American Health Care: Not Dead Yet!

I am back in the USA and just finished my OHSU class on US Health Services Systems. The following is my final that was written with a blog audience in mind.
Some of you may have joined my blog to follow my Philippine adventure and a long extended blog on Health Care Reform is not your cup of tea, please feel free to skip over this submission.
I promise you as I process the past 7 weeks I spent in Manila I've got plenty of material and pictures to share. They will be forthcoming. Enjoy, comments as always are welcome, just keep it civil, Be well! Lynn

      How is the American health care[1] system working for you? Your answer depends on your social status, political views and personal health experiences. Based on Gallup Poll’s series of November 2011 health and health care polls, 6 of 10 are satisfied with their health care costs, while only 2 of 10 are satisfied with the cost of health care nationwide (Newport, 2011). When polled for the most pressing health issue facing Americans, non-disease issues of access and cost replaced illnesses such as AIDS, Cancer or heart disease (Newport, 2011). For some the American health care system is inequitable, unethical and unjust and these poll results come as no surprise. Others struggle with the judgment, but would agree the health care they are paying for does not result in satisfying health outcomes. An additional data point is in the U.S. per capita health care costs out pace any other developed country almost 2 to 1 (Kaiser, 2011). Older Americans and the insured, whether employer or government funded, express the highest levels of satisfaction, 6 of 10. Americans below 50 years express the least satisfaction 5 of 10. There is a majority consensus as 72% agree “our society should ensure universal access to health care, and 60 percent consider it to be a moral…issue” (Levine, et. al., 2007). Exactly how and what is to be done is taking time in our democratic society. The first of the following three sections discusses the current state of health care in regards to cost, an outdated system and justice. The second section provides a philosophic foundation to address equitable, ethical and just health care. Included are some basic suggestions for revising the public funding system. Finally, the third section talks about the ultimate goals and performance outcomes of the recommendations.

Time for Change? 

      Health care costs grew to 17.6% of our Gross Domestic Product (GDP) in 2009. That same year 54.2% of federal revenues went to health care. The following year uninsured Americans climbed to 50+ million people or 16.7% of the population (Galewitz & Villegas, 2010). While expenditures on health care rise, those able to access are declining. The issues of justice and financial sustainability demand a change. How is it, unlike other consumer categories, cost containment of health care eludes us. Why do impoverished segments of the population go untreated until a major health crisis occurs resulting in more costly hospital services? Who ultimately pays for those services?

The Unsustainable Cost of Health Care
     In building a case to restructure health care delivery, it is helpful to start with a simple but brain-numbing review of the numbers. U.S. health care spending, on a slowing trend for this decade, reached almost $2.5 trillion in 2009. Projected spending by the end of 2011 is $2.7 trillion (CHF, 2011). By way of comparison Germany’s total GDP in 2010 was 2.9 trillion (Nationmaster.com, 2010). In 2006, almost ½ of health care dollars went to a mere 5% of the population with expenses at or above $14,601 per person per year (Kaiser, 2009). Medicaid reflects this as 57% of the spending is for 5% of the Medicaid population. Spending is also age determinant, those over 64 averaged $8,776 per person representing 43% of the average spending per person. This is almost twice as much as the 45 to 64 age group and 6 to 7 times as much as the children’s age groups (Kaiser, 2009). Of the nonelderly age group, 40% are on either Medicaid or uninsured and employers or private arrangements cover the remaining 60% (Kaiser, 2010). Interesting to note hospital and physician services received ½ of all health care dollars are spent (Kaiser, 2009). The remaining is spread somewhat equally between pharmaceuticals, dental, vision, administrative, and home care and nursing home care (Eadie, 2004). No easy fixes exist in an industry the size of Germany’s economy or structured to favor a cottage industry status quo (Swensen, et al, 2010). In the words of a Washington D.C. policy man, “Anything would be better than what we are doing now” (Ketch, 2011).
   
     It will take more than what have been feeble attempts to rein in costs as explained by Harvard Business School Economist Dr. Michael Porter. “Cost shifting and reduction methods historically have failed significantly, influencing health care spending levels, and jeopardize the future health of the public” (2008). Dr. Porter warns that these techniques only shift the cost of care to later when poorer health outcomes for the public require greater expenditures down the road (2008). Two realities that exacerbate rising costs are the lack of equity in health care and the failure to provide universal coverage. Inequity is exemplified by those paying taxes to cover the health care of previous workers yet go uninsured themselves (Levine et al, 2007). Lack of societal awareness of who comprises the uninsured sustains inequity. Three quarters of the uninsured are in working families, 54% are ages 26 to 54, 61% are above the federal poverty level, and 61% of uninsured families have one or more full time workers. The lack of universal coverage results in costly inefficiencies such as cross subsidies, those paying for health services additionally cover the cost of the uninsured. A second resulting inefficiency is failure to provide timely care in cost effective settings. Residents of a local family shelter in Gresham, Oregon often use costly emergency room services for abscessed tooth extraction or their children’s earaches because of limited access to preventive dental care or primary care services (MFH, 2011).

     Financing the current structure of health care is not sustainable. First is the unaddressed issue of health insurance. It is not true insurance but rather a combination of classic risk protection insurance, and prepaid health care for preventive care office visits and preexisting conditions. Second financing is not sustainable because arbitrary designations inform the fee for services reimbursement system and impedes innovation. Reimbursements fail to reward positive health outcomes and result in cost sharing, cross subsidies, and inflated health costs (Porter, 2008).

Outdated Service System

     An acute care, cottage industry service model continues to drive U.S. health care (Swensen, et. al., 2010). In spite of 100 years of public health and the more recent discussions of prevention, the health services model remains firmly in a physician/hospital centric model. Dr. Porter’s critique of the current health care system is how the practice of medicine is organized, managed, measured and paid for. He maintains that as long as the basic structure of delivery stays the same, any attempts at cost containment will only cost shift to the health care consumer. In addition, restricted access to preventive services shifts costs to services that are more expensive. He calls the current health care market a zero-sum competition between players that serve to divide value rather than improve it. By way of illustration, when you have one pie and several who want to eat it, cutting different sizes only changes the amounts each gets, it does not increase value beyond what the one pie can deliver. Health care zero-sum competition is when hospitals buy primary practices, or health plans bargain for better prices, or cost shift to patients thus dividing value as it pits the various participants against each other to capture more revenue. To make matters worse for the patient consumer “today’s competition in health care does not equate with value for the patient because financial success for system participants does not equate with success for the patient” (Porter, 2008).

     “Value [is] defined as the health outcome achieved per the dollar spent” (Porter, 2008). The current systems of measuring health costs and reimbursement programs do not capture both the direct and indirect costs as a patient navigates the system for a specific illness or co-occurring diseases. Dr. Porter argues the full cost for care related to the individual’s illness or preventative services is required to assess value. Otherwise, cost containment, improved efficiencies, or patient empowerment is not possible without knowing the actual cost of care from beginning to end. Currently the health care system is demanding more cash via greater employer and patient expenditures (steady rise of the GDP to the current 17%) and universal coverage. In the current delivery system, universal coverage will only extract more dollars and feed a system that is currently not accountable for the value delivered for the cost. Other competitive services in the American economy are accountable via competitive business practices that empower the consumer to choose the best value for their dollar, not so with health care.

Health Care Injustice

     For the purposes of discussing justice in health care, four designated social groups as related to health care follow. First, the health care independent has financial resources for coverage. They can seek alternatives to U.S. health care services including medical tourism. They can afford to pursue good preventative care. Second, the health care dependent, qualifies for Medicaid and Medicare. Currently Medicaid covers children and pregnant women at 133% of the federal poverty level, the disabled and long-term care (individual states can increase coverage). Medicare provides care for those over 65 and is an entitlement program funded by those currently working. Third is the health care indigent, those who do not qualify for Medicaid or Medicare and live below the federal poverty level. They are dependent on community non-profit charity services. Finally, the majority of the population, the health care vulnerable. They are the working, recently unemployed or early retired. They depend on and co-finance employers provided coverage or are uninsured. They are vulnerable in the current system because of the threat of losing coverage or financial ruin due to unexpected health care costs.

     For the health care independent care, quality options exist. The U.S. is touted a premier health service provider, medical tourism allows those with means to access care globally and at lower costs. The adage “It takes money to save money” surely applies. For those over 65 Medicare funds their U.S. care and does on the backs of the younger workers who may not have health care coverage. This group may represent the attitudes discovered in recent research led by Dr. Sussman Oakman. Research revealed that seniors and partisan groups, powerful political influencers, failed to understand the access issues of those at the other end of the experiential system (2010). While those at or below poverty level are suffering, most have access to basic health care from the federal/state safety net. What is troubling is the plight of those just above poverty level, up to and including middle class citizens especially in the 20 to 50--age range. They are funding health care for the poor, retired and disabled yet are unable to afford health care for themselves and their families. Where is the justice in that?

Justice and Value for All 

     System change will be both incremental with possible sudden adjustments all in the context of our political, legal and financial systems. The political system is better for incremental change, while the free-market system reinvents itself regularly to stay viable. Government bureaucracies are slow to adapt, as regulations already in place put restraints on the health care industry that free market proponents say impeded innovation (Cannon, 2009). What motivates the industry as in all business is financial sustainability; therefore, cost of care and outmoded systems are of constant concern. Three health care system challenges addressed above: the cost of health; an outdated delivery system; and injustice in health care access are central to revitalizing and stabilizing the health care system. The following suggests Values-based health care to revitalize health care services and universal access as the philosophical driver of financing care.

Philosophical Foundations

     Before discussing changes to the current system, the following gives a brief overview of a suggested philosophical foundation for health care, each of these are a topic for extensive discussion in and of themselves.
1. Ethical: There is a social responsibility to provide access to basic health care and prevention screening for all Americans. The employed that pay income and Medicare taxes, at the very least should have basic care, as they are funding access for the retired and poor (Levine, et.al., 2007).
2. Fiscal: For health insurance to be sustainable, it cannot be selective- insuring only the chronically ill. At the least all American’s should have catastrophic coverage for unexpected health events. Requiring or providing all with insurance will not solve all health care woes, but sets a fiscal foundation for access (AAA, 2008).
3. Political: Medicaid and Medicare should be block grants that allow local programs to insure or provide services to the uninsured/underinsured, unemployed, retired and disabled (Cannon, 2009). Congress should incentivize wellness program promotion by private industry and protect the poor and working taxpayer with health care access (Kennedy, 2011).
4. Public Health Policy: Shift resources from technology industry subsidies to research and programs for preventive care screening and early treatment of chronic conditions.
5. Delivery structure: Personalized care from a medical home[2] in primary and preventive care practices and Integrated Practice Units in specialty clinics. Reimbursement based on the service providers’ pre-established scope of practice. Established guidelines for management of full cycle of disease are basis to reimburse practices. Reimbursement rewarded based on outcomes adjusted for condition status at point of entry (Kaplan and Porter, 2011).

Financial Sustainability in Value Based Delivery

     Value based delivery will require reform at the practitioner level and increased responsibility from the patient. Continuity of care whether primary-prevention, chronic disease management, acute care or long-term care focused requires a transparent provider system and full patient participation. There is no longer room for physician authoritarianism; health care must be collaborative. Value based delivery from a provider-patient partnership is defined as “the health outcomes achieved per dollar spent” (Kaplan and Porter, 2011). How the practice of medicine is organized, managed, measured and billed for is the responsibility of the service provider, physicians and facility. Disease management and payment is the patient’s responsibility. Managing costs require collaboration between fully informed providers, patients and payers. Value-based care has four defining principles: 1) the goal of care is value; 2) care is organized around medical conditions; (Porter, 2008); 3) measure for patient outcomes; and 4) align reimbursement with value creation (Porter, 2008).

     For the purpose of this discussion, the role of Integrated Practice Units (IPU) promoted by economist Dr. Michael Porter and medical homes illustrate values based delivery. As a patient centric system, an IPU’s goal of service is value added as opposed to cost containment, maximizing revenue or providing full scope of services. Optimized care over the complete cycle of care requires organizing a practice around a medical condition or co-occurring conditions. IPUs recognize and manage the intervention of one physician as impacted by interventions earlier or later in the cycle (Porter, 2008). Utilizing electronic record keeping updated to track the services provided for the patients total care (to include indirect costs of facilities) allow for measuring complete cost of care. Measuring value-based care along the full continuum of care allows the system to adjust for waste, inefficiencies and protects against redundancies. IPU provider teams that have the advantage of scale and experience maximize efficiency from clinic volume, shared equipment and teamwork thus influencing health care costs. Most notable of an IPU benefit is for those with co-occurring conditions. The IPU will provide all related physician and care services. In rare co-occurrences, another IPU provides care, but from the patient perspective, they would have only one point of contact for each IPU (Porter, 2008).

     Medical homes practiced in federally qualified community health centers (FQCHC) are an example of an IPU at a primary and prevention care practice. The health team shares management of the patient’s continuum of care. Value-based care influences the cost of care by raising value. Efficiency of health care is a step to improve access by better managing resources rather than entire sub groups being restricted from access.

     Financing suggestions. Coverage in the form of catastrophic insurance, primary & preventive care services and chronic disease management should be the primary aspects of universal access. Working within the current funding structure of health care public aid, Medicaid expansion would cover primary and acute care expenses of all at or below the poverty level regardless of age or work status. Medicare funded by payroll taxes would expand to include those qualifying for unemployment, the uninsured or underinsured workers above the federal poverty level, and those of retirement age adjusted up to 70. States using private payer systems reimburse to Integrated Practice Units and/or medical homes models funded by Medicaid block grants. Private payer systems use capitated complete cost of disease care models to refund from Medicare block grants. Larger businesses have continued or increased tax incentives to provide catastrophic health insurance for their employees and family members (broadened to non-boarding residents). Additional tax incentives are available for business sponsored wellness programs with the option of employing a prevention/primary care IPU medical staff, with employee/management oversight to protect patient rights. Health Savings Accounts are available for anyone wanting to save tax-free money to cover health care premiums or costs.


Equity, Justice and Compassion: Access for all

     Access defined here based on the Hasting Center Report by Levine et al is “an adequate level of protection from illness and avoidable pain and suffering related to health problems” (2007). It does not mean access to all possible medical alternatives or useful services. Access is interrelated with cost and quality. To provide universal access quality of service is necessary in managing costs. A sustainable system that is equitable controls cost by improving efficiency, not restricting access (Levine et al, 2007). The harsh reality of competing needs for limited resources demands that ethical health services minimize waste and improve efficiency. Providers are not alone in responsibility, patients have an ethical responsibility in how they demand and utilize care. Achieving universal access must acknowledge the ripple effect of using limited resources to increase access and how that will affect the quality of care for all. When societal perceptions of quality are full-unrestricted choices in care, increasing access is cost prohibitive without improving efficiency. Those who are currently benefiting from societal resources whether social services or entitlement programs do so on the backs of the workers taxes who often are unable to afford care for themselves or their families. Reflecting on the 72 percent of Americans who “think our society should ensure universal access to health care, and 60 percent (who) consider it to be a moral rather than a strictly political or economic issue” and “it is inequitable for the uninsured to subsidize those with coverage” (Levine et al, 2007).

Spending for Health

     Two goals. To improve the health of our nation and to manage the cost of care two broad goals with strategies and action items follow: 1) Increase health care access and 2) Improve health care outcomes
     Five strategies. The previous sections support the following suggested strategies to reach these goals. The first four are policy strategies that would require congress to change laws that regulate Medicare and Medicaid.
1) Medicare extended to part time or minimum wageworker or temporarily unemployed who are above the poverty level and uninsured.
2) Put a freeze on current employer provided health care to prevent employers from dumping health care plans, shifting their employees to Medicare.
3) Expand Medicaid to include all at the federal poverty level.
4) Raise the poverty level to reflect the actual cost of food, rent, and utilities for individuals and families.
The final strategy would incentivize expanding the Public Health work force and volunteer service. Several action items that would also require legislative action follow.
5) Reduce future health care demands from the general population by increasing primary care access points and funding prevention programs.
Action items to implement the fifth strategy. 1) Increase capital funding to federally qualified community health centers (FQCHC). 2) Staff FQCHC with medical interns/residents and health care grads enrolled in the U.S. Public Health Service (USPHS) who commit to serve for loan forgiveness or because of federally funded grants they received for their education. 3) The USPHS corps functions as medical home teams or IPUs. 4) Create a volunteer Corps or Reserve Corps of retired Health care providers to mentor health teams and provide health education. 5) Incentivize those receiving federal or state funded health care to attend classes focused on prevention messages and personal health responsibility.

     Performance elements. The economic impact of funding a USPHS corps could bolster the medical training facilities and lowering the overall cost of training. These graduates will staff FQCHC providing prevention based primary care. Marketing the corps to minority students who will receive loan forgiveness packages when they work in the public health/primary care facilities will have a positive impact on minority health care. Current medical home model or IPU clinics and practices can receive Medicare/Medicaid reimbursement as long as they incorporate the following into their practices:
1. Electronic record keeping that:
a. Measures cost of complete continuum of care provided to patient
b. Easily transfers patient records to the patient and the specialty IPU if acute condition occurs.
2. Transparency of records and costs to patients and payers
3. Medical home or IPU practice principles
     Funding in part is by Medicaid/Medicare from state block grants funded by employment taxes. Those companies that fund their own health care programs will be exempt from employer health care taxes. Exemption prevents double funding and incentivizes the private sector to participate in providing health care for their employees.
     By increasing access to primary care, teaching health classes, screening for disease and early intervention the health of the public will improve and lower the cost of acute care services. This too will drive the health care market to invest in primary care, early intervention and prevention services in the private and public sectors.
     No system change will be without drawbacks. The current stratification of classes accessing different levels of care will continue, but resolution should be a priority once the majority of citizens have basic health care and values-based competition controls cost of care. Another drawback, limiting access to some forms of care, is a reality of medicine funded by taxes. Particularly challenging are those currently receiving services. A grandfather clause of completing care begun, but no longer offering services to new patients is a compassionate alternative.
     Additional considerations. Yet to address is the uneasy relationship of health care with technological development of medical devices and pharmaceuticals. Along with long term care of the aged and disabled, they represent the bulk of health care cost increases. Yet research has borne out their worth (Cutler and McClellan, 2001). A recent TED Talks participant, Mick Ebeling inspires with his story of technologists combining their efforts to address a need that insurance caps and government programs could not address. Ebeling created a dream team of computer wizards and technology geeks to build a writing device for a former graffiti artist TEMPT, immobilized by ALS, Lou Gehrig’s disease. Over time, they invented an eyeglass laser device that allows TEMPT to create art (Ebeling, 2011). This story illustrates that it will take more than government policy, finance reform or provider and patient responsibility to meet the challenges of health care reform, it will take the compassionate and innovative actions of all Americans to support those less fortunate.
     Some Personal Thoughts As a middle class member of American society who has had our financial nest egg wiped out by repeated economic meltdowns of the past 10 years the current state of health care financing is very personal, 1/5 of our monthly take home finances our health care premium. We cannot afford the primary care we need due to the $2,500 deductible for each of us. We are in a high-risk pool due to health care reform law provision. We cannot easily apply for new individual coverage due to our age and preexisting conditions. Three of our young adult children have access to lower cost coverage, but we cannot drop them from our coverage without reapplying for a new plan. Nevertheless, we stay in the system, slowly bleeding out financially because at least we have coverage in case of an unexpected disease event. We have witnessed several industry market corrections, the dot com, followed by the communications industry, followed by the financial services industry. It seems only a matter of time before the health care services industry experiences a market correction of its own. It would be preferable to be proactive with health care reform, rather than reactive. The current stalemate in Washington DC is holding us hostage to a broken system that is draining dry those who finance health care, the patient and taxpayer. Health care is a symbiotic system between provider and patient, when the patient cannot afford the primary and preventive care the system benefits with higher payments for acute care. What is honorable or compassionate about a system that funds itself off the preventable acute diseases of its clients?

References 

American Academy of Actuaries. (2008). Fundamentals of insurance: Implication for health coverage. Issue Brief, July 2008.
California HealthCare Foundation, CHF. (2011). Health care costs 101. California Health Care Almanac, May 2011.
Cannon, M.F. (2009). Yes, Mr. President a free market can fix health care. Policy Analysis no. 650, October 19. Retrieved 11/2011 from www.Cato.org
Cutler, D.M. and McClellan, M. (2001). Is technological change in medicine worth it? Health Affairs, September/October 2001.
Eadie, J.S. (2004). Where do we spend our healthcare dollars? EM Resident, June/July 2004. Retrieved 12/7/11 from http://www.emra.org/emra_articles.aspx?id=35152
Ebeling, M. (2011). The invention that unlocked a locked in artist. TED Talks. Retrieved 12/9/11 from http://www.ted.com/talks/lang/en/mick_ebeling_the_invention_that_unlocked_a_locked_in_artist.html Galewitz, P. and Villegas, A. (2010). Uninsured rate soars, 50+ million Americans without coverage. Student Doctor Network, September 19, 2010. Retrieved on 12/7/11 from http://studentdoctor.net/2010/09/uninsured-rate-soars-50-million-americans-without-coverage/
Henry J. Kaiser Family Foundation. (2009). Health care costs a primer: Key information on health care costs and their impact, March 2009. CA.
Henry J. Kaiser Family Foundation. (2010). The uninsured a primer: Key facts about Americans without health insurance, December 2010. CA.
Henry J. Kaiser Family Foundation. (2011). Health care spending in the United States and selected OECD countries, April 2011. Retrieved 12/7/2011 from http://www.kff.org/insurance/snapshot/oecd042111.cfm. Kaplan, R.S. and Porter, M.E. (2011). The big idea: How to solve the cost crisis in health care. Harvard Business Review. Retrieved on 11/25/11 from http://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care/ar/pr
Kennedy, K. (November 25, 2011). Firms bet money will prod employees to health. USA Today.
Ketch, B. (2011). Private conversation with Washington D.C. insider. December 4, 2011.
Levine, M.A., Wynia, M.K., Schyve, P.M., Teagarden, J.R., Fleming, D.A., Donohue, S. K., Anderson, R.J. Savin, J. and Emanuel, E.J., for the Ethical Force Program. (2007). Improving access to health care: A consensus ethical framework to guide proposals for reform. Hastings Center Report, 37:5, 14-19. Mathematica. (2008). Making medical home models work: Moving from concept to practice. Policy Perspective No. 1, December. Retrieved from http://www.massmed.org/AM/Template.cfm?Section=Home6&CONTENTID=30253&TEMPLATE=/CM/ContentDisplay.cfm
Millensen, M. (2010). “Healthcare” vs. “health care”: The definitive word(s). The Doctor Weighs In, August 29, 2010. Retrieved from http://www.thedoctorweighsin.com/%E2%80%9Chealthcare%E2%80%9D-vs-%E2%80%9Chealth-care%E2%80%9D-the-definitive-words/
My Father’s House. (2011). Personal stories shared with author in the summer of 2011 while establishing a Health Team.
Nationmaster.com (2010) Economic statistics. Retrieved on 12/7/11 from http://www.nationmaster.com/graph/eco_gdp-economy-gdp
Newport, F. (2011). Views about personal healthcare costs largely unchanged. Gallup Polls, November 18, 2011. Retrieved 12/7/2011 from www.gallup.com/poll/150836/views-personal-healthcare-costs-largely-unchanged.aspx.
Newport, F. (2011) Editor-in-Chief insights: Top U.S. health problem, then and now. Video Reports, November 17, 2011. Retrieved 12/7/11 from http://www.gallup.com/video/150824/Editor-Chief-Insights-Top-Health-Problem.aspx
Porter, M.E. (2008). Value-based health care delivery. Annals of Surgery, 248:4.
Sussman Oakman, T., Blendon, R.J., Campbell, A. L., Zaskavsky, A. M., and Benson, J. M. (2010). A partisan divide on the uninsured. Health Affairs, 29, No. 4: 706-711.
Swensen, S.J., Meyer, G.S., Nelson, E.C., Hunt, Jr., G.C., Pryor, D.B., Weissberg, J.I., Kaplan, G.S. Dayle, J., Yates, G.R., Chassin, M.R., James, B.C., Berwick, D.M. (2010). Cottage industry to postindustrial care-The revolution in health care delivery. New England Journal of Medicine, January 20, 2010. NEJM.org. Retrieved 12/7/11 from www.nejm.org/doi/full/10.1056/NeJMp0911199.
The Delta Group. (2010). 2010. Is there a correlation between a state’s quality of care and patient satisfaction? 2010 Carechex Research Study. Retrieved on 12/7/11 from www.carechex.com/media/studies.aspx
Williams, S.J. and Torrens, P.R. (2008). Introduction to Health Services, 7th ed. Delmar Cengage Learning. U.S.

[1] Humorous blog entry “Healthcare” vs. “Health Care”: The Definitive Word(s) by M. Millenson.
[2] Medical home models provide accessible, continuous, coordinated and comprehensive patient centered care, and are managed centrally by a primary care physician with the active involvement of non-physician practice staff (Mathematica, 2008)

Filipino Clinicians and Filipino Businesses partner with ICM providing health care for the poor.

Tagbiliran, Bohol.

Minierva Lahaylahay

Yesterday I had the privilege of observing the “brain child” of ICM Program Development leader Minierva Lahaylahay.    A one day, minor surgery medical clinic run by doctors from Cebu City’s Perpetual Succour hospital.Funding was provided through the local Lions club, President George Lim, who coordinated the local businesses including the brand new surgery area in the local hospital Holy Name University Medical Center Foundation.

Surgical Team from Cebu City

       

Having local organizations and regional doctors partner to provide care is one step closer to providing continuity of care for the poorest of the poor.

Head Surgeon

Program Development leader Minierva was responsible for contacting and screening the area’s potential clinic patients through the network of community leaders, the local pastors that ICM supports via training, networking, food and care clinics.   After it was obvious that Minierva’s preplanning and organizational skills had resulted in a smooth running operation, I had time to ask her about her vision and the obvious successful result.  She credited the leadership of ICM Area Head Primo Sistual for allowing her to conceive the idea; foster the community relationships resulting in financial and clinical support from Lion president George Lim and the lead surgeon and work in the pastor network of ICM to identify clinic patients.  Over 500 community members who live in a 3 to 4 hour bus ride were originally identified.  When the scope of the need overwhelmed the resources available Minierva worked with the lead surgeon to focus the purpose of the clinic on minor surgery, requiring only local anesthesia.  The potential patients were told those with cysts and lumps would be prioritized.  She was able to cull the list down to over 100, still a daunting number for a one day clinic.  The lead surgeon came two weeks in advance to prescreen those who requested care to determine if their need fit in the scope of practice for that day, only 15 arrived.  On the day of the clinic when I arrived at 8am at the ICM base, where intake and triage was done, there were already 30+ on the list, which eventually grew to 82.

Intake starting at 8am already a line and a very warm day

The first 15 were sent to the hospital, conveniently located just down the street for the 11am start time.  I joined the staff with the local Lions club members to welcome the surgical staff arriving from their 2 hour ferry ride, as Cebu City is on a different island from Tagbiliran.  We greeted four surgeons; two general, one orthopedic and one vascular along with a surgical intern and surgical resident with 4 assisting nurses. 

All ages were present at the clinic with cysts, lumps and bumps.  Priority was given to those who had a 2 to 4 hour bus ride and would need to be on the return bus late afternoon.  Some were treated and others referred to the lab for X-ray or ultrasound.  Some would have to return when the team scheduled a general surgery clinic requiring general anesthesia. 

Marnett, Jen & Lou, 1/2 the Bohol Health Team

I lost track of the ones I met in the early hours as I had to leave to catch a plane only 3 hours into the clinic, but I was present to hear the sober prognosis of one woman with lymph nodes that where swollen and ulcerated.  She had seen a local doctor; he had diagnosed stage 3 cancer and offered, if she could pay, to remove them.  We are serving the poorest of the poor, so most likely all her resources had been used to get the original diagnosis.  She had shown up that day in hopes of accessing free surgery to remove the lymph nodes.  After one of the attending surgeons assessed her situation it fell to ICM COO Helen Turner, Special Medical Cases leader Lou Cosenas and Minierva to break the somber news.  She had terminal cancer and while a local doctor might be offering surgery that she could not afford, it was recommended that she go home and spend time with her family and allow ICM to help support her with palliative care.  It was a difficult time.  Minierva is a compassionate woman, and this was not what she or any of us would have wished for this woman.

Clinic site

Later in the day as I visited with Bohol Area Head Primo Sistual I reflected on how fantastic it is to see local businesses supporting regional doctors in providing necessary care to the poorest of the Philippines.  It is through local pastors, businesses, and physicians galvanized by International Care Ministries that the generational bondage of poverty can be broken.  A new generation of Filipino leaders like Ms Minierva and Mr Primo, focused on the needs of the most vulnerable have inspired and provided a way for their community to reach out in compassion to provide health care for the poorest members of their community.

Arrived in Manila

My Brain on Sleep Mode

I have arrived in Manila, my new home shared with my husband and 15 yr old for the duration of our ICM assignment.  Five weeks of packing followed by jet lag has been a recipe for brain shutdown, not unlike the sleep mode of my computer.  I have a new awareness of how much we take brain function for granted.  I learned only two weeks into packing that the daily decision making regarding our stuff resulted in my brain “checking out” by 6 at night.  

I re-learned the value to providing it with proper protein, fluids, relaxation and restorative sleep.  Now as I emerge from the fog of jet lag, I look forward to the “normal” demands of adjusting to a new living environment and culture.  I must eat well, drink fluids, exercise and rest if I am to be at the top of my game for the learning curve and new decisions facing me. 

We never know what adventure or surprising turn of events awaits us. Rather than living in consuming anticipation or dread, take the opportunity now to feed and care for your brain, eat well include Omega 3 fatty acids, give it time to rejuvenate with restful play and 8 hours of sleep.

Typhoons! Oh my!

We have arrived right in the middle of typhoon season.  Just as one subsides another system forms off in the Pacific and moves in.  They are devastating but as is typical in the states it is the poor who are most vulnerable to the effects.  The middle class and wealthy typically live on higher ground and are spared any real effects other than the inconvenience of slower travel or at most being confined to home for a day until floods subside.  The poor are regularly evacuated, sheltered and then return home to rebuild.  I would post pictures, but I was confined to the Hong Kong airport for 24 hrs during Nesat and have nothing…

This coming week will be about focusing on school work, looking for apartments and preparing for my first public health team meeting.

Be well…

What we need is sustainability...

Sustainability...a popular term in the green Pacific NW.  Imagine my pleasure when I heard it role off the tongues of Philippine leaders of the island communities participating in ICM Values, Health and Livelihood programs.  The 4 and 6 month  community programs we support are much appreciated. "But what", asked the leaders, "is to be done about sustainability?"  And that is the 40 million Filipino peso ($1 million USD) question.   How is capacity being built into the individuals so that they continue to live out the values, health and livelihood training after the ICM trainers have left?

Before expecting follow through from others a little self reflection is in order here.  How do I sustain healthy living practices?  Three topics come to mind immediately and bear some thought

• Recognizing my value and the worth of my dreams
• having like minded friends and 
• grace for a fresh start each day.

Worth and Vision
When I see myself as an individual of worth and that I have something of value to contribute to my world then choosing healthy practices will support me in my endeavors.

• eating balanced meals using the     My Plate, 
• exercise, "10 minutes at a time is fine"
• regular Rest and Relaxation
• Spiritual renewal and fellowship

Supportive like minded friends always helps

Fresh start each day
Waking with an attitude of thankfulness for a new day, not living for perfection, but enjoying the day and flexibly navigating unexpected events.  Supporting my body, mind and soul with healthy choices of fresh fruits and veggies, positive-supportive thinking and conversations and an attitude of prayer.  It won't change my circumstances, but I can change my outlook and response.

Be Well,

Lynn

Sorting, Storing, Shipping, Selling

We are in the final stages of figuring out what to do with our stuff.  The proverbial light is shining!
Clothes and some personal serving and decorative things are packed to ship Sept. 8th for the Philippines.
We have solved the storage issue and that has made the whole process much easier.  And then there are our dear friends who have stopped by to pack boxes, totes and schlep stuff all over the property.  The repair work has begun around the property and it's looking mighty fine, too bad we can't stay to enjoy it!

Lee and Kit are doing the same thing in Chicago tomorrow moving into their newly wed apartment.  Kit's dad drove their wedding presents to them and will help with the move.

Stephen is a happy freshman at Wheaton enjoying his 4 classes and enthusiastic roommate.

David leaves Thursday morning for London, traveling two days to arrive at Wycliffe College at Oxford to study philosophy for 3 months.

Brad leaves Thursday for Hong Kong and begins an intense 6 week transition time with ICM's current CEO

Andy and I are finishing up preparing the house for renting and starting our respective online schooling programs, my 5th course in the Public Health program at OHSU and his 1st semester sophomore year. We do not have a departure date yet, sometime after September 15th most likely.

Wishing you all well, if you are waiting for a dream to be realized, don't despair when the timing is right and as you are faithful in your current circumstances, it will come together and be SWEET!

Be well!

Handwashing a mother's challenge the world over!

Enjoy the video at the following site
http://blog.caremin.com/2011/08/19/tippy-tap-a-happy-day-for-hygiene/

Dreams do come true!

Last night the board of ICM, International Care Ministries, offered me a position on their public health team!  You could knock me over with a feather!  I went to the Philippines last week to learn about their work and about Manila in preparation for Brad to accept the CEO position.  Yesterday I was offered a job, a dream job in international community public health.  A job I thought impossible considering my late entry into the field of public health.

I will join a very capable public health team;

·        Helen a former psychiatric nurse from Australia passionate about health & wellness promotion in a medical clinic setting. YES! Fist pump!

·        Mindy, a physician from England working with malnourished children, I saw with my own eyes their effective partnership with Feed My Starving Children.

·        Dedicated Filipino nationals, weekly caring for thousands of very poor women and children.

It is a “dream come true!”

A year ago a VP of a major relief and development organization warned me gently that my age and lack of experience in public health made it unlikelihood I could have access to such a role. Thanks be to God he is not bound by limits.

So what is next?  In the weeks ahead I will be doing three things:

1. Preparing Andy to transition to International School as a charity agency in Hong Kong has awarded him with a scholarship.

2. Getting rid of 24 years of household accumulation and renting out the house.

3.  Discovering emotional, prayer and/or financial partners who are passionate about supporting the team and me working to alleviate the physical suffering of the poorest of the poor in The Philippines.

Please don’t pinch me; I don’t want to wake up!

Be well!

Lynn

Click here If you wish to receive email or blog updates regarding the work I will be supporting.

Manila and beyond

We have arrived home from the Philippines and before too much time passes I need to share the final stage of our trip.  We spent the last four days in both Manila and Hong Kong meeting the national staff in Manila and the financing board and support staff in Hong Kong.

An amazingly skilled and passionate group of people.  The Manila staff supports the 5 provincial bases scattered around the islands the Hong Kong staff and board provides the financial backing.

Here is an aerial view of Manila and a modern day Jeepney.  Some of them are REALLY decked out with airbrush portraits and designs outside and padded seats, LED strip lighting and heavy bass booming.  Others, which I intend to frequent more regularly are driven by the older guys with nothing to prove and they use the 20 cents/passenger fee for gas and presumably living expenses.

Hong Kong was amazing, the weather was unseasonable cooler (all relative) the sky was blue (usually smog filled) and the traffic was surprisingly sparse even less than downtown Portland (typical, well developed public transport makes using a car less necessary)

We finished off our trip with a board meeting on the 86ish floor of the tower you see just in the fore ground only 5 floors from the top.    We watch the sun set from the meeting room it was a true pinch me moment.

The islands

We have been traveling in the region of islands referred to as the Visayas were the majority of the 7000 islands are.  Bohol is the resort island with beautiful beaches and warm bathwater swimming.  Negros is a mountain island with the plains growing sugar cane and rice.  The fields were a stunning green as we drove  from Dumaguete to Bacolod visiting rural and smaller town recipients and pastors along the way.  A local pastor is the heart and feet of the community.  He or she is the one who knows who the poorest of the poor are.  They are the ones ICM resources so that the poor receive nutritional support, health education and livelihood training.  When a particularly malnutrition child is identified they come under an intensive feeding program.  We saw a darling little girl named Angel who was born shortly after her older sister and before her mother nutritionally compromised herself could rebound.  Little Angel has never been able to rebound from the nutrient deprivation and now at the age of 3 she looks like a lanky 18 mo old.  Under ICM's malnutrition child operation her hair is filling in and she is gaining weight.  By the time she is an elementary child she will have caught up with her peers.

I have very few pictures of the locals.  It is a bit of a sensitive topic as we listened to a group of pastors conducting their monthly Thrive meeting (ministerial association) share how the poor often feel exploited, believing that we profit from the photographs and they do not.  So, I have wonderful memories and many shots like this one, a rural barangay (neighborhood) path and gate.

Or pictures of us. First Brad geeking out over the vermiculture lab at the local ICM base in Dumaguete or the next one of me reminding the recipients  how important it is to wash hands before cooking and after using the CR (comfort room aka toilet)

Andy had his first motorbike ride to a local animal "zoo" where he saw the tarzier (endangered world's smallest monkey) and pet a python.

Off to visit the urban barangays which have  similar and different challenges than the rural ones

Philippines adventure

I thought for the time being I would post our Philippines adventures here on my wellness blog.  As you will see the trip is related to health and wellness,  but in a very different culture from my own western culture.  As some of you know Brad is considering and being considered as the CEO of International Care Ministries ICM, a faith-based community development organization that works through local churches in impoverished rural towns and slums of the cities.

Brad, Andy and I board Delta for Manila Philippines by way of Tokyo Thursday afternoon for a 15 hour flight that lands in Manila 10pm Friday night, so we loose a day. The following is our 12 day itinerary along with what video and web pages I found by which to share where we are and what we're doing.

We overnight in Manila and then head to the Island Bohol where we will spend our first 3 days meeting the region staff and pastors, visiting the community they serve and learning about the wide range of programs ICM administers.  Sunday (your Saturday night) we'll be attending a slum church. Monday we will be trained in the Values, Health and Livelihood adult curriculum.


Thank You Video from caremin on Vimeo.


The itinerary says we knock off early to help cope with Jet lag, I'm thinking this hammock has my name on it.

Monday evening we head by boat to Dumaguete on the Island of the Province Negros Oriental. This is where our good friends Dave and Rena Larson's twin sons are living.  Dave is responsible for recommending Brad to ICM. After meeting the staff we will visit slum communities and participate in the VHL training that we  learned back at Bohol. Wednesday we will drive 5 hours north to Bacolod in Negros Occidental Province visiting ICM supported communities along the way. 

Thursday we will again meet staff and visit the orphanage in Bacolod. Anyone's head spinning yet??

Friday through Sunday will find us back in Manila learning the area, visiting Faith Academy and you guessed it, meeting the staff :)  Please oh please could I just remember a few of the names when this is over.

After church on Sunday at the local ExPat and then Filippino Churches we fly to Hong Kong to meet the board on Monday.  After this whirlwind experience of a lifetime hopefully we and  ICM will know if we are a match.  Tuesday morning will find us boarding in Hong Kong and the arriving in Portland at 8:30am Tuesday, so we get our lost day back.

I will attempt to post additional blogs from the various hotels we stay in and keep you updated.  Check back or if you are a Facebook fan, I will share my blog updates on my status.

Be well!

MyPlate and PowerPlate Replace the Food Pyramid

Check out these websites for food and recipe suggestions.  I am pursuing adding whole grains and legumes to my summer diet.


http://pcrm.org/health/powerplate/
  http://www.choosemyplate.gov/

For those of you who enjoy political and philosophical sparing here is a site that shows the disconnect between the USDA dietary recommendations and the Farm Subsidy Bill, civil discussions encouraged.
New Dietary recommendations meets the Farm Subsidy Bill