10i Health | Medicare Part D | Psychiatry

Roosevelt 2009



health care

10 Ideas for Health Care
Summer 2009 National Director Hilary Doe Chair of the Editorial Board Gracye Cheng Director of Center for Health Care Robert Nelb National Editorial Board Clayton Ferrara Frank Lin Fay Pappas Melanie Wright Yunwen Zhang The Roosevelt Institute Campus Network A division of the Roosevelt Institute 2100 M St NW Suite 610 Washington, DC 20037
Copyright 2009 by the Franklin and Eleanor Roosevelt Institute. All rights reserved. The opinions and statements expressed herein are the sole view of the authors and do not reflect the views of the national organization, its chapters, or affiliates.



health care

This series was made possible by the generosity of Mr. Stephan Loewentheil.

Table of Contents
Primary Care Using Old TV Spectrum to Expand Rural Home Telehealth David Silver Restructuring the Medicaid All-Or-Nothing Threshold Neil Parikh and Yining “Tommy” Fu Beneficiary-centered assignment for Medicare Part D Tammie Chau Preventive Care Patient-centered Reimbursement for Chronic Diseases Jamie Cohen and Andreas Shepard Nutrition Information at Point of Purchase Kelsey Jones Extending Prescribing Privileges to Clinical Psychologists Jeremy Ford Strengthening Community-based Mental Health Care for Veterans Taylor Johnson Patient-Centered Care Expanding Personal Control of Electronic Health Records Eva Galvan Municipal Identification Cards as Gateways to Health Services Lauren Hunter, Greg Mittl, Jessica Becker, and Eva Galvan Using Biometrics to Coordinate Health Care For Undocumented Patients Yining “Tommy” Fu and Neil Parikh Year in Review Robert Nelb

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p Letter from the Editor
Earlier this year, the Roosevelt Institute Campus Network adopted Think Impact, a model that re-emphasized our organization’s founding goals of looking to young people for ideas and action, twin forces necessary in the pursuit of change. The ideas you will read about in this year’s first 10 Ideas series are the result of the admirable creativity, hard work, and scholarship of Roosevelters. These publications—on Defense and Diplomacy, Economic Development, Education, Energy & the Environment, Equal Justice, and Health—are also a testament to these authors’ engagement with the world. In environments that can be insular, Roosevelters show a willingness to look outwards, to think critically about problems on a local, state, and national level. But, to this end, these publications should only serve as a starting point of a greater process. Roosevelters must be willing to act in the communities where these ideas can most effect positive change. For concepts that you find inspiring, we hope that you are motivated to leverage them for the benefit of your own campus, city or state, and that you seek out channels and movements through which to bring these ideas to fruition. And, in instances where you disagree, we hope that you are challenged to see how you might improve on or adapt an idea. Gracye Cheng Chair of the National Editorial Board

Strategist’s Note P
he Roosevelt Institute Campus Network was founded on the premise that students have great ideas, and in this journal, I think we found some. With so many people talking about health care reform today, new ideas might seem hard to find, but our fellows continue to surprise us with their creativity and innovation. In particular, these ideas are innovative in the way that only students can be. Although we did not dictate any specific theme for this journal, all of the ideas seem to offer a new way of using technology to address long-standing challenges of the health care system. It makes sense that the generation that grew up with the internet and smart phones would be among the first to think about how these tools can be used to create a more streamlined, mobile, and personalized health care system. Unfortunately, students today have not been asked enough to share their great ideas - we hope to correct that error in these pages and in our actions every day as Roosevelters. Perhaps the most exciting thing about student ideas and about this journal is that these ideas are only the beginning of what we can do. You can expect to hear much more from these students in the future. Robert Nelb Lead Strategist for Health Care


Using Old TV Bandwidth To Expand Rural Telehealth
David Silver, University of Colorado - Boulder Develop the bandwidth left unused after the switch to digital television to provide fast internet access for telehealth programs in rural areas. Rural communities face significant social and economic barriers to receiving quality healthcare. Fifteen percent of people in rural areas are below the federal poverty level compared to 12 percent of urban residents. Rural regions are frequently designated as Health Professional Shortage Areas (HPSAs). For example, eight Colorado counties have only one full-time primary care physician – four of which are not accepting new Medicaid patients. Six additional counties lack even a full-time primary care physician, and one rural county has no physician. Home telehealth – the use of remote monitoring of patients’ blood pressure, glucose levels, and other patient information in the electronic system – allows rural access to more centralized health care professionals who can anticipate and prevent avoidable problems. A study completed by the Veterans’ Association found that home telehealth reduced the average number of days hospitalized by 25% and cut overall hospitalizations by 19%.

Key Facts
• Broadband delivery reaches only 31% of the rural population compared to 50% in urban and suburban areas, but virtually all Americans have access to television. • Rural wireless networks transmitting in the TV band can cover four (4) times the area, and at a higher quality of service, than a network transmitting in current unlicensed bands. • A 2009 VA study found a 25% reduction in the average number of days hospitalized and a 19% reduction in hospitalizations for patients using home telehealth.

A major barrier to telehealth in rural areas has been the lack of access to high-speed internet. Telecommunications companies fail to wire low-population density regions for internet because high infrastructure costs and low usage yield minimal returns. But the switch to digital television (DTV) could provide high-speed internet access – along with its many health and community benefits – to rural communities on the waves that television broadcasters no longer use. With a simple adapter, communities will be able to access the internet wherever they have a cable TV. Telecommunications companies currently deliver internet on waves identical to those that television broadcasters use, but at a higher frequency. The frequency of these waves make them much less efficient to send over long distances, as the information on the waves is easily distorted. Because of its lower frequency, television spectrum broadcasts can cover four times the area of higher-frequency signals with higher speeds and quality of service. On November 4, 2008, the FCC voted for the television spectrum to be unlicensed after the switchover to digital television in 2009. Google, Intel, and Microsoft are currently working on devices that harness the television spectrum for

broadband, commonly referred to as “white space”. The greatest successes have come in geographic locations with few preexisting television stations, i.e. rural areas. Rural healthcare providers – and more generally, rural communities – should give great consideration to the use of this new technological resource. High-speed internet access is imperative for the development of telehealth, as demonstrated by the Colorado Telehealth Network’s roughly $11-million investment for wiring rural health clinics and critical access hospitals for broadband. However, this investment is not enough to fully implement home telehealth strategies – transportation issues to health clinics and hospitals still remain a problem for many rural residents. That rural Americans own significantly fewer computers per capita than their counterparts poses a challenge to implementing this strategy. However, Federal programs are already in place that subsidize computer purchases in rural areas. Congress should look to these programs to provide home telehealth patients with computers.

Talking Points
• Broadband is now a utility comparable to electricity, phone lines, and water. It is vital to not only health outcomes, but educational, economic and community development as well. • Telehealth technology promises to increase preventive care measures through home telehealth and collaboration with centralized healthcare specialists. • The switch to DTV will allow citizen access highspeed internet wherever there are TV cables.

Next Steps Congress should fund a grant program to help rural providers purchase adapters so as to use the TV cables that they already have to create interactive telehealth portals. This program could be funded and incorporated into the existing rural health center program.

Brennan, D. M., B. E. Holtz, N. R. Chumbler, R. Kobb, and T. Rabinowitz. “Visioning technology for the future of telehealth.” Telemedicine and e-Health 14, 9 (November 2008): 982-985. Colorado Health Institute. Data. Retrieved April 7, 2009, from http://datacenter.coloradohealthinstitute.org/data.jsp Horrigan, J. B. “Broadband adoption in 2007.” Pew Internet and American Life Project. Retrieved April 7, 2009, from http://www.pewinternet.org/ Press-Releases/2007/Broadband-Adoption-in-2007.aspx LaRose, R., J. L. Gregg, S. Strover, J. Straubhaar, and S. Carpenter. “Closing the rural broadband gap: promoting adoption of the internet in rural America.” Telecommunications Policy 31, (2007): 359-373. Lennett, B. “Rural broadband and the TV white space.” Issue brief #22. New America Foundation: Wireless Future Program, June 2008. 4 p. NAS Recrutiment Communications. “NAS insights: physician recruitment report.” Retrieved April 7, 2009, from http://www.nasrecruitment.com MicroSites/healthcare/Articles/featureH5b.html Spire, M. A review of physician recruitment and training in rural America. Washington, D.C. Washington Health Policy Fellowship Program, August 2000. 16 p. Retrieved April 7, 2009, from http://www.unmc.edu/Community/ruralmeded/fedstloc/RecrRet/national_view_recruitment.htm U.S. Census Bureau. State and County QuickFacts. Retrieved April 7, 2009, from http://quickfacts.census.gov/qfd/states/08000.html United States Department of Veterans Affairs. VA data show home health technology improves access to care. January 2009. http://www1.va.gov/ opa/pressrel/pressrelease.cfm?id=1637 (accessed April 7, 2009). Seshamani, M. V. (2008). Hard times in the heartland: health care in rural America. Retrieved May 6, 2009, from HealthReform.gov: http://www. healthreform.gov/reports/hardtimes/


Restructuring the Medicaid All-or-Nothing Threshold
Neil Parikh and Yining “Tommy” Fu, Rice University Extending Medicaid coverage on a sliding scale to low-income families that earn just above their Medicaid category’s income threshold can help remove the perverse incentive to not meet one’s earning potential solely to receive medical benefits. The idea of a sliding scale fee for low-income patients is currently undergoing testing in Massachusetts (those making more than 150% of the FPL), and so far has proven to be effective – only 2.8% of residents are uninsured and spending from the Health Safety Net Fund dropped by 38% in just two years. Despite this cost cut, it must be noted that Massachusetts still leads all other states in health care spending at $6,683 per capita. Estimate of those affected Key Facts Considering the average price of individual health insurance premi• An estimated 3.6 million Americans have fiums (nearly $5,000), it is those innancial incentive to lower their income just dividuals who qualify under a Medto gain Medicaid benefits because their icaid eligibility group, and earn less earnings above the eligibility threshold are than $5000 above the Medicaid less than the value of health insurance. eligibility level that have the incen• In 2007, only 47% of families earning less tive to purposefully remain below than $40,000 were offered employer-sponthe income threshold to obtain sored health insurance. Medicaid benefits. Income distri• Medicaid spends on average $2,142 per bution tables and current Medicaid adult Medicaid enrollee. Private insurance, numbers lead to an estimate of apmeanwhile, charges an average premium of proximately 3.6 million adults with $4,700 for each adult enrollee. the incentive to intentionally lower their income for medical benefits. However, the number of potential beneficiaries from this policy is much greater as even adults outside the [IEL, IEL + 5000] range would have the chance to join the program – albeit, at a higher premium. The total number of people affected by this policy is dependent on personal preferences, in-depth analysis of state-by-state income distributions, and specific state-by-state income thresholds, and may be addressed after the policy is implemented. In the meanwhile, covering the 3.6 million adults that are the most affected by the policy would cost $7.7 billion. This estimate does not include the premiums paid by patients, which would likely lower the overall cost. Possible Mechanism Because each state sets its own income thresholds for Medicaid eligibility, this proposal would affect patients in each eligibility group and in each state slightly differently. The proposal would offer Medicaid benefits at a subsidized premium – x% of y, where ‘x’

represents the percentage that the patient’s income is higher than the income eligibility threshold, and ‘y’ represents a flat rate at approximately the individual insurance premium. Sample Scenario (Non-working parents in California: $21,203 Income Threshold)

Talking Points
• Medicaid provides full medical benefits (operations, prescriptions, visits) to all qualifying individuals earning less than a state-controlled threshold, but offers nothing for similar individuals who earn just above the threshold. • The majority of Americans considering Medicaid assistance work low-income jobs. Unlike professionals and other white collar workers, these Americans are unlikely to see $5,000 in immediate raises or bonuses. Therefore, it is possible that these workers will perpetually remain below the threshold, in fear that once they rise above it, they will lose health insurance. Sources

Next Steps Considering Medicaid’s structure, it is crucial for state legislators to become involved in this type of policy revision and rethink their eligibility criteria. Consistent with the existing matching scheme, this revised proposal will incentivize state governments to increase their income threshold, so that the federal government will subsidize the health coverage of even more people.

“Estimates of the Number of Uninsured Children Who Are Eligible for Medicaid or SCHIP.” Congressional Budget Office - Home Page. 13 Apr. 2009 <http://www.cbo.gov/doc.cfm?index=8357&type=0>. Facts and Figures 03 2008. MA Health Connector. 13 Apr. 2009 <http://www.mahealthconnector.org/portal/binary/com.epicentric.contentmanage ment.servlet.ContentDeliveryServlet/About%2520Us/News%2520and%2520Updates/Current/Week%2520Beginning%2520March%25209%25 2C%25202008/Facts%2520and%2520Figures%25203%252008.doc>. “Fewer low-income parents are being offered health insurance on the job, or are able to afford it privately.” Robert Wood Johnson Foundation. 22 May 2009 <http://covertheuninsured.org/content/fewer-low-income-parents-are-being-offered-health-insurance-job-or-are-able-afford-it-privat> “Health Care in Crisis: 14,000 Losing Coverage Each Day.” Center for American Progress Action Fund. 13 Apr. 2009 <http://www.americanprogres saction.org/issues/2009/02/health_in_crisis.html>. “Health Spending per Capita.” Kaiser State Health Facts. 22 May 2009 <http://www.statehealthfacts.org/comparetable.jsp?ind=596&cat=5> The Henry J. Kaiser Family Foundation - Health Policy, Media Resources, Public Health Education & South Africa - Kaiser Family Foundation. 13 Apr. 2009 <http://www.kff.org/medicaid/upload/Key%20Medicare%20and%20Medicaid%20Statistics.pdf>. “HINC-06—Part 1”. U.S. Census Bureau. 23 May 2009 <http://pubdb3.census.gov/macro/032007/hhinc/new06_000.htm> “Medicaid Payments per Enrollee, FY2006 -.” Kaiser State Health Facts. 13 Apr. 2009 <http://www.statehealthfacts.org/comparetablejsp?ind=183& cat=4>. “NCHC | Facts About Healthcare - Health Insurance Costs.” NCHC | Home. 13 Apr. 2009 <http://www.nchc.org/facts/cost.shtml>. NESARANational Economic Stabilization and Recovery Act. 13 Apr. 2009 <http://www.nesara.org/files/tax_compare.xls>. Report from Massachusetts Secretary of Health and Human Services Timothy Murphy, to the Massachusetts General Court, “Chapter 58 Imple mentation Update. June 12, 2006. “Total Medicaid Enrollment, FY2006 -.” Kaiser State Health Facts. 13 Apr. 2009 <http://www.statehealthfacts.org/comparemaptable. jsp?ind=198&cat=4>.


Beneficiary-Centered Assignment For Medicare Part D
Tammie Chau, University of California - San Diego By matching beneficiaries’ current medication regimen with the right prescription drug plan, the states’ Department of Health Services can improve beneficiaries’ access to necessary drugs while lowering the cost to the beneficiary, states, and the federal government. Beneficiary-Centered Assignment, a method of matching individuals’ drug needs to a formulary plan, is a cost effective strategy to better serve Medicare-Medicaid dual eligibles. Over 6.2 million low-income seniors and disabled citizens qualify for both Medicare and Medicaid coverage. These dual eligibles are randomly assigned to prescription drug plans (PDPs). These privately-administered PDPs can vary depending on covered drug benefits, premiums, co-payments, and the low-income federal subsidy. As consumers, enrollees have the option of changing their drug coverage using Medicare’s Web-based Plan Finder. However, the majority of dual eligibles do not explore available online options and remain enrolled in randomly assigned PDPs. Using Maine as an example, states should assist in enrolling Key Facts and reassigning dual eligibles to • “Dual eligibles” are those who qualify for both low-cost drug plans that fit beneMedicare and Medicaid. They disproportionficiaries’ needs. The process beately have multiple chronic conditions requirgins by reviewing the last three ing an average of ten (10) or more prescriptions months of an individual’s drug per month. regimen and comparing the po• An estimated total of $47 billion and $53 billion tential out-of-pocket expenses. will be spent in 2009 and 2010, respectively, States should collaborate with on Part D drug benefits. their pharmacist associations • Random assignment of common pharmaceuincluding pharmacy students to ticals can cost a monthly difference of $242 use Medicare’s Plan Finder. In more than the least expensive drug plan. Maine, if an enrollee’s plan does not cover 85 percent of the medications they currently take, then the state can switch drug plans on behalf of the beneficiary. Each participant is then notified by letter about the switch and can opt- out if they prefer not to have their plan changed. On January 1, 2006, dual eligibles transitioned from Medicaid’s comprehensive drug coverage to automatic enrollment in Medicare Part D’s PDP. This random assignment ensured that each drug plan had equal amounts of enrollees instead of tailoring a plan to beneficiaries. Random assignment of eligible enrollees not only complicated beneficiaries’ access to prescription drugs, but also resulted in higher costs for the federal government and states.

Random assignment of PDPs to dual eligibles makes it more difficult for enrollees to obtain necessary drugs. For example, if a drug is not included on the approved list, then the beneficiary must pay out-of-pocket or forego the drug entirely. Allowing states to better accommodate dual eligibles with Beneficiary-Centered Assignment provides coverage for current medication regimens without causing discrepancy in access to prescription drugs. The potential savings for states and the federal government is substantial in maintaining this coverage. Widespread use of Beneficiary-Centered Assignment could streamline enrollees into just several of the available PDPs. In turn, this could influence private plans to compete for enrollment based on adding common drugs to formularies. Talking Points Next Steps There is an ongoing challenge to better serve dual eligibles with their special health needs. Decreasing the widespread confusion for dual eligibles, Medicare Part D should find an alternative method of enrolling beneficiaries into a prescription drug plan. State legislators can enact Beneficiary-Centered Assignment by taking steps to obtain authority granted from CMS to give state pharmacist associations authorization to automatically enroll dual eligibles into cost saving plans that match the beneficiaries’ current drug regimen. • Current assignment of dual eligibles is random and based upon equalizing the number of enrollees in each private drug plan. • Beneficiary-Centered Assignment or intelligent assignment assigns dual eligibles to a prescription drug plan that meets the individual’s needs. • Maine is the only state with authority granted from the Centers for Medicare and Medicaid Services (CMS) to reassign dual eligibles to plans that cover 60 percent to 95 percent of their drugs by evaluating beneficiaries’ drug regimens and plan options.

Laura Sumner et al, “Improving the Medicare Part D Program for the Most Vulnerable Beneficiaries.” Commonwealth Fund, May 2007. Jack Hoadley et al, “The Role of Beneficiary-Centered Assignment for Medicare Part D” MedPAC, June 2007. “The Medicare Prescription Drug Benefit- An Updated Fact Sheet.” Henry J. Kaiser Family Foundation, March 2009. Vernon Smith et al, “The Transition of Dual Eligibles to Medicare Part D Prescription Drug Coverage: State Actions during Implementation” Henry J. Kaiser Family Foundation, February 2006.


Patient-Centered Reimbursement For Chronic Diseases
Jamie Cohen and Andreas Shepard, Amherst College Health care reimbursement methods that follow the patient can help support health care providers who are preventing and controlling chronic diseases. Seventy percent (70%) of health care costs in America are spent on people with chronic diseases. As a result, proper preventative care and chronic disease management could result in huge cost savings and quality of life improvements. For example, the Center for Disease Control estimates that every $1 invested in outpatient training that helps individuals with diabetes manage their disease saves $8.76 in reduced health care costs. They further estimate that foot-care programs that include regular examination and patient education could prevent 85% percent of the amputations caused by diabetes. While the importance of prevention is broadly accepted, creating incentives to encourage prevention has been difficult. Traditional private health insurance has little incentive to cover preventive services, since patients are likely to change insurers before the savings are realized. Merely mandating coverage of certain preventive Key Facts health benefits, however, is often • Nationwide, spending on patients with insufficient. There must be a way chronic diseases accounts for 70% of health to evaluate whether and how efcare expenditures. fectively the care is being used. • The Center for Disease Control estimates New advances in health informathat every $1 invested in outpatient training tion technology can help address that helps individuals with diabetes manage this need by creating ways to monitheir disease saves $8.76 in reduced health tor whether patients are getting care costs. the preventive care they need and • One-third of kidney failure complications ensuring that doctors are compenfrom diabetes are preventable. sated for keeping patients healthy in the long term.

Analysis Investing in chronic disease management programs, preventative care, and education can help lower health care costs and improve quality of life. Although not all preventive services programs are the same, the federal government should require private insurance companies to reimburse providers for chronic disease management and prevention services, according to standards governed by the CDC Preventive Services Taskforce. Improved reimbursement methods are also needed to financially reward those doctors who provide the best care, who under the current system are rewarded with more revenue if they let their patient’ conditions worsen to the point where costly interventions are necessary. In order to track whether patients are achieving their health goals, the organization of medical records will need improvement. The most promising avenues are electronic forms

of health tracking, such as fully electronic personal medical records and self-reporting through social networking applications. The current administration has a head start on this process, since the economic stimulus package included a provision establishing the Office of the National Coordinator for Health Information Technology, but any system that office creates must enable the key feature of matching of patients’ achievement of health goals with their providers’ reimbursement. The challenges of controlling the costs of chronic diseases are be• Fee-for-service reimbursement systems, ing felt across the country, and like Medicare, reward providers who allow will likely be amplified if health patients’ conditions to worsen to the point reforms increasing access to where they need expensive interventions. those without health insurance • Providers who prevent their patients from are passed. In order for any such developing chronic diseases or help their health reform to have a sustainpatients keep their chronic diseases in check able cost in the long term, payreceive very little financial reward. ment reforms will be needed. The • Controlling the costs of chronic diseases will short-term costs – establishing be important to controlling overall health care a more robust electronic health costs. tracking system and of making the first additional payments to providers that are helping their patients meet health goals – will be outweighed in the long run with fewer and better managed chronic diseases. Regardless of whether reforms increasing access are passed, the existing health care system, which already consumes 1/7th of GDP and continues to grow, should be reshaped along similar lines.

Talking Points

Next Steps A starting point for this new reimbursement model is state or federal health insurance programs, including Medicare, Medicaid, or state health insurance options, like Commonwealth Care in Massachusetts. Medicare especially may benefit from the improved management of chronic diseases, since the greatest costs of chronic diseases are found in older patients.

Halvorsen, George. 2007. Health Care Reform Now!. San Francisco: John Wiley & Sons, Inc. Centers for Disease Control and Prevention. “Preventing Diabetes and It’s Complications.” Revised Septem ber 5, 2008. http://cdc.gov/nccdphp/publications/factsheets/Prevention/diabetes.htm “Medicine Online”. Steve Coll. Think Tank blog post: June 9, 2009. <http://www.newyorker.com/online/blogs/ stevecoll/2009/06/medicine-online.html>


Nutrition Information at Point of Purchase
Kelsey Jones, University of Georgia Congress should take immediate action to require that restaurants provide basic nutrition information at point-of-purchase and use innovative technology to disseminate this information, engaging consumers in the process of actively improving their health. This policy uses a two-pronged approach to achieve its goals of improved American health. First, Congress should take immediate action requiring that restaurants provide basic nutrition information at point-of-purchase. Second, the U.S. Department of Health and Human Services (DHHS) should capitalize on the availability of this nutrition information to encourage individual-based, personalized health promotion strategies via online and mobile phone-centered healthy eating programs. Managed by the DHHS, the primary aspect of this policy would require food producers to display calorie, fat, cholesterol, sodium, carbohydrates, and protein content alongside or below each product to offer visible, easy access to such information. Additionally, the Food and Drug Administration’s Recommended Daily Nutrition Values would appear elsewhere on the menu, allowing consumers to use this information as a point-of-reference when evaluating the health quality of meal purchases.

Key Facts
• The United States faces an “obesity epidemic,” with the prevalence of obesity doubling in the last twenty years and the nation reflecting a rate of 66 percent of Americans that are overweight or obese. • Much of this obesity crisis stems from Americans’ consumption of unhealthy restaurant meals. Studies show that if restaurants provide nutrition information to consumers, preferences shift toward healthier meal fares.

To maximize the program’s effectiveness, DHHS should complement the program with a technology-based educational campaign to encourage healthy eating habits and personalized wellness plans. This policy’s dissemination will build upon current governmentsponsored internet resources, such as the U.S. Department of Agriculture’s “My Pyramid” website. Incorporating restaurant nutrition information into the website’s food database, promoting these web-based personalized health and weight loss plans through public educational campaigns, and adapting wellness programs to new technology such as smart phone applications will allow consumers to apply these resources to their needs. Moreover, such technology resources use will allow consumers to create individualized health profiles such that the applications recognize and respond to health concerns such as allergies, low-sodium diets, limited calorie intakes, cholesterol needs, and so forth, when a consumer chooses to dine at a restaurant.

The number of overweight Americans has risen dramatically in recent decades, prompting the U.S. Surgeon General to deem obesity an epidemic. Significantly, obesity accounts for over 300,000 deaths per year and the present generation of youth may not outlive their parents. In aggregate economic terms, obesity costs the United States over $117 billion annually. Coinciding with growing obesity rates, studies show a significant increase in the consumption of restaurant food, which is typically more dense in calories, fats, sodium and sugars than at-home alternatives. Studies show that providing restaurant patrons with nutrition information results in a shift in consumer preferences, allowing for a more efficient market. Health professionals suggest that as consumers move away from high-calorie, high-fat dishes, restaurants will follow suit by replacing those foods with healthier options.

• A policy mandating nutrition information on menus will equip consumers with the skills needed to make healthier dining choices while requiring minimal government intervention and regulation. • While beneficial, menu labeling cannot provide all the information that individual consumers may desire or need; Congress should use nutrition information from restaurants to provide consumers with more comprehensive, low-cost health resources and plans through new technology portals (such as the web and mobile phones).

Talking Points

This policy arms consumers with the ability to make informed choices while avoiding potential inefficiencies of alternative government programs, such as outlawing trans fats or taxing restaurants with less healthy fares. It minimizes administrative costs associated with imposing and enforcing government standards within the private sector. Finally, by using new technology portals such as cell phone applications, individuals will have virtually unlimited access to these resources which they can personalize to their own health needs.

U.S. Department of Health and Human Services (DHHS), The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001), XI. David B. Allison, PhD, Kevin R. Fontaine, PhD, JoAnn E. Manson, MD, DrPH, June Stevens, PhD, and Theodore B. VanItallie, MD, “Annual Deaths Attributable to Obesity in the United States,” Journal of the American Medical Association 282, no. 16 (1999): 1535. S. Jay Olshansky, PhD, Douglas J. Passaro, MD, Ronald C. Hershow, MD, Jennifer Layden, MPH, Bruce A Carnes, PhD, Jacob Brody, MD, Leonard Hayflick, PhD, Robert N. Butler, MD, David B. Allison, PhD, and David S. Ludwig, MD, PhD, “A Potential Decline in Life Expectancy in the United States in the 21st Century,” New England Journal of Medicine 352, no. 11, 1143. U.S. Department of Health and Human Services, “Preventing Obesity and Chronic Diseases through Good Nutrition and Physical Activity,” Centers for Disease Control and Prevention, http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm (accessed October 8, 2007). Shanthy A. Bowman, PhD and Bryan T. Vinyard, PhD, “Fast Food Consumption of U.S. Adults: Impact on Energy and Nutrient Intakes and Over weight Status” Journal of the American College of Nutrition 3, no. 2 (2003): 167. National Restaurant Association, “Frequently Asked Questions,” National Restaurant Association, http://www.restaurant.org/aboutus/faqs.cfm (accessed October 12, 2007). Burton et al., 1673. Burton, 1674. Fred Kuchler, Elise Golan, Jayachandran N. Variyam, and Stephen R. Crutchfield, “Obesity Policy and the Law of Unintended Consequences” U.S. Department of Agriculture Economic Research Service, http://www.ers.usda.gov/AmberWaves/June05/Features/ObesityPolicy.htm (accessed October 7, 2007). John C. Kozup, Elizabeth H. Creyer, and Scot Burton, “Making Healthful Food Choices: The Influence on Health Claims and Nutrition Information on Consumers’ Evaluations of Packaged Food Products and Restaurant Menu Items,” Journal of Marketing 67, (April 2003): 32. Jayachandran N. Variyam, “Nutrition Labeling in the Food-Away-from-Home Sector: An Economic Assessment,” U.S. Department of Agriculture Economic Research Service, Economic Research Report Number 4, http://www.ers.usda.gov/publications/err4/err4.pdf (accessed October 12, 2007).


Extending Prescribing Privileges to Clinical Psychologists
Jeremy Ford, University of North Carolina - Chapel Hill Extend prescribing privileges to clinical psychologists and prepare them through training programs in drug therapy in order to lower costs and mitigate disparities in access to mental health treatment for youth and patients in rural areas. There has been a persisting shortage of psychiatrists in the United States. Due to poor funding and inadequate recruitment from medical schools, child and adolescent psychiatrists will continue to be in short supply, as will psychiatrists practicing in rural parts of the country. Some lawmakers have addressed this shortage by allowing clinical psychologists to prescribe psychotropic medications – drugs for mental illness. Analysis Although some psychiatrists have expressed concern that prescribing psychologists would provide inadequate care and could increase the risk of fatal drug interactions for children, psychologists have proven to be effective prescribers in various settings after training in pharmacotherapy. The Department of Defense launched a project in 1989 to train military psychologists in prescribing psychotropic medications. After two years of training, supervising psychiatrists rated the prescribing skills of graduates as “good to excellent.”

Key Facts
• One in four adults suffers from a diagnosable mental disorder, and 6% suffer from serious mental illness. • There were 6,300 practicing child psychiatrists as of 2003, whereas an estimated 30,000 were needed. • In 2000, large metropolitan areas had 6.9 child psychiatrists per 100,000 youth, but in rural areas, there were 0.3 psychiatrists per 100,000 youth. • The average hourly cost of an appointment is $62.64 with a psychiatrist and $39.44 with a psychologist.

Prescribing psychologists could generate savings for the mental health system and patient. Psychiatrists undergo four years of expensive and broad-based medical training of which only six weeks is dedicated to clinical psychiatric medicine. Psychiatrists also complete an additional four years of residency. Students incur debt that is usually paid off by relatively high salaries following residency – a cost absorbed by patients and the health care system. Doctoral training for psychologists is far less expensive and more specific to mental illness than the medical education of psychiatrists. Given their relatively inexpensive training, psychologists do not accrue as much debt as medical students and usually command lower salaries than psychiatrists.

Stakeholders Americans of all ages with mental disorders, especially those living in rural areas, could benefit from this policy. They would have increased access to necessary psychotropic medications and a greater abundance of prescribers. They would also experience greater savings due to lower transportation and provider costs. Psychologists could benefit economically and professionally from expanded career choices. Psychiatrists would continue to offer a competing approach that focuses on pharmacological intervention rather than psychotherapy.

Talking Points
• After training in drug therapy, psychologists are proficient prescribers of psychotropic medications. • An increased supply of prescribing mental health professionals could address shortages in rural and child mental health care. • Training prescribing psychologists would be significantly less costly than training new psychiatrists, generating savings for mental health systems and patients. Sources

Next Steps Lawmakers should address the shortage of psychiatric services through federal legislation modeled after recent state legislation in New Mexico and Louisiana. Following bill passage and program development at academic institutions, the United States could have its first generation of prescribing psychologists to treat underserved populations in one to two years.

Kim, W.J. “Child and Adolescent Psychiatry Workforce: A Critical Shortage and National Challenge.” Aca demic Psychiatry 27(4):277-292. Kessler, R.C., Chiu, W.T., Demler, O.,Walters E.E. “Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R)”. Archives of General Psychiatry 62:617-627 (2005). Bates, B. “Child Psychiatrists in Huge Demand: Shortage Deemed a ‘Dire Problem’” Clinical Psychiatry News 31:1-5 (2003). Levin, A. “Rural Counties Suffer From Child Psychiatry Shortage” Psychiatr News 41:4 (2006). Pingitore, D.P., et al. “Comparison of Psychologists and Psychiatrists in Clinical Practice.” Psychiatric Services 53:977-983 (2002). National Alliance on Mental Illness. “Prescribing Privileges for Psychologists: An Overview” 2002. http:// www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay. cfm&ContentID=8375. American Academy of Child and Adolescent Psychiatry. “AACAP State Psychologist Prescribing Update.” (2005). National Alliance on Mental Illness. “Prescribing Privileges for Psychologists: An Overview” (2002). http:// www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay. cfm&ContentID=8375. Galka, S.W., et al. “Medical Students’ Attitudes Toward Mental Disorders Before and After a Psychiatric Rota tion.” Academic Psychiatry 29:4 (2005). Salary of Benefits of Psychiatric Residency Program for the University of Washington. http://depts.washington. edu/psychres/salary.shtml. American Psychological Association. Singleton, D., Tate A, and Randall, G. “Report of the 2001 APA Salary Survey” (2003). http://research.apa.org/01salary/index.html. Psychiatrist Salaries (2009). http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_ HC07000027.html


Strengthening Community-Based Mental Health Care for Veterans
Taylor Johnson, University of Michigan Comprehensive peer support programs that allow returning veterans to connect with support networks in their communities and through social networking sites can provide important supplementary mental health services for young veterans returning from Iraq and Afghanistan. Many gaps in the veterans mental health system are creating significant barriers to reintegration for returning veterans. Despite new legislation to expand access to traditional mental health services for veterans, little support is provided to overcome the stigma of receiving mental health services and to ensure continued support between therapy sessions. Peer support specialists fill both of these roles and perform a wide range of tasks to assist consumers in regaining control over their own lives and over their own recovery process, which include: • Serving as models by demonstrating good communication skills, effective coping skills, recovery-oriented living skills, and self-help strategies. • Helping veterans develop and implement treatment plans. • Assisting veterans in attending their activities and appointments.

Key Facts
• The Army’s Mental Health Advisory Team has estimated that 30 percent of high combat marines and soldiers returning from Iraq develop post-traumatic stress disorder (PTSD), anxiety, or depression. • A Vet4Vet survey of veterans demonstrated increasing overall improvement and progress in the recovery process based on number of peer support sessions attended. • Only 42 percent of soldiers and 38 percent of marines who screened positive for a mental health problem in Iraq sought treatment.

Peer support specialists have been identified as an important supplement to relieve the already strained veteran mental health system. Minimal national funding has been appropriated to develop these programs, which has resulted in states implementing veteran peer support programs on a small scale. A grant program to develop training and implement veteran peer support programs throughout the nation can help ensure that veterans have the necessary resources to successfully reintegrate into society upon returning home. In addition to promoting healthy veterans, this legislation creates unique job opportunities that are specifically designed for veterans. Because peer support’s effectiveness relies on the connection of shared experience, these jobs will be filled by veterans who have recovered from illnesses brought about by their experiences in the military.

Analysis The stigma associated with mental illness in the military is one of the many challenges veterans must overcome when accessing mental health services. Because soldiers fear the professional consequences of being diagnosed with a mental illness, they often avoid treatment and instead serve multiple combat tours while suffering from a mental illness, impairing their service. The social stigma associated with mental illness has also led many veterans to abuse alcohol or drugs in order to ‘treat’ their illness, creating a large population of veterans with co-occurring mental illnesses. Peer support specialists provide a unique support network for returning veterans and can also serve as a non-threatening entry point into the mental health system. The opportunity to access peer services will lead to greater awareness and recognition of mental illness in the military, combating the stigma associated with it. Mental health services are most often accessed by veterans at Veterans Administration Hospitals which, • Veteran peer support programs create due to distance or unstable transpaid professional opportunities for veterportation options, can make utilizans and develop important resources for ing those services frequently or in returning veterans. an emergency difficult. By training • Peer support specialists serve as an imveteran peer support specialists portant supplement to traditional mental located in communities throughout health services, easing the strain on the each state, veterans will be able to current veteran mental health system. access services on a local level. In • Mental health resources are not a benefit addition, the use of social networkthat should be given to veterans, rather ing sites will allow for easy access they are an entitlement that veterans have to peer services. Through targeted earned through their service to America. use of these online resources, the peer support program will be able to reach the many young returning veterans who communicate more reliably through online services.

Talking Points

Armstrong, Moe. “What is Peer Support?.” Veteran Recovery. http://www.veteranrecovery.med.va.gov/peer_ support/What_is_peer_support.pdf (accessed June 11, 2009). “Veteran Recovery - Job Description PEER SUPPORT SPECIALIST, GS5 - Mental Health Service.” Welcome to Veteran Recovery. http://www.veteranrecovery.med.va.gov/announce/positions/Peer_Support_Speciaist_ Position_Description.htm (accessed June 11, 2009). Armstrong, Moe. “What is Peer Support?.” Veteran Recovery. http://www.veteranrecovery.med.va.gov/peer support/What_is_peer_support.pdf (accessed June 11, 2009). “America’s Wounded Warriers.” Veterans for America. www.veteransforamerica.org/wp-content/up loads/2007/12/trends-in-treatment-r2.pdf (accessed June 11, 2009). Center for Community Support & Research, Wichita State University. “Vets4Vets Program Evaluation.” Vets 4 Vets - Peer Support For Iraq And Afghanistan-Era Vets. http://www.vets4vets.us/ (accessed June 11, 2009). Ibid Alvarez, Lizette. “After the Battle, Fighting the Bottle at Home - Series - NYTimes.com.” The New York Times - Breaking News, World News & Multimedia. http://www.nytimes.com/2008/07/08/ us/08vetshtml?pagewanted=1&_r=1 (accessed June 11, 2009).


Expanding Personal Control of Electronic Health Records
Eva Galvan, Yale University Health information technology efforts should be expanded to include the creation of an online, integrated personally-controllable health record (PCHR), which would monitor the advancement of certain long-term illnesses by suggesting tailored action plans according to the patient’s specific condition. The 2009 stimulus package has dedicated funding for health care providers to adopt health information technology (HIT). To offset the cost and difficulties encountered in adopting HIT, the stimulus package includes a provision for electronic health records (EHRs) with various features such as “patient demographic and clinical health information.” The United States Department of Veterans Affairs has already registered hundreds of thousands of veterans to use MyHealtheVet, a PCHR website, to find caregivers, apply for prescription refill, track labs, and keep food and activity journals, among many other services.

Key Facts
• The 2009 stimulus package provides grants around $19 billion to health care providers to support the adoption or upgrading of health information technologies. • Over two-thirds of hospitals had at least partially implemented EHR programs in 2006, and 10 percent of hospitals were using computerized physician order-entry. • Health administration costs in 1999 totaled at least $294.3 billion in the U.S., or $1,059 per capita, while Canada spends $307 per capita.

While the stimulus package has already outlined terms of EHR development and HIT implementation, an easily understandable, patient-accessible system such as PCHRs incorporated into new HIT programs is a logical and critical next step. The federal government could provide overall coordination for this initiative through a new online portal, MyHealth.gov, modeled after MyHealtheVet. Analysis Upgrading and standardizing EHRs to allow for patient access online will improve the quality of care that patients receive and ensure that patients can better manage their own treatment. The benefits of creating a simple PCHR system far exceed any cost of creating and distributing it alongside the upgraded HIT that hospitals will be receiving through the stimulus package. Close monitoring of chronic illnesses such as diabetes will lessen their overall impact on and cost to American society. To be successful, PCHRs would have to be not only fast and simple for the doctor to use during appointments but also easy for the patient to understand. The MyHealtheVet website has achieved this goal with its “Frequently Asked Questions” section and clear explanations of the resources it offers. “Wellness Reminders” such as the ones used by

the MyHealtheVet PCHR website can remind patients of appointments or to adhere to lifestyles consistent with maintaining health. Stakeholders Everyone benefits from the implementation of integrated PCHRs; however, patients at risk of or suffering from chronic illnesses and multiple co-morbidities will be most affected because the most significant gains can be made through personalized disease management. The burden of using this program to its full potential will rest with medical professionals and facility administrators, who will have to make sure the patient understands how to access the useful information, and with patients, who have to make the commitment to access the information. Next Steps The first step to imple• Although the stimulus package has provided funding menting an integrated, for EHRs, it failed to provide for a comprehensive papatient-accessible PHR tient-accessible system. program is to find fund• Upgrading and standardizing EHRs to allow for patient ing, either from Conaccess will improve the quality of care that patients regress or through existceive and ensure that patients can better manage their ing funding directed to own treatment. the Office of the Na• Creating a patient-accessible system is currently feational Coordinator for sible because of ongoing initiatives for large-scale upHIT. The National Cogrades in HIT; the collaboration to develop a baseline ordinator should then EHR system should additionally be required to inteoversee the design of grate patient access. a flexible, uniform program, compatible with the EHR programs already funded by the stimulus package. The program must be written through close collaboration between public health experts, medical professionals, program designers, and any existing private programs. The last phase will involve implementation and expansion measures similar to those being envisioned for the baseline EHR programs.

Talking Points

“Continued Progress: Hospital Use of Information Technology.” American Hospital Association. 2007. <http:// www-03.ibm.com/industries/global/files/continuedprogress.pdf> (accessed April 5, 2009). “My HealtheVet – The Gateway to Veteran Health and Wellness.” The United States Department of Veteran Affairs. 30 April 2009. <http://www.myhealth.va.gov> (accessed May 5, 2009). “Speaker Nancy Pelosi: American Recovery and Reinvestment Act.” <http://www.speaker.gov/newsroom/ legislation?id=0273> (accessed April 5, 2009). “The American Recovery and Reinvestment Act of 2009.”<http://frwebgate.access.gpo.gov/cgi-bin/getdoc. cgi?dbname=111_cong_bills&docid=f:h1enr.pdf> (accessed April 5, 2009). Woolhandler, Steffie, Campbell, Terry, Himmelstein, David U. “Costs of Health Care Administration in the United States and Canada.” N Engl J Med, 349 (2003) 768-775.


Using Municipal Identification Cards as Gateways to Health Services
Lauren Hunter, Greg Mittl, Jessica Becker, and Eva Galvan, Yale University Municipal ID cards can increase access to free and low-cost health services, especially for immigrants and the uninsured. Cities across the country have recently implemented municipal identification cards, recognizing the potential for such cards to incorporate immigrants and other underrepresented groups into the city community. Like driver’s licenses, municipal ID cards contain the bearer’s photograph, address, and date of birth, as well as a unique identifying number and an expiration date. Unlike driver’s licenses, all city residents – regardless of immigration status – may obtain municipal ID cards.1 The first such card was New Haven’s “Elm City Resident Card” (ECRC), which has inspired programs in other cities, notably San Francisco.2 In addition to acting as a form of identification, some municipal ID cards offer services, such as debit or library capabilities. In March 2009, the Elm City Resident Card was linked to a program that offers a 20 percent discount on all prescription drugs at CVS pharmacies, making this discount available to uninsured New Haven residents with an ECRC.3 The incorporation of a prescription drug discount into a municipal ID card was a first step toward utilizing these cards as gateways for health services.

Key Facts
• As of 2005, there were 46.6 million uninsured Americans (15.9 percent of the population).4 • Immigrants use about half as many health services as U.S.-born individuals.5 • About 10 percent of all ambulatory health care expenditures are for emergency room services.6 • 7370 New Haven residents have applied for the Elm City Resident Card.7

Analysis There are several ways in which a municipal ID card can increase resident access to free and low-cost health services. One possible approach is to embed personal health information on the card itself – an especially compelling option since health providers regularly struggle to locate the medical histories of immigrants and the uninsured. The card could simply display basic health information, such as the bearer’s allergies and organ donor status. A more complex version of the card would be an electronic health record offering a comprehensive medical history. Several options require greater involvement on the part of the municipal government. A city can compile information on low-cost health care and include a box on the ID card application form that residents can “check” in order to receive the compilation when they receive the ID card. This approach responds to the disjointed and confusing nature of American health care by providing straightforward instructions for access. Another

option for city governments is to market the card as a “safe space” icon to the immigrant community. For example, a city could create a program for familiarizing providers with immigrant health and financial needs. When providers complete the program, they are “certified” by the city and can, perhaps, display the ID card icon in their office. The costs of implementing and maintaining the ID cards are minimal. New Haven’s card is actually funded by supportive organizations outside of the city government.8 The costs of the health components are also small and consist primarily of administrative time invested in communicating with providers, advocacy groups, etc. Stakeholders Reassuring immigrants that providers are familiar with their needs and presenting the uninsured with financially-feasible health care options will encourage both groups to visit physicians earlier, contributing to their well-being. In addition, significant financial benefits flow to the taxpayer. When the uninsured and impoverished are financially able to access preventative services, their costly use of emergency rooms decreases. Lastly, the entire city is strengthened when its members feel safe, healthy, and valued. Next Steps With more than 7,000 people signed up for the ECRC in New Haven, and other cities implementing or proposing similar cards, the future of the municipal ID card as a health service gateway may be at a turning point. City government – both the executive and legislative branches – must support the creation of municipal ID cards. Incorporating health components into existing cards can involve collaboration between city government and community health centers, hospitals, and myriad advocacy groups.

Talking Points
• Municipal ID cards can become navigation tools for fragmented and confusing health systems, providing residents – immigrants and the uninsured, in particular – increased access to needed health services. • Connecting municipal ID cards to low-cost health services saves taxpayers’ money by reducing the burden of immigrants and the uninsured on our emergency rooms. • Municipal ID cards, especially when they include a public health component, encourage immigrants to become stakeholders in the community, improving resident relationships and decreasing crime.

1. Matos, Kica. “The Elm City Resident Card: New Haven Reaches Out to Immigrants.” New England Community Developments 4 (2008): 1-7. 2. “SF City ID Card.” City and County of San Francisco, Office of the County Clerk. 2 Apr. 2009 <http://www.sfgov.org/site/countyclerk_index. asp?id=78261>. 3. “New Haven Prescription Discount Card.” City of New Haven. 2 Apr. 2009 <http://www.cityofnewhaven.com/Mayor/PrescriptionCard.asp>. 4. “The Number Of Uninsured Americans Is At An All-Time High.” 29 Aug. 2006. Center on Budget and Policy Priorities. 2 Apr. 2009 <http://www. cbpp.org/cms/?fa=view&id=628>. 5. Mohanty, Sarita A., et al. “Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” American Journal of Public Health 8 (2005): 1431-1438. <http://www.ajph.org/cgi/content/abstract/95/8/1431?ijkey=8c08cb8559640f816a8266203327208226734af7&ke ytype2=tf_ipsecsha>. 6. Machlin, Steven R. “Expenses for a Hospital Emergency Room Visit, 2003.” Medical Expenditure Panel Survey. Jan. 2006. Agency for Healthcare Research and Quality. 2 Apr. 2009 <http://www.meps.ahcpr.gov/mepsweb//data_files/publications/st111/stat111.pdf>. 7. Lu, Carmen. “ID card drive aims to draw Elis.” 1 Apr. 2009. Yale Daily News. 2 Apr. 2009 <http://www.yaledailynews.com/articles/view/28402>. 8. Matos, Kica. “The Elm City Resident Card: New Haven Reaches Out to Immigrants.” New England Community Developments 4 (2008): 1-7.


Using Biometrics To Coordinate Health Care For Undocumented Patients
Yining “Tommy” Fu and Neil Parikh, Rice University Coupling fingerprint and retinal scanners with already existing Electronic Medical Record (EMR) software will help medical institutions streamline information access and avoid redundant treatments and expenses for undocumented patients. Patient identification is a major barrier to care for the 3.5 million homeless people and 15 million undocumented immigrants currently living in the U.S. Illness among these populations is exacerbated by their lack of stable residence and safe storage for identification documents such as driver’s licenses and insurance cards. These documents are the primary means of patient identification currently used by healthcare centers. In their absence, physicians and clinics pour substantial time and resources into identifying patients in order to treat them. New advances in biometric Key Facts technology, like fingerprint and • In 2000, our nation’s hospitals spent close to retinal scanners, can help re$190 million on undocumented patients. duce this disconnect by quickly • 20 percent of the uninsured (compared with 3 and conveniently measuring bipercent of those with coverage) say their usual ological data for the purpose of source of care is the emergency room. identification. By syncing these • An estimated $60,000 in government appromobile devices with existing priations would be required to equip every EMR software, healthcare cenFederally Qualified Health Center in the U.S. ters could extend the advantagwith a Biometric-EMR system. es of digitally organized health information to a population that previously could not be tracked within the system. Integrating EMR and biometric identification would allow doctors to obtain the health history of even the most undocumented or incapacitated patient with just the swipe of a finger. The specific use of fingerprint biometrics is a new approach that builds on a history of unsuccessful efforts to address the challenge of patient identification. Biotracking devices like USB bracelets and radio-frequency identification (RFID) cards were all vulnerable to loss, malfunction, or misplacement. The use of fingerprint identification would circumvent this persistent obstacle by eliminating the risk of identification loss altogether. In past years, pilot programs combining these technologies have been implemented successfully at the Mayo Clinic in Minneapolis, MN and Catholic Health Systems in Buffalo, NY. The idea has yet to be applied to undocumented patients, the group that may, in fact, benefit the most from it. New advances in biometric technology make this approach inexpensive and easy to disseminate. Feedback from health information companies suggests that with the attainment of compatibility between different software systems and standards, this protocol

can be implemented readily with fingerprint scanners as inexpensive as $30. Meanwhile, savings from the reduction of uncompensated care are projected to reach up to $74 million in Houston alone. Immigrant communities may be concerned that health data would be connected to immigration data in order to identified undocumented citizens, but with appropriate privacy safeguards health data can be kept separate. In addition, if biometric data are used to identify all patients who come to community health centers, then the ability to single out non-citizens will also be diminished. Stakeholders This novel Biometric-EMR protocol would principally benefit undocumented patients such as the homeless. They will no longer have to undergo the entire regimen of clinical tests each time they visit a health center, enabling them to receive better care and opening up time and diagnostic resources for additional cases. Physicians who treat these patients also stand to benefit. Greater convenience and speed in obtaining mediTalking Points cal histories will allow them • For medical personnel, the greater efficiency, relito treat more patients and ability, and speed of information access enabled by provide more comprehena Biometric-EMR system translates into better prosive care. Lastly, hospitals ductivity and continuity of care for patients. and clinics will benefit from • It can also reduce obligatory expenses such as reduced congestion and emergency room services by improving their effiwaste of resources. ciency and preventing waste. Next Steps The authors have already begun a pilot program at the HOPE Clinic, a Federally Qualified Health Center (FQHC) in Houston, TX, to assess the cost-saving and efficiency benefits of this EMR-Biometric protocol over a sixmonth trial period. If successful, the program will seek to introduce this Biometric-EMR protocol to clinics in the Houston Metropolitan area, the state of Texas, and ultimately around the U.S. Meanwhile, similar programs can be implemented nationwide in other certified FQHC clinics. As evidenced by the successes in New York and Minnesota, it is feasible to integrate these biometric tools with existing medical institutions. Sources
“Biometric scanner used for hospital security. (01-JUN-05) Hospital Access Management.” AccessMyLibrary - News, Research, and Information that Libraries Trust. 13 Apr. 2009. http://www.accessmylibrary.com/coms2/summary_0286-12207924_ITM. “Can EMR save you money?” Medical Practice Management Trends. 13 Apr. 2009. http://www.medicalpracticetrends.com/technology/emr-savemoney/. Lawrence, Stacey. “Biometrics Bring Fingerprint ID to Hospitals - Health Care.” Research, Best Practices and News for Information Technology Executives - CIO Insight. 13 Apr. 2009. http://www.cioinsight.com/c/a/Health-Care/Biometrics-Bring-Fingerprint-ID-to-Hospitals/. “NCHC | Facts About Healthcare - Health Insurance Coverage.” NCHC | Home. 13 April 2009. http://www.nchc.org/facts/coverage.shtml. “Total FQHCs - United States -.” Kaiser State Health Facts. 13 April 2009 http://www.statehealthfacts.org/profileind.jsp?ind=424&cat=8&rgn=1. Combs, Susan. “The Uninsured: A Hidden Burden on Texas Employers and Communities.” Texas Comptroller of Public Accounts. 13 April 2009. http://www.window.state.tx.us/specialrpt/uninsured05/.

• The quicker and more convenient check-in process enabled by Biometric patient identification may increase patient satisfaction and make primary care a more attractive alternative to expensive emergency and catastrophic care.


Center for Health Care Year in Review
Robert Nelb, Lead Strategist and Senior Fellow for Health Care The articles in this journal are just the surface of the work that the Health Policy Center has done this year. In this final section, I hope to highlight the some of the great work that goes on behind the scenes and the lessons learned for other students who hope to turn their ideas into policy. Of course, the Roosevelt Institute Campus Network is not like most think tanks. We do not sit around in rooms all day and write pages and pages of papers that are destined for the recycle bin. We engage students from communities across the country and are motivated by their fresh perspectives to try and make a tangible impact in the world. It is a model that we have summed up in a simple phrase: Think Impact. Think Impact is about so much more than publishing articles in a journal. It is the process of how we come up with our ideas and way that we use the power of our ideas to make real change. It is easy to dismiss the ideas of young people as naïve or inconsequential, but in this past year alone, our fellows have already made a tangible difference. In the years to come, I have no doubt that our ideas will be changing the world. Think Most of the ideas in this journal were developed in the spring of 2009 at our second annual student health policy conference. Students from all across the country convened in Washington, DC to hear from experts, advocates, and policymakers, including Lauren Aronson, the policy director for the White House Office of Health Reform. From the very start we were Think thinking of the audience for our pol• Think of your audience when choosing icy ideas. your topic. • Value diversity and bring together many A select group of Roosevelt fellows different perspectives. also participated in a special writing • Meet with community members and workshop to further their ideas. One draw from your personal experiences in of the best parts of this workshop order to make policy that is relevant to was hearing the various perspectives real needs. from our diverse group of students from all across the country. Not only did we hear from students of many different backgrounds, but we were also able to share ideas with students from different disciplines, such as engineering and business, in order to develop the kind of interdisciplinary ideas that are so important for health policy. Although conferences in Washington are exciting, the real work of Roosevelt happens outside the beltway. With a network of chapters at universities across the country, the

Roosevelt Institute Campus Network is especially equipped to investigate issues at the local level. This year, three of our chapters -- the University of North Carolina, Amherst, and Yale University -- organized site visits with their local community health centers in order to learn first hand about problems in the health care system. By getting outside the classroom, our fellows were able to develop new, innovative ideas, like the Yale health policy center’s article in this journal about using municipal ID cards as a gateway to help improve access to health services. Impact Once our students develop new ideas, communication is an important part of the policy process. This journal is just one of our many policy venues to communicate new ideas. This year we published Roosevelt Rx, our first journal of student health policy ideas; we organized policy discussions on our blog, and published op-eds and letters to the editor in major newspapers, including the New York Times. Words alone are not enough, however, so we have also been active in organizing events and projects to help turn our ideas into reality. In addition to organizing events in Congress to promote our policies, some of our fellows have been taking action to implement their policy ideas at the local level. For example, Tommy Fu and Neil Parikh at Rice University received funding to implement a pilot program of their biometrics policy in Houston. Students who do not have the resources and connections of more established organizations, but that does not mean we cannot make a difference. Despite all these successes, we also know that change is not easy. Impact I have learned this lesson my• Communicate your idea in many different self through a policy idea about forms. automatic enrollment in public • Try out your idea on the local level, where you health insurance programs that may be able to have a more direct impact. I published in one of Roosevelt’s • Keey trying, no matter what. first journals. Although the idea seemed simple, change didn’t happen overnight. However, after publishing commentary about the idea in many different newspapers and working with many different partner organizations, I am now pleased to say that the idea was recently published by the Brookings Institution’s Hamilton project and became a part of the recently passed Children’s Health Insurance Program Reauthorization Act. Change doesn’t happen alone and it does not happen overnight, but it is possible.


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