- Email: [email protected]
Poverty: An Iowan perspective
PAGE 34
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
JUNE 2008
Poverty: An Iowan perspective Cynthia Christensen, MSN, CVN, ARNP, and Elaine Gates, RN, BS
Poverty affects every person in America whether you are one of the rich or one of the poor. Our daily quality of life is determined by our shelter, access to clean water and food, and health status. Our quality of health is often determined by our access to health care. There are many disparities in health care, and business and societal expenditures are associated with these. Business costs can be measured in the number of inpatient and outpatient days, the number of requests for specialty care, and the amount of medication use.1 One study2 showed that among elderly rural adults with type 2 diabetes, predictors of specialty care use included gender, socioeconomic status, education, diabetic medication use, and self-rated health. These factors reflect an increased risk of complications. Societal impact of disparities can result in increased disability, poverty, family stress, premature death, or mortality.1 In the period from 2002 to 2004, 15.5% of the US population was without health insurance coverage.3 In Iowa that number was 10.1%, which may be related to a higher number of persons 16 years or older in the workforce, 69.9% compared with 65.9% nationally.4 The per capita income for Iowans in 2005 was $23,340, lower than the national income of $25,035.4 Despite this, fewer Iowans had incomes below the poverty level (10.9% vs. 13.3% nationally).4 A large number of Americans without insurance coverage have chronic illnesses,5 including diabetes, heart disease, and depression. Many of these persons delayed or did not receive care because of the cost. Multiple barriers to health care exist, such as access to health care, including not having insurance, not having a usual source of care, lack of transportation, location of providers, lack of child care, and many others.1 There has been a perception of greater equity of health care in older Americans because of the availability of Medicare, but this does not appear to be true. One study5 of Medicare beneficiaries between 1995 and 1997 showed that 11% delayed care because of the cost or not having a specific source of care. In 2003, there were 40,203,000 Medicare enrollees in the United States; 479,000 of those lived in Iowa.6 Barriers to health care for persons aged 65 years and older include out-of-pocket expenses related to supplemental insurance coverage, race, education, age, and gender.5 Satisfaction with provider services may also affect perceptions of access to From House Call Services, Des Moines, Iowa. Corresponding author: Cynthia Christensen, MSN, CVN, ARNP, 604 N 8th Street, Grimes, IA 50111 (E-mail: cindichr@aol.
com). J Vasc Nurs 2008;26:34-36. 1062-0303/2008/$34.00 Copyright © 2008 by the Society for Vascular Nursing, Inc. doi:10.1016/j.jvn.2007.09.001
health care and clinical outcomes. In the Cardiovascular Health Study,5 the most common barrier to seeking health care was the doctors’ lack of responsiveness to concerns, cited by 32.9% of respondents. Other barriers identified were medical bills, transportation problems, street safety, fear of discovering a serious illness, fear of unneeded tests, not having a regular doctor, taking care of others, and work responsibilities.5 This study concluded that the persons at greatest risk for confronting barriers were those with the lowest income, those in the oldest age group, females, those with less education, and those lacking secondary insurance, with income being the strongest factor. The fact that income has such an impact on Medicare beneficiaries carries over to their use of medications. Those persons without prescription coverage use fewer medications, which is associated with worse health outcomes. Cost-related underuse of medications is common among adults with chronic illness.7 Many Medicare beneficiaries are on fixed incomes. Once the money budgeted for out-of-pocket expenses has been spent, the cost for medications may compete directly with other necessities, such as food and utilities.7 Studies have shown7 that a better physician–patient relationship quality is associated with less cost-related skipping of medications. Better communication with patients may reveal their inability to pay for medications, and changes can be made to better fit their budget. Patients will also be able to make informed decisions about medications and other treatments. It is important to realize this application even for those persons with prescription coverage. There are so many plans, tiers of payment, and periods in which all medications are out of pocket until another level of expenditure is reached that it is difficult for the patient and practitioner to choose appropriate treatments. Better communication with all persons involved, including pharmacists, can lead to increased medication compliance. For a nurse practitioner in the state of Iowa, these factors are important. Iowa ranks sixth6 among the states with the largest population of persons 65 years and older and first in the nation for the proportion of adults 85 years and older.8 Our practice consists of an internist, a registered nurse, a part-time receptionist, and me. We have tried to eliminate some of the barriers to health care by seeing clients in their homes. All of our clients are home-bound because of the inability to drive, need to remain in the home to care for a loved one, or refusal to go to a clinic for health maintenance. We have approximately 365 patients, many who are seen on a monthly basis. According to the Senior Living Program Income Guidelines FY089 (Table I), 95% of our patients are low income and 1.4% are of moderate income; 15.6% of those in the low-income category are less than 60 years of age. The 2005 estimated population for the state of Iowa shows 14% of the population is aged more than 65 years compared with 12.1% nationally.4 In our current practice, 66% of our patients are 75 years of age or older. Our practice struggles with many of
Vol. XXVI No. 2
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
TABLE I SENIOR LIVING PROGRAM INCOME GUIDELINES FY08 Senior Living Program Trust funding is available to low and moderate-income persons 60⫹ years of age. Low income: ● Single person ⱕ$22,428 annually. ● Couple ⱕ$33,624 annually. (For each additional person in household, add $11,196.) Moderate income: ● Single person $22,429 to $30,630 annually. ● Couple $33,625 to $41,070 annually. (For each additional person in household, add $11,196.) the barriers Medicare recipients face throughout our country. When the Medicare D prescription plans were introduced, it was chaos for our patients and our office. Many of our clients had no family support to sift through all of the options and find a plan for coverage. Others found themselves signing up for a Medicare health maintenance organization, not realizing this changed their basic Medicare coverage and eliminated some previously covered services. Medications and their ordering present the biggest problem for our patients. Along with trying to remember which medications are covered under different plans, we also find many drugs are not covered without prior authorization, and some are not covered at all. This results in a delay in starting medications and added work for office staff. We continue to have clients without any prescription coverage and must carefully chose medications to best fit their budget and health care needs. We have also found some agencies that target the elderly and low-income clients, selling them insurance plans and then switching the insurance provider so the salesman can receive another commission. This results in greater cost and lower quality of health for our clients through increased cost of prescriptions or delay in obtaining medications until the correct medication for the new insurance plan is determined. When these changes are combined with a decrease in understanding of what is happening or the importance of the medication, patients may wait weeks before receiving medications when the problem is discovered at their next visit. This is reduced when there is also a home health nurse involved in patient care who reviews medications with the patient and alerts our office when they are not received. There are also companies that offer supplies with no support for repairs. Some patients, lured by commercials promising no money from them, will order a wheelchair or other needed item. If appropriate, a prescription is written and the item is obtained. This works well until a breakdown occurs and repairs are needed. Some companies offer no repair support, forcing the patient to incur out-of-pocket expenses for repairs or shipping. Many supplies needed for the patient to remain safely in the home, such as commodes or shower bars, are not covered under a patient’s insurance plan. This results in higher costs for patients or increased risks of falling, which lower their health status.
PAGE 35
We also found companies that target patients who are receiving monetary assistance or programs for unnecessary or extra supplies. For example, we have patients who receive incontinence supplies from a vendor. Every month the company calls the patient to see what supplies are needed. They may ask if they would like additional supplies the company offers, such as a heating pad. Without the proper diagnosis this item will not be covered by their insurance and result in greater out-of-pocket costs for the patient. Another example is a patient with cough and congestion related to cigarette smoking and environmental allergies. The patient found nebulizer products on the Internet that he thought would help his congestion. The company first sent him a nebulizer machine and medications, and then sent our office a prescription request. Because he had no proper diagnosis for nebulizer treatments, I could not provide a prescription. This company has made repeated efforts to collect payment for these items. If the patient pays out of pocket, he or she risks not having money for medication or food. If the patient does not pay, he or she risks having to work with a collection agency. Poverty also reduces access to specialty care. Many of our patients have mobility limitations that require the use of a wheelchair. Finding rides to appointments is difficult. We are able to provide x-ray, limited ultrasound, and laboratory services in the home. If a patient requires a computed tomography scan, magnetic resonance imaging, specialty service, or hospitalization, the patient must travel to the site. The cost of a wheelchair van one way is $79.00, and an ambulance ride one way is $1500.00. These are both out-of-pocket expenses. We also find less family support among our patients in poverty, often because they are struggling to meet their own needs. One way to decrease this burden would be better communication among primary care providers, hospitals, other facilities, and specialty offices to decrease repeating of nonessential testing and appointments requiring travel expenses. An additional barrier to quality health care is provider reimbursement. There was a 10% reduction in Medicare payments last year with an anticipated 10% reduction in reimbursement this year for providers who care for Medicare recipients. As our population lives longer, there are more persons receiving Medicare, and many of these persons have complex health issues. There is more time required to care for these patients and more time spent on the phone with the least amount of reimbursement. Some providers are limiting the number of Medicare patients they will see. This results in decreased access to health care and decreased continuity of care because patients may not be able to return to specialists they have seen in the past. This will also increase the time a person must wait before being seen, often leading to further complications. Although we have been able to eliminate the lack of transportation and not having a usual source of care as health care barriers for our patients, we struggle daily with many other barriers. Our practice relies on the assistance of home health care agencies to educate and reinforce information our patients need for informed decisions. We spend hours on the telephone problem-solving with patients, providing reassurance and emotional support. Some patients call to speak with the nurse just to tell him or her they have made it through another day and receive assurance that someone in their life cares about them. We also work with the Department
PAGE 36
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
of Human Services and other government and private agencies to help provide food and a safe environment for our patients to live in. While on call one weekend, the internist stopped (with his family waiting to go to the State Fair) to deliver a bag of fast food to a patient’s home who had called him for help because his brother was in the hospital and there was nobody to provide food for him. We also struggle with couples who are without families to assist them. Often, one of the persons may need hospital care but refuses admission because there is no one to care for their partner who cannot be left alone. Temporary care is not covered by insurance and requires out-of-pocket payments few can afford. There are many risk factors affecting the health of our patients, including obesity, diabetes, cardiovascular disease, and cigarette smoking. As health care providers, we are challenged to better convey the impact these risks have on our patients’ quality of life and motivate them to change, but we need more resources. We must work on a local and national level to talk with our congressional and senatorial representatives to make real changes in health care and to provide better access to health care for those in poverty. Personal letters to our representatives citing real problems may help to clarify the issues and illicit focused changes in policies for all persons in need. I also encourage my patients to write to their representatives when they have had problems. Our policy makers cannot remain isolated from the effects of the changes they enact. It is also important to explore options within our own communities that may be used to help our clients, such as senior outreach programs and elderly waiver programs that bring already budgeted funds to those in need and services with a fee schedule based on income. It will take all of us
JUNE 2008
working together to eliminate poverty as a barrier to quality health care.
REFERENCES 1. Baquet C, Carter-Pokras O, Bengen-Seltzer B. Healthcare disparities and models for change. Am J Manag Care 2004;10 Spec No:SP5-11. 2. Bell RA, Quandt SA, Arcury TA, et al. Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER diabetes study. J Rural Health 2005;21:198-205. 3. Centers for Disease Control and Prevention, National Center for Health Statistics. Available at http://www.cdc.gov/nchs/ data. Accessed July 13, 2007. 4. American Fact Finder. Available at http://factfinder.census.gov. Accessed July 13, 2007. 5. Fitzpatrick AJ, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health 2004;94:1788-94. 6. U.S. Census Bureau. Available at http://www.census.gov/ prod/2006pubs/p60-231.pdf. Accessed July 13, 2007. 7. Wilson IB, Rogers WH, Chang H, Safran DG. Cost-related skipping of medications and other treatments among medicare beneficiaries between 1198 and 2000. J Gen Intern Med. 2005;20:715-20. 8. Buckwalter KC, Maas M. Meeting the mental health needs of older Iowans. The Iowa Nurse Reporter. March 7-9, 2007. 9. Aging Resources. Available at http://www.agingresources. com/resourcesinformation.html#ElderlyWaiver. Accessed August 22, 2007.
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
JUNE 2008
Poverty: An Iowan perspective Cynthia Christensen, MSN, CVN, ARNP, and Elaine Gates, RN, BS
Poverty affects every person in America whether you are one of the rich or one of the poor. Our daily quality of life is determined by our shelter, access to clean water and food, and health status. Our quality of health is often determined by our access to health care. There are many disparities in health care, and business and societal expenditures are associated with these. Business costs can be measured in the number of inpatient and outpatient days, the number of requests for specialty care, and the amount of medication use.1 One study2 showed that among elderly rural adults with type 2 diabetes, predictors of specialty care use included gender, socioeconomic status, education, diabetic medication use, and self-rated health. These factors reflect an increased risk of complications. Societal impact of disparities can result in increased disability, poverty, family stress, premature death, or mortality.1 In the period from 2002 to 2004, 15.5% of the US population was without health insurance coverage.3 In Iowa that number was 10.1%, which may be related to a higher number of persons 16 years or older in the workforce, 69.9% compared with 65.9% nationally.4 The per capita income for Iowans in 2005 was $23,340, lower than the national income of $25,035.4 Despite this, fewer Iowans had incomes below the poverty level (10.9% vs. 13.3% nationally).4 A large number of Americans without insurance coverage have chronic illnesses,5 including diabetes, heart disease, and depression. Many of these persons delayed or did not receive care because of the cost. Multiple barriers to health care exist, such as access to health care, including not having insurance, not having a usual source of care, lack of transportation, location of providers, lack of child care, and many others.1 There has been a perception of greater equity of health care in older Americans because of the availability of Medicare, but this does not appear to be true. One study5 of Medicare beneficiaries between 1995 and 1997 showed that 11% delayed care because of the cost or not having a specific source of care. In 2003, there were 40,203,000 Medicare enrollees in the United States; 479,000 of those lived in Iowa.6 Barriers to health care for persons aged 65 years and older include out-of-pocket expenses related to supplemental insurance coverage, race, education, age, and gender.5 Satisfaction with provider services may also affect perceptions of access to From House Call Services, Des Moines, Iowa. Corresponding author: Cynthia Christensen, MSN, CVN, ARNP, 604 N 8th Street, Grimes, IA 50111 (E-mail: cindichr@aol.
com). J Vasc Nurs 2008;26:34-36. 1062-0303/2008/$34.00 Copyright © 2008 by the Society for Vascular Nursing, Inc. doi:10.1016/j.jvn.2007.09.001
health care and clinical outcomes. In the Cardiovascular Health Study,5 the most common barrier to seeking health care was the doctors’ lack of responsiveness to concerns, cited by 32.9% of respondents. Other barriers identified were medical bills, transportation problems, street safety, fear of discovering a serious illness, fear of unneeded tests, not having a regular doctor, taking care of others, and work responsibilities.5 This study concluded that the persons at greatest risk for confronting barriers were those with the lowest income, those in the oldest age group, females, those with less education, and those lacking secondary insurance, with income being the strongest factor. The fact that income has such an impact on Medicare beneficiaries carries over to their use of medications. Those persons without prescription coverage use fewer medications, which is associated with worse health outcomes. Cost-related underuse of medications is common among adults with chronic illness.7 Many Medicare beneficiaries are on fixed incomes. Once the money budgeted for out-of-pocket expenses has been spent, the cost for medications may compete directly with other necessities, such as food and utilities.7 Studies have shown7 that a better physician–patient relationship quality is associated with less cost-related skipping of medications. Better communication with patients may reveal their inability to pay for medications, and changes can be made to better fit their budget. Patients will also be able to make informed decisions about medications and other treatments. It is important to realize this application even for those persons with prescription coverage. There are so many plans, tiers of payment, and periods in which all medications are out of pocket until another level of expenditure is reached that it is difficult for the patient and practitioner to choose appropriate treatments. Better communication with all persons involved, including pharmacists, can lead to increased medication compliance. For a nurse practitioner in the state of Iowa, these factors are important. Iowa ranks sixth6 among the states with the largest population of persons 65 years and older and first in the nation for the proportion of adults 85 years and older.8 Our practice consists of an internist, a registered nurse, a part-time receptionist, and me. We have tried to eliminate some of the barriers to health care by seeing clients in their homes. All of our clients are home-bound because of the inability to drive, need to remain in the home to care for a loved one, or refusal to go to a clinic for health maintenance. We have approximately 365 patients, many who are seen on a monthly basis. According to the Senior Living Program Income Guidelines FY089 (Table I), 95% of our patients are low income and 1.4% are of moderate income; 15.6% of those in the low-income category are less than 60 years of age. The 2005 estimated population for the state of Iowa shows 14% of the population is aged more than 65 years compared with 12.1% nationally.4 In our current practice, 66% of our patients are 75 years of age or older. Our practice struggles with many of
Vol. XXVI No. 2
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
TABLE I SENIOR LIVING PROGRAM INCOME GUIDELINES FY08 Senior Living Program Trust funding is available to low and moderate-income persons 60⫹ years of age. Low income: ● Single person ⱕ$22,428 annually. ● Couple ⱕ$33,624 annually. (For each additional person in household, add $11,196.) Moderate income: ● Single person $22,429 to $30,630 annually. ● Couple $33,625 to $41,070 annually. (For each additional person in household, add $11,196.) the barriers Medicare recipients face throughout our country. When the Medicare D prescription plans were introduced, it was chaos for our patients and our office. Many of our clients had no family support to sift through all of the options and find a plan for coverage. Others found themselves signing up for a Medicare health maintenance organization, not realizing this changed their basic Medicare coverage and eliminated some previously covered services. Medications and their ordering present the biggest problem for our patients. Along with trying to remember which medications are covered under different plans, we also find many drugs are not covered without prior authorization, and some are not covered at all. This results in a delay in starting medications and added work for office staff. We continue to have clients without any prescription coverage and must carefully chose medications to best fit their budget and health care needs. We have also found some agencies that target the elderly and low-income clients, selling them insurance plans and then switching the insurance provider so the salesman can receive another commission. This results in greater cost and lower quality of health for our clients through increased cost of prescriptions or delay in obtaining medications until the correct medication for the new insurance plan is determined. When these changes are combined with a decrease in understanding of what is happening or the importance of the medication, patients may wait weeks before receiving medications when the problem is discovered at their next visit. This is reduced when there is also a home health nurse involved in patient care who reviews medications with the patient and alerts our office when they are not received. There are also companies that offer supplies with no support for repairs. Some patients, lured by commercials promising no money from them, will order a wheelchair or other needed item. If appropriate, a prescription is written and the item is obtained. This works well until a breakdown occurs and repairs are needed. Some companies offer no repair support, forcing the patient to incur out-of-pocket expenses for repairs or shipping. Many supplies needed for the patient to remain safely in the home, such as commodes or shower bars, are not covered under a patient’s insurance plan. This results in higher costs for patients or increased risks of falling, which lower their health status.
PAGE 35
We also found companies that target patients who are receiving monetary assistance or programs for unnecessary or extra supplies. For example, we have patients who receive incontinence supplies from a vendor. Every month the company calls the patient to see what supplies are needed. They may ask if they would like additional supplies the company offers, such as a heating pad. Without the proper diagnosis this item will not be covered by their insurance and result in greater out-of-pocket costs for the patient. Another example is a patient with cough and congestion related to cigarette smoking and environmental allergies. The patient found nebulizer products on the Internet that he thought would help his congestion. The company first sent him a nebulizer machine and medications, and then sent our office a prescription request. Because he had no proper diagnosis for nebulizer treatments, I could not provide a prescription. This company has made repeated efforts to collect payment for these items. If the patient pays out of pocket, he or she risks not having money for medication or food. If the patient does not pay, he or she risks having to work with a collection agency. Poverty also reduces access to specialty care. Many of our patients have mobility limitations that require the use of a wheelchair. Finding rides to appointments is difficult. We are able to provide x-ray, limited ultrasound, and laboratory services in the home. If a patient requires a computed tomography scan, magnetic resonance imaging, specialty service, or hospitalization, the patient must travel to the site. The cost of a wheelchair van one way is $79.00, and an ambulance ride one way is $1500.00. These are both out-of-pocket expenses. We also find less family support among our patients in poverty, often because they are struggling to meet their own needs. One way to decrease this burden would be better communication among primary care providers, hospitals, other facilities, and specialty offices to decrease repeating of nonessential testing and appointments requiring travel expenses. An additional barrier to quality health care is provider reimbursement. There was a 10% reduction in Medicare payments last year with an anticipated 10% reduction in reimbursement this year for providers who care for Medicare recipients. As our population lives longer, there are more persons receiving Medicare, and many of these persons have complex health issues. There is more time required to care for these patients and more time spent on the phone with the least amount of reimbursement. Some providers are limiting the number of Medicare patients they will see. This results in decreased access to health care and decreased continuity of care because patients may not be able to return to specialists they have seen in the past. This will also increase the time a person must wait before being seen, often leading to further complications. Although we have been able to eliminate the lack of transportation and not having a usual source of care as health care barriers for our patients, we struggle daily with many other barriers. Our practice relies on the assistance of home health care agencies to educate and reinforce information our patients need for informed decisions. We spend hours on the telephone problem-solving with patients, providing reassurance and emotional support. Some patients call to speak with the nurse just to tell him or her they have made it through another day and receive assurance that someone in their life cares about them. We also work with the Department
PAGE 36
JOURNAL OF VASCULAR NURSING www.jvascnurs.net
of Human Services and other government and private agencies to help provide food and a safe environment for our patients to live in. While on call one weekend, the internist stopped (with his family waiting to go to the State Fair) to deliver a bag of fast food to a patient’s home who had called him for help because his brother was in the hospital and there was nobody to provide food for him. We also struggle with couples who are without families to assist them. Often, one of the persons may need hospital care but refuses admission because there is no one to care for their partner who cannot be left alone. Temporary care is not covered by insurance and requires out-of-pocket payments few can afford. There are many risk factors affecting the health of our patients, including obesity, diabetes, cardiovascular disease, and cigarette smoking. As health care providers, we are challenged to better convey the impact these risks have on our patients’ quality of life and motivate them to change, but we need more resources. We must work on a local and national level to talk with our congressional and senatorial representatives to make real changes in health care and to provide better access to health care for those in poverty. Personal letters to our representatives citing real problems may help to clarify the issues and illicit focused changes in policies for all persons in need. I also encourage my patients to write to their representatives when they have had problems. Our policy makers cannot remain isolated from the effects of the changes they enact. It is also important to explore options within our own communities that may be used to help our clients, such as senior outreach programs and elderly waiver programs that bring already budgeted funds to those in need and services with a fee schedule based on income. It will take all of us
JUNE 2008
working together to eliminate poverty as a barrier to quality health care.
REFERENCES 1. Baquet C, Carter-Pokras O, Bengen-Seltzer B. Healthcare disparities and models for change. Am J Manag Care 2004;10 Spec No:SP5-11. 2. Bell RA, Quandt SA, Arcury TA, et al. Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER diabetes study. J Rural Health 2005;21:198-205. 3. Centers for Disease Control and Prevention, National Center for Health Statistics. Available at http://www.cdc.gov/nchs/ data. Accessed July 13, 2007. 4. American Fact Finder. Available at http://factfinder.census.gov. Accessed July 13, 2007. 5. Fitzpatrick AJ, Powe NR, Cooper LS, Ives DG, Robbins JA. Barriers to health care access among the elderly and who perceives them. Am J Public Health 2004;94:1788-94. 6. U.S. Census Bureau. Available at http://www.census.gov/ prod/2006pubs/p60-231.pdf. Accessed July 13, 2007. 7. Wilson IB, Rogers WH, Chang H, Safran DG. Cost-related skipping of medications and other treatments among medicare beneficiaries between 1198 and 2000. J Gen Intern Med. 2005;20:715-20. 8. Buckwalter KC, Maas M. Meeting the mental health needs of older Iowans. The Iowa Nurse Reporter. March 7-9, 2007. 9. Aging Resources. Available at http://www.agingresources. com/resourcesinformation.html#ElderlyWaiver. Accessed August 22, 2007.