Running head: ACCESS TO CARE: 100 YEARS LATER 1

Access to Care: 100 Years Later

Shannon Lee Shearer
Cox College




ACCESS TO CARE: 100 YEARS LATER 2
Access to Care: 100 Years Later
In 1915, the diagnosis of diabetes was a death sentence for a child. The only treatment
for juvenile onset diabetes was starvation, making the last months of the patients life incredibly
torturous for the starving patient and the helpless family. The discovery of insulin in 1922 was a
medical miracle for those who were able to receive it, though many more met their untimely
death waiting for an injection of the miracle drug to become available. Even the power and
money of the rich could not buy insulin because of scarcity; the producers of insulin could not
meet the overwhelming demands of diabetic children who needed the medication before they
met starvation, coma, gangrene, or death (Cooper & Ainsberg, 2010). The lack of availability of
insulin in the 1920s resulted in a great disparity for patients who truly needed it. Even now,
approaching 100 years later, the availability of many medical treatments and cures remain
unavailable to patients because of finances, access, or inconsistencies in care. We will discuss
three inconsistencies in the current healthcare system that creates disparity among those
attempting to seek healthcare treatment.
A 30 year old female presents to the doctors office complaining of shortness of breath
that has been going on for two weeks. The patient has a nine month old baby and has been
taking birth control pills for contraception. Her breathing is normal at rest and her oxygen
saturation is 94% in the clinic. She states that she is very short of breath when she is vacuuming
or walking upstairs. The patient has a normal examination and chest x-ray in the clinic, and is
recommended to have a computed tomographic scan of the chest at the local hospital to rule out
a pulmonary embolism. The hospital is called and the test can be performed if the patient comes
now. The patient goes over to the hospital to check in and is informed that because of her lack of
insurance, she will be required to pay a 10% estimate up front before the test is performed. Her
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husband has recently lost his job and with a new baby at home, she feels like she cannot pay the
$400 and tells the woman at the desk she will reschedule. The patient goes home and tells her
husband that her chest x-ray was fine and nothing was wrong. The next morning she is found
dead in her bed, an autopsy revealing multiple pulmonary emboli.
Many uninsured patients do not attempt to seek medical treatment because they have no
means to pay without assistance from an insurance plan. The high cost of testing and treatment
also deter patients from seeking preventative and wellness care. When faced with the decision to
pay for medical tests or food and electricity, meeting basic needs is most often the choice. Many
patients make the choice every day to skip medications, forgo treatments, or take half doses to
make their medications last longer. Patients without private insurance, Medicare, or Medicaid
coverage to assist them to meet the high cost of medical treatment are not afforded the same
level of healthcare as those with assistance.
The Affordable Care Act (ACA) of 2009 was enacted under the direction of President
Obama to cure the countrys failing health care system (American Public Health Association
[APHA], n.d.). Many Americans suffer disparity when trying to obtain health care and medical
treatment because of their inability to pay. President Obamas primary selling points of the ACA
are to increase quality and affordability of health insurance to millions of uninsured Americans,
remove preexisting conditions that prevent individuals with chronic conditions access to
affordable care and extend Medicare and Medicaid benefits to more people (American Public
Health Association [APHA], n.d.). The basic provisions of the ACA require that all Americans
must obtain health insurance, either through the national medical exchange system, through their
state health exchange system, their employer provided insurance plan or by application for
Medicare or Medicaid. Those who do not enroll for some sort of health insurance benefit will be
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taxed on their 2014 federal tax return, a fee of $95 for the first year, increasing each year until
2017 (Haus, 2013). This tax is implemented as a stimulus for all persons to obtain health
insurance to assist with chronic medical conditions and catastrophic medical events, events that
lead to approximately 68% of all personal bankruptcies (National Patient Advocate Foundation,
2012, p. 1). Had the patient in the given situation had health insurance, would the outcome have
been different? Providing health care access to those who do not have it through an employer
based insurance or other means is an excellent means to improving preventative and wellness
care to those who usually wait to seek treatment until they are acutely ill. The ACA removes
copays for wellness and preventative medical services, like mammograms, immunizations,
colonoscopies, and prenatal and newborn care visits, encouraging prevention before an actual
illness occurs (Schaffer, 2013). This is a key intervention to improving the health of the country
as a whole.
Changing the focus of health disparity to a focus on health equality is another positive
intervention to improve the health of the nation. Taking the focus off of the negative aspects
among races and ethnicities and focusing the agenda on improving the quality of health care to
an equal level among all Americans can provide a common goal. For example, educating
parents of children in low income housing of the triggers associated with asthma like pollutants,
roaches and poor air exchanges is unworthy if the parents live in a public housing development
infected with these pollutants. Instead, the focus should be on mandates for housing codes that
require improved clean air technologies (Srinivasan & Williams, 2014). This change of focus
from disparity to equality is a necessary component of achieving a healthier nation.
A 52 year old female went to her physicians office after complaining of getting lost at
Wal-Mart and being unable to find her way home. She tells him that she has been having weird
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spells of forgetfulness that are new and worrisome. She cannot put her finger on it but feels
like something is not right. Her physician orders an MRI of her brain, a test that requires a
precertification by her insurance company. Her insurance denies the order because the patients
symptoms do not warrant the test to be performed. Her physician sends a letter to argue the
reasoning for the testing and the patient waits for word that it is approved. A few weeks later,
the patient is admitted directly to the hospital from her physicians office for another forgetful
spell. The patient has a magnetic resonance imaging (MRI) of her brain that reveals a 6 cm
mass in the right temporal lobe consistent with glioblastoma. Within an hour of admission the
patient suffers a massive seizure, is intubated and air evacuated to a Level I trauma center with a
neurologist on staff. The patient never regains consciousness, had all life prolonging machines
removed a week later and expired. Though she had private insurance, the patient did not have
access to the same standard of care to that of a patient whose insurance does not require a
precertification for testing. Had the patient had insurance that did not require precertification,
she would have been immediately referred for surgical intervention, the treatment of choice for
glioblastoma with a survival rate of 27% at two years (Davis & Mulligan Stoiber, 2011, p. 292).
This 52 year old mother of two teenage boys lost her life waiting for her insurance to grant a
preauthorization.
Decision making by the primary care provider requires respect, integrity, trust, honesty
and an intimate patient relationship. These relationships give health care providers the tools
necessary to make decisions that are specific to the care of each patient (Shipman, 2010). Many
insurance companies require a prior authorization for non-emergent medical testing to be done,
even though it is ordered by the patients medical physician, the person who best knows the
patients healthcare status. This prior authorization process leaves patients waiting for necessary
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treatment or testing while an unknown reviewer examines the patients record and determines
whether or not the insurance provider feels like the test is necessary. This leads to issues in
timeliness of treatment. To reduce disparities among patients who must rely on insurance to
authorize testing, a pilot program involving 60,000 physicians in Minnesota was developed using
a point-of-order decision support application instead of the prior authorization process (Solberg,
Vinz, & Trevis, 2012). This application was met with increased satisfaction among the
practitioners by providing immediate authorization for patient testing and reducing paperwork
and time spent on the phone for office staff. The estimated savings on inappropriate testing was
approximately $84 million from 2007-2009 (Solberg et al., 2012, p. 422). Implementing a similar
bedside point-of-order testing program nationwide has the potential to save lives and reduce
disparities for those who must wait for insurance, Medicaid, or Medicare replacement plans to
preauthorization their ordered tests or treatments. This could reduce waiting times and improve
continuity of care for many chronic and acute conditions that require frequent radiographic
testing, like monitoring tumor growth in cancers.
A 32 year old up-and-coming businessman was spending the weekend with his extended
family at a cabin in northeastern Arkansas. He needed to make a quick business call but could
not get a signal at the cabin, so he got on a four-wheeler and drove to a spot that was higher up
the mountain, telling his family he would be right back. When he did not return after about 30
minutes, his sister and wife went to check on him. The male was found lying off the path with
the four-wheeler on top of him, a large bleeding wound to the back of his head. His mother, a
nurse, was summoned to his side and she found him unconscious with a weak pulse and labored
respirations. She bandaged his wound and when he became pulseless, initiated cardiopulmonary
resuscitation (CPR) while the others called 9-1-1. The mother, an emergency room nurse, knew
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time was of the essence and instructed the men to put him in the back of the family car and drive
toward the ambulance, which was over 45 minutes away from their location. The mother
continued CPR in the vehicle until they met the ambulance. The patient, despite his mothers
quick thinking and resuscitative efforts, suffered from hypovolemic shock and expired. This
situation exemplifies the fact that patients in rural areas do not have the same access to care that
patients in suburban or metropolitan areas are afforded. Had the patient been minutes away from
an emergency service instead of hours, the patients outcome could have been very different.
In 2008, Arkansas was cited as having the worst emergency care system in the nation and
in 2010 the Arkansas fatality injury rate was 31 percent higher than the national average
(Arkansas Department of Health, 2012, p. 2). The Arkansas Trauma System, established in 2009
by the passage of the Trauma System Act, was developed to provide patients in rural areas of
Arkansas access to specialty care that may be limited in some areas but available in others. The
basis of the system focuses on getting patients to the appropriate medical facility that is able to
best meet the needs of each patient (Arkansas Department of Health, 2012). Enacted to improve
the access to care of patients living in rural areas, the system organizes care through a radio
triage system that coordinates available specialties at designated trauma centers throughout the
state. This system ensures that patients get not only to the nearest facility, but also to the nearest
facility that can immediately meet the patients needs. This system has also improved the
acceptance time of trauma patients waiting in the emergency room who need a specialty
consultation or intervention from several hours wait time to an average acceptance time of 7
minutes (Arkansas Department of Health, 2012, p. 11). Implementation of a similar system for
emergency care management as a national initiative would be highly beneficial for patients,
especially those in rural areas, to improve outcomes and decrease mortality rates. A Healthy
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People website initiative for 2020 increases the proportion of persons who have access to rapidly
responding pre-hospital emergency medical services to all Americans (healthypeople.gov).
Federal funding for this standard of care in all rural areas would support states that currently
have limited resources in rural areas and increase the access to care of individuals who have
limited healthcare resources simply because of their location.
Though the increases in medical technology and advances in medications and treatments
have been significant in the past 100 years, patients continue to suffer inequality related to access
of care. The patient situations explained above are all true stories of disparities that resulted in
loss of lives. Patients with limited finances or lack of insurance, patients with insurance that is
controlled by management systems that dictate patient treatment, and those who live in areas
where advanced medical care is unattainable continue to suffer discrepancies in the current U.S.
healthcare system. Though we have come a long way since the invention of insulin in 1920, one
can only hope that it does not take another 100 years to see improvement in the access of
healthcare for all Americans.
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