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State Budget Constraints: The Impact on Medicaid
This fact sheet summarizes the relationship of Medicaid with state budgets and discusses the current fiscal challenges in the states and how it is affecting Medicaid programs.
The Henry J. Kaiser Family Foundation
GTE Seeks Quality at the Right Price
12/24/2000
By Charles Ornstein Reprinted with permission of The Dallas Morning News
CHAMPAIGN, Ill. If George Crowling put pencil to paper, his job description would read something like this: fortune-teller, penny-pincher, paper pusher and private detective.
In short, Mr. Crowling manages health benefits. He is the person charged with finding health insurance programs for thousands of workers at GTE Corp. and the voice that soothes irate workers when they have problems with their HMOs.
Each spring, Mr. Crowling assumes the role of sleuth. The regional health-care manager travels Texas and the Great Plains, ferreting out information on the HMOs that insure GTE’s workforce. He’s looking for signs of trouble, proof of improvements and a personal commitment to the telephone company’s quality-driven focus.
Mr. Crowling and two other regional health-care managers have kept an eye on GTE’s medical spending for years. And they continue doing so despite a merger with Bell Atlantic Corp. that created Verizon Communications Inc., the nation’s largest local telephone company.
Last year, GTE spent about $1 million on salaries and travel expenses for Mr. Crowling and the two other health-care managers. That’s a fraction of the $548.7 million cost of covering health care for its employees, retirees and dependents in 1999.
Yet, their negotiating prowess and knowledge of health plans has held GTE’s increase in medical expenditures to 8 percent for 2001 at a time when competitors have seen their costs skyrocket by 15 percent or more. The savings amount to millions of dollars.
In using in-house experts instead of hired consultants to negotiate with health plans, GTE breaks ranks with most of corporate America, as it has done since the early 1990s when it aggressively sought to shift employees into HMOs.
On the road again
Mr. Crowling logged thousands of miles in his pursuit of the right health plans. One two-day trip in May found him visiting four insurers.
The first day, he racked up frequent-flier miles from Albuquerque, N.M., to St. Louis before renting a car for a three-hour drive to Champaign, Ill. But he wasn’t done there. In the course of a two-day stay, he made two round trips between Champaign and St. Louis a total of 900 miles.
On every site visit, Mr. Crowling carried a black binder prepared by his assistant, JoAnn Phillips, whom he credits with maintaining his sanity. Inside the notebook are directions to his meetings, HMO enrollment figures and the HMO’s responses to a standard GTE questionnaire.
At his first stop in Champaign, Mr. Crowling spent 21/2 hours at PersonalCare, an HMO that covers about 100 GTE employees. He discussed prescription drug costs and efforts to reduce medical errors.
Todd Petersen, PersonalCare’s senior vice president and chief financial officer, is more accustomed to dealing with consulting firms. GTE is one of the few national clients to visit his health plan, he said.
His health plan has benefited from GTE’s emphasis on quality. PersonalCare has won a coveted spot as one of GTE’s benchmark plans because of its high scores on national quality and satisfaction surveys. The honor means that GTE pays a greater share of the premium for employees who enroll.
“They’re probably the only company that we do business with that actually backs up what they say,” Mr. Petersen said. “Every other company gives lip service to quality. But at the end of the day, it’s really about our provider network and price, as opposed to quality.”
A veteran of the health-care business, Mr. Crowling knows what questions to ask. As a consultant, he helped stabilize financially troubled Bay Pacific Health Plan in California.
Each of his counterparts has credentials in finance or health care. On the West Coast, Tom Davies had been a senior vice president at Blue Cross of California. Jim Astuto, who handles the East Coast, worked in the finance department at H.J. Heinz Co. before coming to GTE 13 years ago.
“It’s always an advantage, in relating to vendors, to have worn their shoes, to have worked in their arena,” said Mr. Davies, who is based in San Ramon, Calif. “When it comes to developing market strategies and plan designs, having this background has been one of the keys to our success.”
Mr. Astuto, who works in the Atlanta suburbs, said he made 19 trips this season from Florida to Maine to review about 50 health plans. He is also the point man for designing prescription payment plans that make consumers aware of costs.
“If you’re dedicated to providing the best, you need to get out there,” Mr. Astuto said. “You can look at all the quantitative markers on them, but sometimes you just need to get out there and hear the speeches.”
Benefits of site visits
It’s amazing, Mr. Crowling said, what he learns just from site visits.
At PersonalCare in Champaign, for instance, he saw data illustrating how patients shifted away from specific, high-cost drugs when the HMO increased their co-payments. Those patients moved to lower-cost drugs that the HMO described as equally effective.
“People are remarkably honest with us, sometimes shockingly honest about what’s happening or what’s going to happen,” Mr. Crowling said.
When trouble is brewing, he and his colleagues said, insurers in their regions call to prepare them before flare-ups prompt employee questions. Mr. Astuto, for example, learned of contract stalemates between hospitals and HMOs in Massachusetts, Florida and Kentucky long before the providers made the information public.
In Kentucky, Mr. Astuto encouraged the health plan to stand its ground and avoid paying the higher reimbursements requested by the physicians.
Three years ago, Mr. Davies helped facilitate an agreement between an HMO in Washington state and a large medical group. “[The two sides] painted themselves in a corner,” he said. “There was no way to get out without breaking the relationship.”
Because GTE provided insurance to 2,600 HMO members who used those doctors, Mr. Davies said he felt obligated to intervene.
“We were able to talk to both sides in very direct ways,” he said. “The top management of both the medical group and the company got together and hammered out an approach.”
First to the table
When GTE started offering HMOs to workers in 1988, it was part of the first wave of employers to embrace programs that offered $5 doctor visits, no claim forms and rules governing access to medical services.
But the company did not fully embrace the managed-care concept until four years later, when it hired its regional health-care managers to find quality HMO choices.
Since then, GTE has been a leader in transferring employees to managed care. In 1997, it was one of the first employers to increase patient co-payments for physician office visits to $10 from $5. A year later, it began charging varying co-payments for prescription drugs, separating medications into generic or one of two brand-name categories.
The moves gave employees a feel for the rising health-care costs that the company was paying and came on top of the monthly contributions that employees made to insurance premiums.
Unlike GTE, most companies hire consulting firms to manage health insurance benefits or at least assist with managing it. In fact, GTE’s merger partner, Bell Atlantic, does so, leaving Verizon with something of a hybrid system for the 2001 benefit year.
Some employers prefer consultants because of their expertise, tools and relationships with health plans, said Erich Blumberg, a consultant for Hewitt Associates, which administers GTE’s benefits program.
“The process of selecting and managing plans has become very complex,” said Mr. Blumberg, who’s in Hewitt’s Dallas office. “For more employers than not, it’s a once-a-year event. … You just don’t want to have the staff.”
GTE’s use of regional health-care managers almost unheard of today began in 1992.
“Virtually nobody was doing this,” Mr. Crowling said. “The concept that we would actually bring on a crew of people that would do nothing but evaluate health plans full time, … we were speaking Greek to them.”
Holding costs steady
He, Mr. Davies and Mr. Astuto have tried to earn their keep by managing costs in an arena that seems ungovernable, and they have achieved success. The amount of money GTE spends per person was exactly the same to the dollar in 1999 as it was in 1994.
Today, the chief threat to their success lies no further away than the corner drugstore. Like other corporations around the nation, GTE has sought ways to cut the cost of prescription drugs.
In 2001, GTE will take over the prescription programs of 25 HMOs in a pilot program that sets different co-payments for the same drug. Working with its pharmacy-benefit manager, GTE will allow patients to pay $15 co-payments for certain drugs such as Prozac for depression or Zocor for high cholesterol after meeting certain requirements. Otherwise, they would pay a $25 co-payment.
To qualify for the lower co-payment on Prozac, for instance, a GTE employee must show treatment from a mental-health professional. (The information would not be shared with the company.)
“When the product is more appropriate and absolutely required for your good health, it’s covered, and it’s covered at a lower amount,” said Patricia Wilson, a pharmacy consultant who has worked with GTE for more than a decade.
The goal, officials say, is to get high-cost drugs in the hands of people who really need it while discouraging their use among those who don’t meet the criteria.
“If people are using a drug because their doctor wrote it and doesn’t know any better, that’s not going to fly,” Mr. Astuto said. “This area has to be managed. It’s eating us up.”
Although the cost of prescription drugs has grabbed the spotlight, the health-care managers perennially focus on containing increases in premiums.
No state has been more conducive for cost-cutting in this area than California.
There, HMOs abound, and Mr. Davies has called the shots for the last two years. He has specified what GTE is willing to pay and told HMOs to take it or leave it.
“They all gave us proposals, and we came back and said, ‘We’ve read your proposals. They’re all over the map,'” Mr. Davies said. “None of them are adequately justified and this is what we’re willing to pay.
“It’s a free market, free world and they can withdraw. And several did.”
But don’t confuse Mr. Davies with a bully. “It’s a close working relationship. It’s not a bully thing,” he said. “We have a good deal of mutual respect and trust.”
GTE, for instance, provides its California HMOs with a detailed breakdown describing to which plans they lost members and from which plans they gained enrollees.
The firm also provides the HMOs with copies of all complaints and compliments. And it shows the HMOs where their premiums rank in relation to their peers.
Although Mr. Davies can virtually name his price in California, he and his colleagues say they’ve learned that the lowest price doesn’t always mean the best deal.
GTE is one of the few companies that turns down health premiums that are too low. Designed to recruit new members, such premiums often last for only one year, company officials said, and the subsequent increase will wipe out any gain.
One Texas health plan offered to reduce GTE’s rate by 3 percent for 2001. Instead of accepting, Mr. Crowling proposed a 3 percent increase. He said paying more now ensures stability later.
“We try to manage for the long term, and a one-year dip followed by a second-year increase is not what we have in mind,” he said. “We think we’re better off paying a reasonable amount for what we anticipate getting.”
Mr. Crowling’s job is to know what’s reasonable across a broad swath of the central United States that extends from his home base in Irving up to Champaign, Ill. That’s where his site visits pay off, he said.
09/06/2001
By Robert DavisReprinted with permission of USA Today
LAREDO, Texas Hector Salino waits patiently as his wife sees a nurse at their local medical clinic.
But he is in no ordinary waiting room, and she is in no ordinary clinic. He stands in the sweltering heat by his dusty pickup, not far from his home, as his wife gets her health care inside a specially equipped, air-conditioned truck. The medical visit is free, and no questions are asked especially the question most dreaded by millions of Hispanics living illegally on this side of the border. In health circles here, few people care if any patient who enters the door is a legal U.S. resident.
The medical mantra here is just treat; don’t ask.
As President Bush and Mexican President Vicente Fox meet this week to negotiate key immigration issues, health officials across the nation are paying more attention to preventive-care visits like the one the Salinos recently made to the mobile clinic. Immigrants, most of them from Mexico, are settling in surprising numbers across the nation’s midsection.
While California, Florida, Illinois, New York, New Jersey and Texas have the highest number of legal and illegal immigrants, the states in between from Oregon to the Carolinas have seen the fastest growth in immigrant populations, the latest Census found.
“These places are not used to dealing with immigration,” says Jeffrey Passel of the Urban Institute, a think tank on public policy. “Their health care systems may not be set up to deal with these populations.”
Hospitals, already facing financial difficulties, face many challenges, from figuring out ways to unclog emergency rooms to translating Spanish to English.
“Texas, California and Florida have managed this for a long time,” says the American Hospital Association’s Rick Wade. Now, “some of our members who were not dealing with it are now having to deal with it.”
Law sometimes forbids treating illegals
The number of Hispanics living in the USA soared in the past 10 years, according to the 2000 Census. Today, the number of Hispanics roughly equals that of black Americans.
The immigrants who enter illegally have changed the look of many American homes. Ten percent of children now live in a house with an illegal immigrant, the Urban Institute says.
The illegal residents are coming in droves, numbering as many as half a million a year, and the last thing they want to do is make their presence known.
“As an undocumented immigrant, you are extremely hesitant to receive services and help,” says Clarissa Martinez De Castro, director of state and local public policy for the National Council of La Raza, a Hispanic advocacy group. “You just want to work, support your family and keep a low profile.”
One concern is that any health worker could feel compelled to report the illegal immigrant.
“We have to be careful, because what we are doing is technically illegal,” says Steve Saldana of Catholic Charities in San Antonio, which helps poor Hispanic families get free medical care. “If you know where an illegal alien is, you are supposed to report them.”
But some immigrants also fear that accepting help will hurt later attempts to become a legal resident. Legal residency is bestowed upon immigrants who show, among other things, they don’t need federal aid.
In 1996, a federal law put restrictions on which immigrants could get Medicaid. At the same time, some immigrants were asked in widely reported cases to repay Medicaid benefits or risk their residency status.
Use of public benefits by immigrants dropped more than 30% from 1994 to 1997.
Recently, the push has been in the opposite direction. Last month, the Bush administration announced changes in Medicaid aimed at making it easier for states to provide insurance for children, including illegal immigrants. But confusion and fear remain.
A legal fight is ongoing in Houston, where the hospital district has been told to stop using public money to treat illegal immigrants. Texas Attorney General John Cornyn says the 1996 federal law prohibits states from offering non-emergency health care to illegal immigrants. The case is being watched by hospitals across the nation.
Health officials want to treat the new residents.
“The kind of treatment they get here is vital,” says David Lauricella, spokesman for the Laredo Health Department. “If we don’t treat them here now, they’ll end up in the emergency room later.”
But they’ve found here that simply offering care isn’t enough. Coaxing immigrants out of their homes and into the health system takes a lot of effort.
Key to success: Being nice
Beside the truck-turned-clinic near the Salinos’ home along the Rio Grande, Sister Rosemary Welsh of Mercy Regional Medical Center has taken to the streets of immigrant towns along the border colonias to make a difference in the hospital.
“We’re trying to train them not to use the emergency room as a clinic,” she says. In the process, she has perfected one solution to the immigration health problem a key tip that she shares with colleagues looking for help.
Be nice. “We were the barriers,” Welsh says. “We were not nice, and we made people feel stupid. That was our biggest barrier.”
As Salino’s wife finishes in the tractor-trailer clinic, he smiles with gratitude.
“Mercy, they are good people,” he says. “That’s great for people here.”
The Henry J. Kaiser Family Foundation
2001/02 Kaiser Media Fellowships Program
Kaiser Media Fellowships program sitevisit to Seattle, WA and Vancouver, British Columbia, Canada Sunday, August 4–Friday, August 9, 2002
Accommodations :
Sunday, August 4-Wednesday, August 7/Seattle: W Seattle Hotel, 1112 Fourth Avenue, Seattle, WA 98101 Wednesday, August 7-Friday, August 9/Vancouver: Metropolitan Hotel, 645 Howe Street, Vancouver, British Columbia, Canada V6C 2Y9
Sunday, August 4-Seattle, WA 6:15pm: Drinks 7:00pm: Dinner–Studio 3, 2nd floor, W Seattle Hotel Monday, August 5-Seattle, WABriefings at Studio 6, 3rd floor, W Hotel 8:30 am: Buffet breakfast 9:00 – 12:00am: Bob Putsch, Cross-Cultural Health Care Program and other invited speakers -Interpretation and language services: current issues/problems caring for immigrant populations -Infant mortality -Outreach to underinsured/uninsured women and children 12:00- 2:00pm: Working lunch 2:30 – 4:00pm: Treating asthma in the home, Lung Association of Seattle 4:15 pm: Maren Grainger-Monsen, M.D., Filmmaker-in-Residence; Senior Research Scholar, Stanford University Center for Biomedical Ethics-Multicultural training of doctors -Melanie Tervalon, MD, University of California San Francisco School of Medicine-The Multicultural Health Program, Children’s Hospital, Oakland, CA 6:30pm: Meet in hotel lobby and walk to restaurant 7:00pm: Dinner, Wild Ginger, 1401 Third Avenue, Seattle
Tuesday, August 6-Seattle, WA 8:30 am: Depart hotel by van Visit to Group Health Cooperative 521 Wall Street [corner of 6th Ave. and Wall St.], Seattle, WA 98121 9:00 am: Buffet breakfast -Welcome by Cheryl Scott, CEO, Group Health; Gary Feldbau, MD, medical director 10:00 – 11:15 am: Panel 1: A behind the scenes look at a “high performing plan”: Ted Eytan, MD; Matt Handly, MD; Karen Merrikin, JD; Hugh Stradley, MD 11:15-11:30 am: Break 11:30 am-12:45 pm: Panel 2: Pharmaceuticals-evaluating drug safety and efficacy: Jim Carlson, PharmD; Matt Handley, MD; Brian Harris, MPH; Marc Mora, MD 12:45pm-1:45 pm: Working lunch Panel 3: Providing culturally competent care-research, outreach and implementation: Bill Beery , MPH; Ted Eytan, MD; Paula Lazano, PhD; Ed Wagner, MD 2:00 pm: Depart by van Visit to Harborview Medical Center 325 9th Avenue, Seattle, WA 98104 2:30-5:00 pm: –Community House Calls program –Multicultural diabetes project –Cancer prevention, focused on Asian-Americans (Contact: Bria Chakofsky, Community House Calls program) 5:15 pm: Depart by van for hotel 6:30 pm: Meet in hotel lobby, walk to restaurant 7:00 pm: Dinner, Dahlia Lounge, 2001 Fourth Avenue (at Virginia Street) Seattle
Wednesday, August 7-Seattle, WA/Vancouver, Canada 7:00 am-8:00 am: Pick up boxed breakfast, Earth & Ocean restaurant, W Seattle Hotel 8:00 am: Depart hotel by van-bring overnight bag 10:00 am-12:00 pm: Visit to Lummi Tribal Health Center, 2592 Kwina Road, Bellingham, WA 98226 -Barbara Finkbonner, Director, Lummi Tribal Health Center; 2001 Kaiser Native American Health Policy Fellow -Darrell Hillaire, Chairman, Lummi Tribe -Aaron Thomas, Communications Director, Lummi Tribal Health Center 12:00 pm-1:30 pm: Working lunch 2:00 pm: Depart by van for Vancouver, Canada 4:00 pm: Arrive/check in, Metropolitan Hotel, Vancouver 7:30 pm: Meet in hotel lobby 8:00 pm: Dinner, Connaught Room, Metropolitan Hotel
Thursday, August 8-Vancouver, CanadaConnaught Room, Metropolitan Hotel
8:30 am: Buffet breakfast 9:00 am-12:15 pm: Briefings on the Canadian healthcare system; pharmaceutical drug policies; health issues for aboriginal peoples –Steve Morgan, PhD, Canadian Institutes of Health Research Postdoctoral Fellow, Centre for Health Services and Policy Research, University of British Columbia –Jeff Reading MSc, PhD, Scientific Director, Canadian Institutes of Health Research, Institute of Aboriginal Peoples Health; Associate Professor & Research Chair, Department of Public Health Sciences, University of Toronto 12:15 pm: Working lunch–2002 Kaiser Media Fellows discuss their projects 3:00 pm-5:00 pm: Visit to Multicultural Family Centre, REACH Community Health Centre –Carole Christensen, program director, Multicultural Family Centre –Jessica Chenery, program coordinator, Healthy Eating Active Living Diabetes Prevention Program 6:30 pm: Meet in hotel lobby, walk to waterfront restaurant 7:00 pm: Dinner, Five Sails, 300-999 Canada Place
Friday, August 9 am: Fellows depart
Participants
2001 Kaiser Media Fellows:
2002 Kaiser Media Fellows:
Invited reporters:
Kaiser Foundation staff:
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03/21/2002
By Robert DavisReprinted with permission of USA Today
Denver paramedic Otis McKay Jr. saw the fear in the young woman’s eyes just before he mowed her down with his 5-ton ambulance.
The seasoned paramedic had seen people die before. But watching 19-year-old Virginia Magalhaes-Rosa trying in vain to outrun his out-of-control ambulance in December 2000 — seeing her disappear beneath the flashing lights in the grille of the rig — haunts him every time he turns on his siren.
”I’m still spooked when I drive Code 10 (Denver lingo for an emergency run),” McKay says. ”I see shadows, I see cats, I see birds, I see leaves falling from the trees. Any sudden move in the periphery. I don’t think you ever get over that.”
Paramedics toil to save lives. But those inside the breakneck world of emergency medical services have long known of a huge danger that is rarely acknowledged to outsiders: Ambulances are among the most dangerous vehicles on the road, involved in a disproportionate number of crashes.
Now, however, more experts are questioning publicly the time-honored belief that seconds, or even minutes, are crucial to survival when transporting a patient to an emergency room. There is, in fact, no scientific proof that ”running hot” — street slang for operating with lights and siren — saves lives.
”You can’t prove from the literature that EMS (emergency medical services) saves more lives than it takes,” says Jeff Clawson, chairman of the certification board for the National Academies of Emergency Dispatch based in Salt Lake City.
”Speed has never saved anybody’s life. Period,” says W.H. ”Bill” Leonard of Medical Transportation Insurance Professionals, one of the top insurance underwriters of ambulances across the nation.
Running hot doesn’t even shave off much time, according to previous studies. One found that lights and siren reduce response times by 106 seconds in big cities and by 43.5 seconds in rural areas.
Clawson says it’s a myth that the public expects a lights-and-siren response to every emergency. ”That’s not what the American public thinks,” he says. ”They want it to come out right and not kill people in crosswalks when they don’t need to.”
Yet, ambulances are 13 times more likely to be involved in an accident than other vehicles in terms of the number of accidents per miles driven, according to a study in Houston in 1993. That study found that ambulances also are five times more likely to be involved in a crash that causes an injury.
Worse, an ambulance is an unforgiving vehicle to collide with — especially on an emergency run.
In fatal, multi-vehicle ambulance crashes between 1980 and 2000, the number killed in the other vehicle was 21 times greater than the number of ambulance drivers who died, according to a USA TODAY analysis of National Highway Traffic Safety Administration data. More than three-fourths of the fatalities were people who were not in the ambulance.
But because there are relatively few fatalities each year — 33 in 2000 (the last year for which complete data were available) out of millions of ambulance calls — federal officials say there is no pattern that triggers any alarms.
”There is not a lot of data out there,” says Jeffrey Runge, a former street medic and emergency room doctor now heading the National Highway Traffic Safety Administration. His agency collects data on fatal accidents and sets response guidelines. ”It tells me there is not a huge safety problem.”
Many in the industry disagree. ”This is a very, very big problem,” Leonard says.
A need for ‘the growler’
By some estimates, there are 15,000 ambulance crashes a year, though nobody keeps a complete count. Medics often are cleared of wrongdoing even when they crash while running a red light because ”failure to yield to emergency vehicle” laws give the medics the upper hand legally.
Even so, across the nation both male and female medics have served time for killing others while running hot. In those cases, the medic was found guilty of crimes such as driving negligently or recklessly. And an ambulance accident can cost an emergency medical system millions of dollars.
In an effort to curb these crashes, there are two major strategies at work in some cities across the nation to make emergency medical response safer.
First, the same kind of ”black box” technology that has helped make passenger jets safer is now monitoring some ambulances.
Mounted under the ambulance’s front seat is the box that medics call ”the growler.” By measuring more than 25 parameters of the vehicle’s operation, such as acceleration, braking and the use of seat belts, lights and sirens, this black box gives medics — and their supervisors — a precise picture of their every move on the road.
The boxes give audible cues to drivers when they are nearing or exceeding predetermined parameters for accelerating, braking and turning. When a medic takes a turn too fast, the growler clicks like a Geiger counter. If the medic exceeds the preset limit for a full second, the tone changes and the driver knows he or she has just been hit with a computerized violation of the driving policy.
The boxes, installed on only a minority of the nation’s ambulances, appear to have corralled the driving behavior of nearly 300 medics in the Florida system in a matter of weeks.
”We’ve seen direct results from this,” says Scott Springstead, operations supervisor for Sunstar Emergency Medical Services of Pinellas County. ”We’ve seen a reduction of 20-to-1 in the severity of our crashes.”
Mirrors still get clipped and fenders get bent, but there have been no big accidents, he says.
Despite success, the boxes, also called ”Big Brother” and worse by some medics, aren’t always popular. They threaten one of the primary perks of the job: Running hot through crowded streets is a thrill.
”Our workforce is young, largely male, and we all drive with a little testosterone when we shouldn’t,” Springstead says. ”There was a little bit of that bravado, a little bit EMT and a little bit race-car driver. That’s a bad attitude to take in an ambulance with you.”
But he says he can still drive fast, observe the limits of the black boxes and be certain that his city will see no change in response times.
”The message is, we have a job where minutes matter and seconds matter, and we need to be aware of that,” Springstead says. ”But rather than just floor it and cross your fingers, there is a science to how you can navigate your vehicle. We have a responsibility to the safety of our citizens.”
More selective about response
Another method that some cities are using to reduce the number of fatal ambulance crashes is smarter dispatch. If medically trained dispatchers can determine that the person on the other end of the phone line does not need a crew to rush to the destination — the theory goes — accidents can be prevented and lives saved.
Though many crews in the nation’s fragmented and diverse emergency medical systems can recall emergencies where their fast action saved lives, those calls are rare. People who are choking, bleeding to death or in cardiac arrest are few and far between in the modern emergency medical system. And those cases are easy for medically trained dispatchers to identify on the phone. When the situation is desperate, help can be sent in a hurry, Clawson says.
But the more common calls to 911 come from people who are not suffering life-threatening problems. In big cities, routine cases — people who lack insurance, do not have a doctor and simply need access to basic health care — clog the system.
This creates a backlog of runs and adds a sense of urgency to the medically mundane.
”This keeps the ambulances stretched thin,” says Leonard, a former street medic. Paramedics may be tempted to use lights and siren to transport a patient from a nursing home to a hospital, he says, to get back in service faster to be available to help people who are more likely to be saved.
Many of the fatal accidents have occurred as ambulances raced to the hospital with patients on board who were relatively healthy and medically stable. Others have occurred when medics were rushing to the side of a person with a sprained ankle or other non-emergency, USA TODAY found.
Some emergency medical systems are making medical judgment calls in the dispatch center to reduce the number of times their ambulances respond with lights and siren. Medically trained dispatchers can be more selective about what gets a hot response.
In Virginia, the Richmond Ambulance Authority uses both the black box ”growler” in the rig and state-of-the-art emergency medical dispatching to sort through calls.
In a darkened room full of colorful computer terminals displaying maps with ambulances and people in need across the city, street medics are at the consoles working the radios and phones.
On a recent day, as one medic gathered information and gave advice to a person having an allergic reaction, another radioed a colleague in an ambulance to start driving toward the address.
The ambulance was rolling within seconds, but the medic who was still on the phone determined that the case of hives did not need a lights-and-siren response. There was no trouble breathing. There was no immediate threat to life.
The medic gave simple medical instructions, including advice to call back if anything changed before the ambulance arrived.
”The emphasis in emergency medicine,” says Jerry Overton, the system’s executive director, ”is right here in dispatch.”
Hurtling into a pedestrian
But even the emergency medical systems that take steps to reduce the risk of crashes can’t prevent every tragedy.
In Denver, where paramedics sort calls in the dispatch center and medics get advanced driver training, running hot is still a danger.
It was a cold evening in December 2000 as Otis McKay drove his ambulance past the Cathedral of the Immaculate Conception where people were out looking at Christmas lights.
Virginia Magalhaes-Rosa was walking with others near the majestic steps of the cathedral.
As McKay responded to a call for a man with chest pain, he had a green light at an intersection. A van in the left lane stopped at the green light, and McKay passed the van on its left, cruising by in the left turn lane at about 35 mph.
As the ambulance came up beside the van, the van’s driver, Jose Campos-Ortega, inexplicably turned toward the ambulance.
”My partner yelled, ‘Watch out! Here he comes!’ ” McKay says.
The van struck the ambulance near the front tire, damaging the brakes and steering system.
As the ambulance veered across two lanes, McKay saw that he was heading straight for pedestrians in front of the church. He tried to steer toward the stairs of the church. ”I’m thinking I’d rather hit the building than the pedestrians,” he says. ”I’m stomping on the brakes, and the vehicle is slowly coming to a stop.”
But when the rig hit the curb, the braking and steering systems failed completely.
”The force of the vehicle hitting the curb shot me from going left back onto the sidewalk,” he says. Magalhaes-Rosa, a Brazilian immigrant, had been running toward the church, ”but when she saw that I was steering toward the church, she changed her mind and ran on the sidewalk.
”She is literally running in front of me. It sounds like a horrible cartoon,” McKay says. ”She is trying to outrun the speed of the ambulance. I watched her go underneath the vehicle.”
When the rig stopped, McKay called for help on a police radio. His partner told the ambulance dispatcher to send one ambulance for the man with the chest pain and another for the woman.
McKay climbed beneath the ambulance, ”hoping she will roll over and call me names and scratch and kick me.” She only gazed and gasped a few times.
He pulled her out, snaked a breathing tube down her throat and into her trachea, started an intravenous line and loaded her into another ambulance that raced her to the nearby trauma center.
She died hours later.
Campos-Ortega pleaded guilty to careless driving resulting in death and received 18 months’ probation. He is still paying for Magalhaes-Rosa’s funeral as part of his restitution.
McKay was cleared, but he is forever changed. ”You cover it up and paint over it, but once a good guy kills a person, the only thing you can do is swallow it and go on the best you can,” he says.
2001 Kaiser Media Fellowships Program
Kaiser Media Fellowships program sitevisit to San Antonio and Laredo, TX:Sunday, July 29-Friday, August 3, 2001
Accommodations: The Menger Hotel, 204 Alamo Plaza, San Antonio, TX 78205 (Tel: 210-223-4361; fax: 210-228-0022)
Sunday, July 29
Meet in Miami airport6:30pm: Meet in hotel lobby
7:00pm: Dinner, The Grant Room, The Menger Hotel, with Bibi Lobo, vice president, National Latino Children’s Institute
Monday, July 30-San Antonio
The Grant Room, The Menger Hotel8:30am: Buffet breakfast
9:00am-12:00pm: Overview briefings on national and regional immigration trends, issues; immigrant health policy and financing issues; medical interpretation services –Jeff Passel, The Urban Institute: Overview briefing on national and regional immigration trends, Census data –Leighton Ku, Center on Budget and Policy Priorities: Immigrants’ utilization of health services; impact on safety net providers
12:00pm: Working/buffet lunch
12:30-3:30pm: –Mara Youdelman, staff attorney, National Health Law Program: Medical interpretation services and related policy issues –Josh Bernstein, National Immigration Law Center: Overview of current national/regional immigration legal, welfare and policy issues
3:45pm: The AVANCE program Promotora and Health Initiatives: –Marisa Chapa, Maria Hudson, and Mercedes Perez de Colon
4:30pm/4:45pm: (Optional) Walk from hotel two blocks to the San Antonio Express-News
5:00pm: Visit the San Antonio Express-News
6:00pm: Return to hotel
6:45pm: Meet in hotel lobby, drive to restaurant
7:00pm: Dinner, Pico de Gallo, 111 S. Leona Street
Tuesday, July 31-San Antonio
The Grant Room, The Menger Hotel
8:30am: Buffet breakfast
9:00am-10:30am: Clarissa Martinez, director of state and local public policies, the National Council of La Raza: U.S./Mexico bi-national perspective on border issues and migration
10:45am-12:00pm: Anne Dunkelberg, Center on Public Policy Priorities, Austin:Texas state immigration and health policy legal issues:
12:00pm: Working lunch at hotel
12:50pm: Depart hotel by van
1:15pm: Arrive, Texas Diabetes Institute/University Health SystemUniversity Center for Community Health–Briefings and visit to the University Health System/Texas Diabetes Institute-financing indigent care; the CareLink program (insurance for county residents under 200% of federal poverty); financing trauma care; diabetes-contact: Ms. Leni Kirkman, public affairs department, University Health System
5:00pm: Depart Texas Diabetes Institute; return to hotel
6:45pm: Meet in hotel lobby
7:00pm: Dinner with Tom Ferguson, M.D., editor and publisher, The Ferguson Report, Paesano’s Ristorante, 111 West Crocket
Wednesday, August 1-am: San Antonio; pm: Laredo
8:30am: Depart hotel by van-bring overnight bag
9:00am-11:00am: Meeting at Catholic Charities–Theresa Coles Davila, Center for Legal and Social Justice–Steve Saldana, executive director, Catholic Charities
11:00am: Depart Catholic Charities by van
11:30am: Arrive The Guenther House, 205 East Guenther Street
11:30am: Working lunch, followed by visit to The Texas Center for Infectious Disease-TB, Hansen’s Disease, etc. Visit/Working lunch with hospital Director, Mr. Jim Elkins; colleagues; and potentially Texas health department staff
3:15/3:30m: Depart Texas Center for Infectious Disease by van for Laredo
6:00pm/6:30pm: Arrive/check in, La Posada hotel, 1000 Zaragoza Street, Laredo, TX 78040
7:30pm: Meet in hotel lobby
8:00pm: Dinner, El Rancho restaurant, 2134 Avenida Guerrero, Nuevo Laredo, with health and border health officials, and local health groups
Thursday, August 2-Visit to Laredo
7:30am: Depart hotel by van-border area issues: –Visit to Gateway clinic and El Cenizo colonias (c. 10 miles from Laredo)–Visit to Laredo port of entry, border patrol facility
Contacts: David Lauricella, public affairs department, Laredo Health Department; Jacque Crouse, public affairs department, INS regional office
12:15pm: Working lunch
4:00pm: Depart Laredo for San Antonio
7:00pm: Arrive The Menger Hotel
7:40pm: Meet in hotel lobby, walk to restaurant
8:00pm: Dinner, Boudro’s, 421 East Commerce
Friday, August 3
am: Fellows depart
Search the entire kff.org site or review a list of publications in a specific topic area:
Prior to 2003, travel and research grants were awarded to print and broadcast journalists and editors to report on health policy and public health issues for publication/broadcast. For details of the mini-fellowship awards for 1997-2001, see below.
Fourteen journalists were awarded Kaiser Media Mini-Fellowships in 2001/2002, to research and report on the following issues:
Constance Alexander, freelance writer and independent producer, WKMS-FM:
Jenni Bergal, reporter, The Sun-Sentinel, Fort Lauderdale, FL:
Jill Brown, managing editor, Managed Care Week:
Dudley Clendinen, author:
Mary Coffman, co-director, Medill News Service, Washington, D.C.:
Barbara Feder, medical reporter, The San Jose Mercury News:
Jean Fisher, health/business writer, The News & Observer, Raleigh, NC:
Susan Thom Loubet, public radio host, KUNM/Radio, New Mexico:
Camille Mojica Rey, freelance writer:
Ann Pappert, freelance writer:
Tom Paulson, science/medical reporter, and Mike Urban, photographer, The Seattle Post-Intelligencer:
Julie Reynolds, editor, El Andar magazine:
Stephen Smith, managing editor and correspondent, American RadioWorks, Minnesota Public Radio:
Jamie Stobie, public television documentary producer:
Ten journalists were awarded Kaiser Media Mini-Fellowships in 2000/2001, to research and report on the following issues:
David Barry, freelance health writer:
Karen Brown, health and general assignment reporter, WFCR-FM public radio, Amherst, MA:
Elena De La Cruz, features writer, La Opinion, Los Angeles:
Tamara Hill, medical/news reporter, Corpus Christi Caller-Times, TX:
Karen Houppert, freelance writer:
Beatrice Motamedi, freelance writer and editor:
Elizabeth Neus, national reporter, medical/health care policy, Gannett News Service, Washington D.C:
DeShong Perry, producer, KPNX-TV/Phoenix, AZ:
Jane West, freelance television documentary and feature producer:
Eric Whitney, independent radio producer:
Twelve journalists were awarded Kaiser/National Press Foundation Media Mini-Fellowships in 1999/2000, to research and report on the following issues:
Cassie M. Chew, health care reporter, Bureau of National Affairs, Inc.:
Dan Collison, independent radio and television documentary producer:
David Hanners, investigative reporter, The St. Paul Pioneer Press:
Tom Jennings, independent documentary producer:
Susan Leffler, independent special projects producer, West Virginia Public Radio Network:
Sharon Lerner, reporter and columnist, The Village Voice:
Click here to see Sharon Lerner’s work.Julia Lobaco, national editor, Vista magazine:
David Nather, health care reporter, Bureau of National Affairs, Inc.:
Dmae Roberts, independent documentary public radio producer:
Sabin Russell, reporter, The San Francisco Chronicle:
Sally Squires, reporter, Health Section, The Washington Post:
Bill Zeeble, reporter, KERA-FM Radio, Dallas:
Ten journalists were awarded Kaiser/National Press Foundation Media Mini-Fellowships in 1998/99, to research and report on the following issues:
Lori Bergen, public television producer, Kansas Public Television:
Bill Lichtenstein, producer, The Infinite Mind public radio series, New York City:
Andy Miller, health/business reporter, The Atlanta Journal-Constitution:
Duncan Moore, reporter, Modern Healthcare:
Ann Pappert, freelance health and medical journalist, New York City:
Mary Beth Pfeiffer, projects editor, The Poughkeepsie Journal:
Mario Rossilli, reporter, The Sun-Sentinel, Fort Lauderdale, FL:
Terri Russell, medical reporter, KOLO-8 Television/Reno, Nevada:
Eric Schoch, science and technology writer, The Indianapolis Star and News:
Eric Whitney, associate producer, High Plains News Service, Montana:
Ten journalists were awarded Kaiser/National Press Foundation Media Mini-Fellowships in 1997/98, to research and report onthe following issues:
Julie Appleby, health/business reporter, Contra Costa Times
Rea Blakey, health reporter, WJLA-7 Television/Washington, D.C.
Ariana Cha, public health/race and demographics reporter, The San Jose Mercury News
Debi Chard, health and medical reporter, WCSC-5 Television/Charleston, South Carolina
Andrew Finlayson, associate news director, KTVU-2 Television/San Francisco and Oakland
Joel Kaplan, S.I. Newhouse School of Public Communications, Syracuse University, New York
Medill News Service, (radio and television), Medill School of Journalism, Northwestern University
Sue Reinert, business/health reporter, The Patriot Ledger
Terri Russell, medical reporter, KOLO-8 Television/Reno, Nevada
Stephen Smith, senior producer/national projects, Minnesota Public Radio
The Kaiser Family Foundation, which funds the Media Mini-Fellowships Program, is an independent health care foundation and is not affiliated with Kaiser Permanente or Kaiser Industries.
The Henry J. Kaiser Family Foundation: Recent Mini-Fellows’ Work
Jenni Bergal, reporter, The Sun-Sentinel, Fort Lauderdale, FL Project: The Broward County mental health court-a model way to address cases involving mentally ill defendants?
New voluntary court system helps mentally ill inmates get their lives back on track, Sun Sentinel, November 24, 2002
Karen Brown, health and general assignment reporter, WFCR-FM public radio Project: Mental health problems and options among immigrant communities, especially war refugees.
Reports on mental health among refugees in Western Massachusetts, February 2001 onwards
Dan Collison, independent radio and television documentary producer Project: Mentally ill ex-offenders-making the transition back to the community.
Elena de la Cruz, features writer, La Opinion, Los AngelesProject: Asthma and air contamination–chronic asthma among Latino children, the effects of air pollution, and prevention efforts.
Liz Doup, reporter, The Sun-Sentinel, Fort Lauderdale, FL Project: AIDS in South Florida. AIDS in South Florida, Sun Sentinel, June 8, 2003.
Susan Leffler, independent special projects producer, West Virginia Public Radio Network Project: The impact of welfare reform on access to health care for the working poor in West Virginia.
Transportation and Health Care, Transitional Medicaid, Inadequate Health Insurance, CHIP Frustrations (.pdf)The news features were broadcast over the ten station WestVirginia Public Radio Network. Each story was broadcast three times during peakdrive time news programs. Stories were produced by Susan Leffler.
Sharon Lerner, reporter and columnist, The Village Voice Project: Sex education in schools, and federal funding for abstinence-only education programs.
The Sex-Ed Divide, The American Prospect vol. 12 no. 17, September 24, 2001 – October 8, 2001
Bill Zeeble, reporter, KERA-FM Radio, Dallas Project: Diabetes, with particular focus on minority communities at highest risk.
Diabetes: A Ticking Time Bomb, October 2- November 17, 2000Thanks to KERA 90.1 FM for producing and broadcasting the series, and to Public NewsRoom for developing the website.
The Henry J. Kaiser Family Foundation: Kaiser Media Fellows: Brenda Wilson
December/January 2001
By Brenda Wilson Reprinted with permission of Heart and Soul.
SexSmarts
The Kaiser Family Foundation has teamed up with seventeen, the nation’s top teen magazine, to create SexSmarts, a campaign to provide young people with information and resources on sexual health issues. The on-going campaign, begun in 2000, addresses a range of topics from decision making about sex, including how to say no, to the real facts on HIV and other sexually transmitted diseases (STDs). It includes special articles in the magazine, a monthly column and resources at seventeen.com, and other consumer education materials. Under the partnership, seventeen (a PRIMEDIA magazine) and Kaiser also survey teens quarterly about their knowledge and attitudes about sex and sexual health. These nationally representative survey snapshots help to frame the SexSmarts campaign, and the results are distributed to thousands of media and youth advocates nationwide.
SexSmarts Articles in seventeen Magazine 2000-2003
SexSmarts Surveys 2000-2003
Virginity and the First Time. This survey examines teen’s attitudes and opinions about virginity and first sexual activity among adolescents. It covers a variety of issues related to decision making, including when and why some teens hoose to have sex and what issues and concerns influence their decision to wait (October 2003).Summary of Findings Toplines Gender Roles. This survey on teens and gender roles considers many old stereotypes that persist among teens today, reflecting a double standard when it comes to relationships and sexual decision-making (December 2002).Summary of Findings Toplines Relationships. This survey examines the way teens think about sexual activity, STD testing, contraceptive use and condoms within different types of relationships (October 2002).Summary of Findings Toplines Teens and Sexual Health Communication. This survey is about sexual health communication between teens and their parents, health care providers and partners (July 2002).Summary of Findings Toplines Sexual Activity and Substance Use Among Youth. This survey addresses the pressures and decisions faced by teens and young adults involving alcohol, drugs, and sexual activity (February 2002).Sexually Transmitted Disease. This survey examines teen knowledge and attitudes about sexually transmitted diseases, including risk, testing and treatment (August 2001).Sexual Health Care and Counsel. This survey focuses on what teens say are barriers to sexual health care services for themselves, and their peers (May 2001).“Safer Sex,” Condoms and “the Pill”. This survey reveals what teens think about safer sex, what they know (and don’t) about their options for contraception and protection (November 2000).Decision Making. This survey addresses some of the complex issues influencing teenagers’ decision making about sex and relationships (September 2000).
SexSmarts OnlineThe SexSmarts campaign includes a website at seventeen.com – one of the top sites for teens. At http://www.seventeen.com/sexsmarts teens read monthly columns, find online resources and hotlines, and take quizzes testing their knowledge on sexual health issues. The website is promoted in seventeen magazine.