision contrary to your wishes. It is best to designate someone ahead of time, and to make sure that you have written down what your wishes would be in the event of various medical situations.

While it can be a topic hard to discuss, it is important to plan ahead. Doing so makes things easier on those left behind and ensures that you have the final say on how your assets are passed on. According to Bettina Lawton, the best time of year to begin your legacy planning is around the time you pay your taxes, as you frequently need the same fiscal documents in order to make your plans. You need to decide whom it is who can best fulfill your will. Sometimes a spouse or child isn’t the right choice, as financial positions, such as executors, trustees or someone with a designated financial power of attorney needs to either be good with financial details or capable of supervising those who are. You also need to make plans for what happens if your designated person dies or is incapacitated at the same time, or before, you are.

For more information, you can email Bettina Lawton at [email protected] or visit LawtonLegacyPlanning.com for an estate planning guide so you know what information you need and what decisions you should be making.

by Rachel Simon

Healthcare in Virginia – Senator George Barker

(Dec. 4, 2017) Catherine Read interviews State Senator George Barker (D-39) to discuss Healthcare in Virginia. Sen. Barker represents the 39^th District, which includes southern Fairfax County and parts of Prince William County and the City of Alexandria. His academic credentials include an undergraduate honors degree in Economics and Public Health, along with a Masters degree in Public Health Policy and Management, both from Harvard University. For 30 years, Sen. Barker has worked for Northern Virginia’s regional health planning agency, the Health Systems Agency of Northern Virginia. He has worked hard to contain skyrocketing health care costs, promote quality of care and ensure access to medical care for all Northern Virginians. He spoke today about the current state of healthcare and how we can best move forward to serve all Virginians, along with the importance of expanding Medicaid in Virginia.

Sen. Barker first gives an overview of how healthcare is delivered to the most needy in our community. In the 1980’s, Fairfax County was visionary in how it established Community Health Care Network to deliver care to the uninsured (although the centers do take insurance and Medicaid payments if patients have coverage). Officials recognized the importance of treating people for day-to-day illnesses and preventative care, so that trips to the Emergency Rooms could be minimized and costs could be kept down.

During George W. Bush’s administration, there was bipartisan support for a similar federal model to be employed. When a new system was established, Fairfax County was able to take advantage of federal dollars to support their ever-growing operations. Fairfax County now contracts with INOVA and has three centers located in South County, Merrifield and Reston designed to serve people who make up to 200% of the poverty limit. Alexandria, Arlington and Prince William also have also employed a similar free clinic model. One of the challenges faced by patients is that the clinics can be located far away from their homes, and the trip could be difficult or expensive. Additionally, many people do not even know that these centers exist to serve them. If the General Assembly were to expand Medicaid, these centers would not be so over-burdened, as many would opt for covered care closer to home.

The Children’s Health Insurance Plan (CHIP) has dominated the news cycle for many weeks now. The program is set to expire, and Congress will have to fund it in order for the program to be sustained. Developed by Orrin Hatch and Ted Kennedy back in the mid-1990’s, CHIP was designed to specifically serve children and pregnant women whose families incomes fell in the 133%-200% of the poverty limit (in today’s dollars, for a family of four that range would be $27,000-$40,000). These are the working poor, who are making enough money to make ends meet, but cannot afford private insurance. Sen. Barker shared that in Virginia this program is called FAMIS (Family Access to Medical Insurance Services). There are approximately 68,000 children and about 1,000 pregnant women throughout the commonwealth enrolled in this program. Recent statistics show that approximately 1/3 of the births in Virginia are to women who are covered in this program. (Since the air date, Congress did in fact fund this program)

When pressed about how Virginia stacks up to other states, Sen. Barker said that Virginia is consistently ranked as of the best and most efficient Medicaid programs in the country. They have been inventive, creative and out front in supporting programs that create incentives for people to do the right thing. He notes that the state is, however, quite frugal. The reimbursement rates lag behind others, as Virginia does not reimburse doctors at competitive rates. This is challenging because fewer doctors are then opting to accept Medicaid payments.

In the final segment of the show Catherine discusses the Affordable Care Act with Sen. Barker. Looking back to 2010, President Obama used a very Republican framework for creating the ACA. It was modeled after the Massachusetts healthcare system implemented by then Governor Mitt Romney. The main goal was to target the uninsured and to address rising costs. At the time the US was spending 20% of its GDP on healthcare. No other advanced western nation spends more than 13% of their GDP. Although vehemently opposed by the GOP controlled Congress, Sen. Barker shared that the result has been that more people are insured, it has helped decrease the deficit, expenditures have been less than projected and the revenues that support the expenditures have been higher than expected.

In order for the ACA to work properly, the idea is that everyone needs to be insured so that there is a large, divese “pool” of people paying into the system. This spreads out the risk amongst all people, and allows insurance companies to take on the risk of covering all patients, even those with illness and preexisting conditions. Unfortunately, the recent tax bill passed by Congress has taken away the penalty for the individual mandate. This basically tells young, healthy people that you do not have to seek coverage – just wait until you are older and need insurance. Sen. Barker’s estimate is that 13 million people will lose their coverage under this scheme.

Looking ahead to 2018, Sen. Barker is encouraged by the prospect of expanding Medicaid in Virginia. Back in 2014, when states became eligible to participate in the federally subsidized program, the Virginia General Assembly opted to not take the federal dollars to expand the program. Hundreds of thousands of Virginians continue to go uninsured because they make too much money to qualify for Medicaid, but do not make enough money to afford insurance on the exchange. In past years, both the Governor and the Senate have favored opting into the federal program, but the House has flat out rejected it. With the new makeup of the House of Delegates this year (Democrats picked up 15 new seats in this past election) Sen. Barker indicates that there is real hope of getting this passed.

Although Medicaid has failed over the past 4 sessions, Sen. Barker did want to point out that there have been some advances and new initiatives in covered services. As far as mental health and behavioral health is concerned, people who previously did not qualify for benefits can now access them, and don’t necessarily need to wait to qualify. This helps to get people what they need when they need it, before it become a crisis situation where they can harm themselves or others. Additionally, the ARTS (Addiction Rehabilitation Treatment Services) was established. This progam is targeted to those suffering from substance abuse, so that treatment is more readily available and less expensive. The success of these programs, according to Sen. Barker, justifies moving ahead with Medicaid expansion.

Since this interview aired, the General Assembly has proposed the biennial budget for 2018-2020. The House budget did include Medicaid expansion, however the Senate budget did not include the program. The budget conferees are currently negotiating the status. The GA session ends on March 10, and they hope to have things resolved so the budget can be passed and sent on to the Governor.

by Catherine Read

The Financial Diaries: How American Families Cope in a World of Uncertainty

The most fundamental way to reduce the volatility that Americans face is through improvements in job quality . . . the Great Job Shift has resulted not only in lower wages but also unpredictable scheduling, inadequate hours, and less job security. Alongside those challenges are diminishing opportunities for training and advancement, and an erosion of benefits such as paid leave and employer provided health care and retirement coverage.

Jonathan Morduch and Rachel Schneider presented the findings contained in their book The Financial Diaries: How American Families Cope in a World of Uncertainty at the Aspen Institute’s Summit on Inequality & Opportunity held in Washington, DC, on March 16, 2017.

Researchers followed 235 low and middle-income families for one year and delved into their daily decision making about how they managed their household finances. They were from various regions of the country and represented a variety of family structures, but at least one member of every household (and often more) were working.

This is an excellent companion book to Lisa Servon’s The UnBanking of America which also addresses how working people are using every means at their disposal to make ends meet – often without the help of traditional financial institutions. In both books, the strength of the research is in the qualitative approach to understanding the real world context of decision-making. These are people’s stories – real people caught between a rock and a hard place. Data is limited in what it can show us – patterns and practices – but it’s not telling us WHY.

What Morduch and Schneider found is that people are struggling with variable income that has spikes and dips that don’t mesh with their financial obligations. Even families whose annual income is sufficient to cover their basic living expenses have months where they dip below the poverty line. Throughout this book the importance of the Earned Income Tax Credit (EITC) kept coming up as the saving grace for families to pay down debt or get back on their feet in February and March of each year.

Living hand to mouth does not leave room for unexpected healthcare costs and car repair. Those were the two things that most often imploded a fragile budget because they are necessities. A car to get to a job was a must have for the majority of people in this research group. Which only points to the EPIC FAILURE of this country to invest in better transportation options. And health care costs for those who are uninsured are still forcing people into bankruptcy over unpaid bills.

This book covers so much territory in 178 pages. What keeps hard working people down are a confluence of factors – not just one or a few. Some of these we can lay at the feet of businesses who have shifted a certain level of risk from their own bottom lines and placed it on workers – with “just in time” staffing, variable hours and schedules, and no paid benefits. Companies now worship at the altar of profit margins and quarterly returns for shareholders – not investing in their employees as Henry Ford once did so that he created a class of consumers who could purchase what they produced. Other factors include some bad public policy.

Most government savings policies – especially tax deductions for retirement savings and housing – were directed toward high-wage employees, not janitors and cafeteria workers. In 2013, the United States spent almost $400 billion in federal tax subsidies for homeownership and retirement savings. That was 30 percent of all federal tax expenditures. About 70 percent of the savings from the mortgage interest and property tax deductions went to the top 20 percent of earners. Almost none went to the bottom 40 percent.

The reality of what people are doing to get by should give us all pause. Not enough people in our communities are thriving and the amount of energy required just to survive is not some great American Dream. It is a constant and stressful nightmare that is being handed down from one generation to the next in our post WWII economy. Wage stagnation began in the early 1970s and the picture for the future is bleak unless significant changes are made in the creation of better jobs with basic benefits, public policy that spreads out benefits to all income groups, and the willingness of financial institutions to change how they assess people’s credit worthiness and their investment in services to better support low-income working class people.

This book points out time and again that there is a difference between “insolvency” and “illiquidity.” Yet despite existing, and very sophisticated technology, and access to reams of personal financial data, financial institutions appear to have few incentives to better meet the needs of millions of working people who are struggling to match up their income to their expenditures on a weekly and monthly basis. This economic uncertainty and instability has been labeled in sociological terms as “precarity” defined as “a precarious existence, lacking in predictability, job security, material or psychological welfare. The social class defined by this condition has been termed the precariat.”

This precariat are millions of working people in this country – friends, neighbors, colleagues, co-workers and family members. We can’t begin to solve problems we don’t fully understand. This book goes a long way in describing the lives of people all around us in a way they would not likely share with us. That is a very powerful thing in seeing these issues not as ideological debates about masses of nameless faceless people we don’t know, but as humanizing issues of public policy down to the devastating financial impact of a broken down car on a neighbor’s ability to survive in very real terms.

I highly recommend this book. I think it will benefit every person who reads it.

by Catherine Read

Center to Champion Nursing in America – Inside Scoop

(Feb. 6, 2017) Catherine Read interviews Winifred V. Quinn, PhD, Director of Advocacy & Consumer Affairs for the Center to Champion Nursing in America. The CCNA is a collaborative effort of the AARP Foundation, AARP and the Robert Wood Johnson Foundation. Dr. Quinn talks about the hurdles facing Certified Nurse Practitioners (CNPs) in providing healthcare services in each of the 50 states. Requirements differ from state to state as far as physician oversight/collaboration with CNPs in the services they deliver to patients. States with rural populations have been the first to remove barriers to nurses providing services “to the full extent of their education and training.” More recently, the Veterans Administration has created a policy that allows nurses to provide services to the full extent of their education and training through VA facilities regardless of restrictions in place within individual states.

In the second segment, Catherine is joined by Andrea Brassard, PhD, RN, and Senior Strategic Policy Advisor to the Center to Champion Nursing in America. Dr. Brassard still engages in providing clinical nursing services on a limited basis in addition to assisting in CCNA’s policy creation. She brings a unique perspective to the benefits and challenges of allowing Certified Nurse Practitioners (CNPs) and Advanced Practice Registered Nurses (APRNs) to provide a full spectrum of healthcare services for which they have been trained. She points out that Nursing is consistently ranked as the No. 1 “Most Trusted Profession” in the United States and speaks to the varied skills nurses bring to their profession.

David DeBiasi, Associate State Director of AARP Virginia, joins Catherine in the third segment to talk about how the Affordable Care Act influenced modifications to the physician oversight requirement of Certified Nurse Practitioners here in Virginia. Instead of moving forward, Virginia’s policy moved “sideways.” The tweak to the policy has not allowed CNPs to practice to the “full extent of their education and training” and the resulting consultative/collaborative model has created a business model that doesn’t work for CNPs. While CNPs are required to collaborate with a physician in delivery of healthcare services through file reviews, physicians are not required to collaborate with CNPs. This has created instability in these relationships that undermines the creation of a viable business model.

Ultimately, the delivery of healthcare services in areas where there is a shortage of General Practitioner Physicians relies on removing barriers to nurses practicing to the “full extent of their education and training.” This realization that friction points are impacting the delivery of healthcare services have spurred states across the country to develop and pass less restrictive policies. Virginia currently does not have pending legislation in the 2017 Legislative Session. Going forward, it’s in the best interest of the public to understand these issues and why it’s important to advocate for nurses who will ultimately provide the bulk of the care for an aging American population.

Nursing is increasingly moving from clinical settings to community settings. Baby Boomers started hitting 65 in 2011 and will continue to hit that benchmark in enormous numbers through 2026. These are savvy consumers who fully expect to “age in place” in their homes and not in institutions. Quality of care for this growing population of Americans hinges on less restrictive policies for CNPs and APRNs and supporting healthcare models that are financially feasible for nurses to deliver healthcare in a variety of settings that meet the consumer’s needs.

by Catherine Read

Nurses in the 21st Century – Melissa Batchelor-Murphy

(Dec. 12, 2016) Catherine Read discusses the changes in the nursing profession with Melissa Batchelor Murphy, PhD, RN-BC, FNP-BC. Since Florence Nightingale first introduced nursing as a profession in the 19th century, there has been a steady evolution around what it means to “practice nursing.” There is now a variety of educational pathways, degrees and specialities within the field.

Dr. Batchelor-Murphy walks through what the various designations mean and how Advanced Practice Registered Nurses (APRNs) are delivering a great deal of the healthcare among specific populations like those in rural areas and to veterans being served by the Veterans Health Administration. A ruling just this week by the U.S. Department of Veteran Affairs (VA) grants three APRN roles (nurse practitioners, certified nurse-midwives, and clinical nurse specialists) the ability to practice to the full extent of their education and training.

There is legislation at both the Federal level and state level to address regulations around what services APRNs may provide without needing a collaborating physician to sign off. Regulations vary from state to state with many states with high rural populations recognizing that a physician shortage in remote areas creates a challenge for delivery of basic health services. As more physicians specialize, the pool of General/Family Practitioners shrinks.

Nurses are also increasingly choosing to pursue specialities, although the distribution is uneven. Dr. Batchelor-Murphy who focuses her nursing practice on geriatric patients is part of only 1% of three million nurses nationwide who has chosen to do so. Despite a population hitting age 65 at a rate of 10,000 per day, there are not enough gerontologists to meet the need.

Dr. Batchelor-Murphy addresses the challenges of a lack of diversity among nurses, the cost considerations in pursuing a degree in nursing and the shortage of nurse educators in programs around the country. While much is being done to raise the visibility of the nursing profession and to increase the scope of services APRNs are able to provide, there is a long way to go in attracting both men and women of diverse backgrounds to consider the field.

More information and inquiries for Dr. Batchelor-Murphy can be sent to her via her website at www.DementiaCareNP.com