A call for better immigrant care (American College of Physicians annual meeting)

The ACP asks the federal government to develop a policy to ensure health care access while balancing the need to regulate immigration.

By — Posted May 2, 2011

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A physician's ethical obligation to treat all patients who need care is a challenge when it comes to the nation's immigrant population, according to the American College of Physicians.

Too often, the debate about how to control access to the nation's borders clashes with immigrants' need for access to medical care by generating mistrust and blocking basic health services, said ACP Immediate Past President J. Fred Ralston Jr., MD.


Dr. Ralston

"Currently, immigrants, both documented and undocumented, face many barriers to adequately accessing badly needed health care," he said. "Access to health care should not be restricted based on immigration status."

The ACP is calling for a national immigration policy on health care that would balance the country's need to control its borders with the costs of denying care to immigrants, says a position paper released April 7 at the ACP Internal Medicine 2011 meeting in San Diego. At the same time, taxpayers shouldn't be expected to subsidize coverage for undocumented immigrants, the paper says.

Such issues often are addressed at the state level, creating an inconsistent system that fosters confusion, said Robert G. Luke, MD, immediate past chair of the ACP's Board of Regents.

Some states are considering legislation targeting illegal immigrants, including some that would affect medical care. In South Carolina, for example, lawmakers are debating legislation to make it a felony to transport illegal immigrants, even to a hospital.

Proponents of stricter immigration controls say it's unrealistic to ask the federal government to ensure access to health care for immigrants without asking taxpayers to bear the bulk of the cost. "The bigger question is where is the money going to come from," said Steven Camarota, PhD, director of research at the Center for Immigration Studies. The Washington, D.C.-based organization's mission is to provide information on the "consequences of legal and illegal immigration into the United States."

Challenges of caring for immigrants

Immigrants make up about 13% of the U.S. population, and 69% of those are in the country legally. Researchers estimate that 11 million to 12 million immigrants are undocumented, the ACP paper says.


Dr. Luke

Immigrants can buy private health insurance, but many work low-wage jobs that lack employer-sponsored coverage. They cannot afford to pay for their own health care and often live in fear of being reported to authorities for seeking medical attention, Dr. Ralston said.

The American Medical Association opposes any regulations or legislation that would punish physicians for caring for illegal immigrants or require them to report a patient's immigration status.

Most legal immigrants can't qualify for Medicaid until they have been in the U.S. for five years, the paper said. As a result, many turn to charity clinics, community health centers and hospital emergency departments.

CommunityHealth operates two clinics in Chicago that provide free care to the uninsured with the help of volunteers and private donations. At its larger clinic, about 75% of patients are native Spanish speakers and about 15% are native Polish speakers, said internist Babs Waldman, MD, CommunityHealth's volunteer medical director.

Immigrant patients typically have at least one chronic condition, such as diabetes or heart disease, and that condition often hasn't been managed properly, Dr. Waldman said. Some have been hospitalized for an acute condition but didn't receive follow-up care after they were discharged. "Often, they have had spotty, if any, medical care," she said.

Language is another barrier. Even with some translators onsite, Dr. Waldman said she fears some things may be lost in translation.

Referring immigrants for specialized care also is a challenge, said James A. Hotz, MD, internist and clinical services director of Albany (Ga.) Area Primary Health Care Inc. Community clinics typically have agreements with area hospitals to provide care for referred patients, but immigrants often are wary of being sent to another facility.

Costs of denying care

Limited options cause many immigrants to delay medical care until an emergency. Delaying treatment for communicable diseases, in particular, is costly and potentially harmful to others, said David Ansell, MD, professor and vice president of clinical affairs at Rush University Medical Center in Chicago.

In emergency cases, the Emergency Medical Treatment and Active Labor Act requires hospitals to screen and stabilize all patients, and many immigrants -- both legal and illegal -- qualify for Medicaid coverage for emergency care.

A 2009 study in the American Journal of Public Health estimated that 45,000 deaths annually were linked to lack of health insurance. About 40% of immigrants have private insurance and 60% are uninsured, the ACP said. U.S. citizens are the majority (78%) of the uninsured.

"People have this misconception that the undocumented make up a significant portion of the uninsured and take up a lot of resources, which is not true," Dr. Waldman said. "When they do go to the emergency room, the cost is significantly greater than it would have been to treat them along the way."

Under the health system reform law, illegal immigrants would be barred from buying coverage under new health insurance exchanges.

People shouldn't be prevented from paying out-of-pocket for health coverage, Dr. Ralston said. Allowing them to buy health insurance would alleviate everyone's costs, he said.

But Camarota, of the Center for Immigration Studies, said the research is inconclusive as to whether covering the uninsured reduces costs. The center estimates that immigrants make up 14.5 million, or a third, of the uninsured, and illegal immigrants are 17% of the uninsured.

"The estimated cost of providing health care at all levels of care to illegal immigrants is $4.3 billion a year," Camarota said. "It's big."

The issue would be better solved by stemming the flow of immigrants into the U.S., said Ira Mehlman, media director for the Federation for American Immigration Reform, a Washington, D.C.-based nonprofit that advocates tighter immigration controls and an end to illegal immigration. "Instead of looking for ways to cover those [medical] costs, maybe we should be saying, 'Gee, maybe this isn't such a great policy in the first place.' " The Center for Immigration Studies, cited earlier, was founded under the federation and later became independent.

The ACP said developing a national immigration policy on health care is a daunting challenge, Dr. Ralston said. "Any national immigration policy will need to balance the legitimate needs and concerns to control our borders and to equitably differentiate in publicly supported services for those who fully comply with immigration laws and those who do not," he said. "However, access to health care for immigrants is crucial to the overall population of the U.S. We all have a vested interest in ensuring that all residents have access to necessary care."

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Medicaid must be made sustainable, ACP says

The federal government must ensure that Medicaid is equipped to cope with increased demands as the nation moves forward with the health system reform law and grapples with the federal budget, the American College of Physicians said in a position paper released April 8 at its annual meeting.

Under the Patient Protection and Affordable Care Act, Medicaid enrollment could grow by more than 18 million by 2019, and primary care physicians will handle the bulk of those patients, said ACP Immediate Past President J. Fred Ralston Jr., MD.

"The law will dramatically alter the landscape of health care access and delivery," he said.

In preparation, Medicaid should be revised to ensure its long-term sustainability, the ACP said. Physician payments must cover the costs of providing care, and administrative barriers to patient and doctor participation should be minimized, Dr. Ralston said.

The program should emphasize quality over quantity and provide patients with options for long-term care beyond nursing homes, said Robert G. Luke, MD, immediate past chair of the ACP's Board of Regents.

The position paper lists 12 recommendations for improving Medicaid and health care reform. They include instituting uniform eligibility requirements nationwide, reducing fraud and waste, and ensuring patient access to innovative reforms such as the medical home model.

Some states offer higher payments for physicians and other health professionals who establish a medical home for Medicaid enrollees, the paper states. But establishing such homes takes time and teamwork, said physicians leading sessions on the model of care.

Embracing the medical home

Medical Associates Clinic and Health Plans in Dubuque, Iowa, operates as a medical home with a variety of methods to improve efficiency and care, said internists Christine Sinsky, MD, and Thomas Sinsky, MD.

Patient visits are planned, lab work is done in advance and prescription renewals are bundled once a year. Time is allotted for rapid-access appointments, and workload is distributed with nurses handling tasks such as responding to phone calls and updating electronic medical records.

"We plan relentlessly," Dr. Christine Sinsky said.

Ninth Street Internal Medicine Associates in Philadelphia also uses the medical home model. The practice has agreements with specialists in areas such as behavioral health and oncology to ensure communication and collaboration on referrals, said Allan Crimm, MD, managing partner of the group.

Health reform is an opportunity for the profession to move closer to patients and return to the human side of medicine, Richard Baron, MD, said during the ACP meeting's opening session. "For too long, our gaze has been directed to science and has been diverted from our patients," said Dr. Baron, group director of Seamless Care Models at the Centers for Medicare & Medicaid Services' Center for Medicare and Medicaid Innovation.

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Meeting notes

Meeting notes from the ACP annual meeting:

Physicians debate patient access to their doctors' notes: Whether patients should have ready access to doctors' notes in electronic medical records is a subject of debate. Those in favor say the notes help patients be more informed and involved in care. But opponents say the notes are written by doctors for doctors and could be easily misunderstood by those without a medical education.

"My notes can't serve multiple judges," Ronald N. Rubin, MD, professor at Temple University School of Medicine in Philadelphia, said during a session at the American College of Physicians meeting.

Thomas L. Delbanco, MD, said patients already have the right to view doctors' notes, but often don't because of a cumbersome process to request them. Some institutions like the University of Texas MD Anderson Cancer Center already invite patients to view doctors' notes. "Transparency, whether we like it or not, is here to stay," said Dr. Delbanco, professor at Harvard Medical School in Boston.

More diversity sought in physician work force: The nation needs more diversity among its doctors to treat an increasingly diverse population, panel speakers said at the meeting.

Minority physicians are more likely to work in underserved areas and treat poorer, sicker patients, said Lisa A. Cooper, MD, MPH, professor at Johns Hopkins University School of Medicine in Baltimore. Patients also are more likely to be satisfied seeing a doctor of the same race, she said.

"Physician work force diversity is really key to improving health care outcomes," said Marcella Nunez-Smith, MD, assistant professor at Yale University School of Medicine in Connecticut.

There is a history of discrimination against minority doctors, including closing of medical schools serving blacks and women in the early 1900s and exclusion of minorities from physician organizations, Dr. Nunez-Smith said. Many minority physicians still feel discriminated against in their workplaces and by patients, she said.

New ways to reach patients: Physicians must use new technologies to communicate with patients, said Daniel Z. Sands, MD, MPH, assistant clinical professor at Harvard Medical School and director of clinical informatics at Cisco Internet Business Solutions Group in Boston.

Technologies such as email, video conferencing and telemedicine can help doctors efficiently connect with patients, yet many doctors don't use them, said Dr. Sands, who led a session at the ACP meeting. "When you look at studies on how we connect with patients, we do a bad job. We're going to have to diversify the ways we interface with patients."

For example, video conferencing can help physicians connect face-to-face with patients and cut travel costs. Some health systems have developed secure websites that allow patients to access health records and request prescriptions or referrals. But physicians should select only technologies that best serve their needs. Offering too many options creates confusion.

"This is a training process for both us and our patients," he said.

Power differential poses risk of sexual harassment: Many scenarios in medical practice may qualify as sexual harassment, Dr. Anita Palepu, an internist and professor at the University of British Columbia in Vancouver, said during a session. Such harassment may involve a physician dating a patient, a male faculty member making sexually explicit comments at work or a female professor inviting a male resident to share a hotel room at a conference, she said.

When there is a power differential between people who are romantically involved, there is a risk of harassment, said Diane K. Shrier, MD, psychiatrist and clinical professor at George Washington University Medical Center. People in a position of power should not take advantage of their position.

"Some relationships that appear to be consensual on the surface are not in fact consensual," she said. "There are gray areas."

Those who feel harassed may confront the harasser, talk to a supervisor, contact an outside arbiter like the U.S. Equal Employment Opportunity Commission or find another job, Dr. Shrier said.

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External links

American College of Physicians Internal Medicine 2011 meeting, with more information about lectures, presentations and other developments (link)

"National Immigration Policy and Access to Health Care," American College of Physicians, April 7 (link)

"Medicaid and Health Care Reform," American College of Physicians, April 8 (link)

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