Case study:Case study:A health care clinic for A health care clinic for the uninsured faces the the uninsured faces the

problem of treating problem of treating illegal immigrantsillegal immigrants

Laura RedmondLaura RedmondNursing 587Nursing 587

Drexel UniversityDrexel University

A Challenge to the SystemA Challenge to the System

In September 2008, The Stuart Clinic choose In September 2008, The Stuart Clinic choose to change policy and ask for citizenship to change policy and ask for citizenship status prior to treatmentstatus prior to treatment

Driven by increased costs and potential of Driven by increased costs and potential of losing secondary care agreements with losing secondary care agreements with hospital, local care officeshospital, local care offices Found it could not afford to provide the tests Found it could not afford to provide the tests

previously paid by Martin Memorialpreviously paid by Martin Memorial

Both agreed to restrict care to legalized Both agreed to restrict care to legalized residents only residents only

A Challenge to the SystemA Challenge to the System

Decision has far-reaching implicationsDecision has far-reaching implications

Has the potential to influence the non-Has the potential to influence the non-profit health care landscapeprofit health care landscape

Should VIM institute a national policy Should VIM institute a national policy change restricting care for illegal change restricting care for illegal immigrants using additional eligibility immigrants using additional eligibility requirements based on residency statusrequirements based on residency status

Volunteers in Medicine (VIM)Volunteers in Medicine (VIM)

Started in 1992 in Hilton Head, SCStarted in 1992 in Hilton Head, SC

Currently, 200+ VIM clinics nationwideCurrently, 200+ VIM clinics nationwide

Relies on donated time from volunteers Relies on donated time from volunteers and retired health care professionalsand retired health care professionals

Provide primary and preventative health Provide primary and preventative health care exclusively for :care exclusively for : Those who cannot afford private insurance Those who cannot afford private insurance

and do not qualify for federal or state aid and do not qualify for federal or state aid

Volunteers in Medicine Volunteers in Medicine (VIM)(VIM)

Accepts no federal or state funds, thrives Accepts no federal or state funds, thrives through private philanthropy through private philanthropy

Partners with secondary care centers Partners with secondary care centers (hospitals, offices) (hospitals, offices) Provides diagnostic services and treatmentsProvides diagnostic services and treatments Given as charity careGiven as charity care

VIM is not a safety-net programVIM is not a safety-net program

Prevention is key conceptPrevention is key concept

The ProblemThe Problem

Estimate 45.7 million people without insuranceEstimate 45.7 million people without insurance over 12 million illegal immigrants over 12 million illegal immigrants

May overwhelm clinics and absorb resourcesMay overwhelm clinics and absorb resources

VIM has strict eligibility requirements, but VIM has strict eligibility requirements, but notnot on statuson status

Decision can have financial, legal, and ethical Decision can have financial, legal, and ethical ramifications and may threaten the public ramifications and may threaten the public healthhealth

DecisionDecision

VIM should institute a national VIM should institute a national organizational policy change based on:organizational policy change based on: Societal and marketplace demandsSocietal and marketplace demands Financial risk involvedFinancial risk involved Threat to VIM missionThreat to VIM mission Risk to not being able to serve intended populationRisk to not being able to serve intended population

Fragility of current U.S. health care Fragility of current U.S. health care system makes delay inadvisablesystem makes delay inadvisable Added eligibility requirements ensures VIM Added eligibility requirements ensures VIM

viabilityviability

BarriersBarriers

Would face few barriers due to current Would face few barriers due to current legislation and public opinionlegislation and public opinion Many already believe there should be limits in placeMany already believe there should be limits in place

Exception would be volunteers’ personal and Exception would be volunteers’ personal and ethical beliefsethical beliefs Staff discomfort could lead to decreased volunteer Staff discomfort could lead to decreased volunteer

workforceworkforce May be unable to turn those in need awayMay be unable to turn those in need away Staff could be turned into unwitting immigration Staff could be turned into unwitting immigration

watchdogswatchdogs

FacilitatorsFacilitators

Projected cost-savings to VIM clinics and Projected cost-savings to VIM clinics and secondary care centers secondary care centers

Positive impact as clinics are decompressed Positive impact as clinics are decompressed and those qualifying for care receive proper and those qualifying for care receive proper resourcesresources

Provider motivation Provider motivation

Public opinion could be both barrier or Public opinion could be both barrier or facilitator facilitator Some communities may support restricting care; may Some communities may support restricting care; may

be met with resistance in others be met with resistance in others

ImplementationImplementation Establish a consensusEstablish a consensus

VIM national officers and board of directorsVIM national officers and board of directors

Transition team Transition team Present policy changePresent policy change Reassure volunteer workforceReassure volunteer workforce

Pilot programsPilot programs For clinics serving large illegal populationsFor clinics serving large illegal populations Use volunteer and patient feedbackUse volunteer and patient feedback Target goal: 12-18 months with future VIM clinics Target goal: 12-18 months with future VIM clinics

using revised policyusing revised policy

Ongoing guideline developmentOngoing guideline development

EvaluationEvaluation

Compare VIM clinics locally and nationallyCompare VIM clinics locally and nationally Patient numbersPatient numbers Resource usageResource usage Financial contributionsFinancial contributions

Public Health DepartmentPublic Health Department Epidemiological statistics Epidemiological statistics MorbidityMorbidity

Reviews/collaboration with secondary Reviews/collaboration with secondary care partnerscare partners

Affect to tertiary care departmentsAffect to tertiary care departments Financial impactFinancial impact

Future ConsiderationsFuture Considerations

Interventional CareInterventional Care Internet-based treatment and telemedicineInternet-based treatment and telemedicine Culturally specific, yet anonymous Culturally specific, yet anonymous Assumes access to cost-efficient technologyAssumes access to cost-efficient technology Upholds both civil and ethical obligationsUpholds both civil and ethical obligations

Use of immigrant specialists or nurse Use of immigrant specialists or nurse navigatorsnavigators Specifically trained in illegal immigrant issuesSpecifically trained in illegal immigrant issues Assists patients in navigating the complex health Assists patients in navigating the complex health

care systemcare system Serve as a resource for securing careServe as a resource for securing care

Future ConsiderationsFuture Considerations

Mobile units for community outreachMobile units for community outreach

Negotiated partnerships to offset costsNegotiated partnerships to offset costs Immigrant activist groupsImmigrant activist groups Faith-based preventative or cultural centersFaith-based preventative or cultural centers Worldwide charities Worldwide charities Foreign consulatesForeign consulates

Limited collaboration could:Limited collaboration could: Coordinate compensation agreements for Coordinate compensation agreements for

reimbursementreimbursement Exempt volunteer caregivers from ethical dilemmaExempt volunteer caregivers from ethical dilemma

“ “Never doubt that a small Never doubt that a small group of thoughtful, committed group of thoughtful, committed citizens can change the world”citizens can change the world”

--Margaret MeadMargaret Mead

THANK YOU!THANK YOU!

ReferencesReferences Copsey, H. (2008, October 8). Stuart clinic cuts free services for illegal Copsey, H. (2008, October 8). Stuart clinic cuts free services for illegal

immigrants, will immigrants, will require documentation. require documentation. Florida’s Treasure Coast Florida’s Treasure Coast and Palm Beachesand Palm Beaches. Retrieved from . Retrieved from http://www.tcpalm.com/news/2008/oct/04/clinic-cuts-free-services-for-illegal-

immigrants/ Emergency Medical Treatment and Active Labor Act of 2003 (42 C.F.R. Emergency Medical Treatment and Active Labor Act of 2003 (42 C.F.R.

489.24), 489.24), amending the Consolidated Omnibus Budget amending the Consolidated Omnibus Budget Reconciliation Act of 1985 (42 Reconciliation Act of 1985 (42 U.S.C. 1395dd), section 1867 of the Social U.S.C. 1395dd), section 1867 of the Social Security Act of 1935 (H.R.7260). Security Act of 1935 (H.R.7260). 108108thth Congress (2003). Retrieved Congress (2003). Retrieved February 4, 2009, from February 4, 2009, from http://www.ssa.gov/OP_Home/ssact/title18/1867.htm#t

Free Clinic Federal Tort Claims Act (42 U.S.C. 233), amending section Free Clinic Federal Tort Claims Act (42 U.S.C. 233), amending section 194 of Health 194 of Health Insurance Portability and Accountability Act of 1996 Insurance Portability and Accountability Act of 1996 (Public Law 104-191), (Public Law 104-191), section 224 of the Public Health Service Act of section 224 of the Public Health Service Act of 1944 (42 U.S.C. 201). 1081944 (42 U.S.C. 201). 108thth Congress (2004). Retrieved February 11, Congress (2004). Retrieved February 11, 2009, from 2009, from http://bphc.hrsa.gov/policy/pin0424.htmhttp://bphc.hrsa.gov/policy/pin0424.htm

Goldman, D. P., Smith, J.P., & Sood, N. (2005). Legal status and health Goldman, D. P., Smith, J.P., & Sood, N. (2005). Legal status and health insurance insurance among immigrants.among immigrants. Health AffairsHealth Affairs, 24 (6): 1640-53. , 24 (6): 1640-53.

  

ReferencesReferences McKeon, E. (2006). Treating illegal immigrants: the ANA aims to protect McKeon, E. (2006). Treating illegal immigrants: the ANA aims to protect

nurses nurses against potential criminal penalties. Retrieved February 5, 2009, from against potential criminal penalties. Retrieved February 5, 2009, from http://www.nursingworld.org/ajn/2006/jun/politics.pdfhttp://www.nursingworld.org/ajn/2006/jun/politics.pdf

Mead, M. (n.d.). The Institute for Intercultural Studies. Retrieved on February Mead, M. (n.d.). The Institute for Intercultural Studies. Retrieved on February 18, 18, 2009, from 2009, from http://www.interculturalstudies.org/Mead/index.htmlhttp://www.interculturalstudies.org/Mead/index.html

Morse, A., Blott, A., Speasmaker, L., & Dwyer, L. (2006, November 17). Morse, A., Blott, A., Speasmaker, L., & Dwyer, L. (2006, November 17). Immigrant Immigrant policy- 2006 state legislation related to immigration. National policy- 2006 state legislation related to immigration. National Conference of Conference of State Legislatures Immigration Policy Project. Washington, State Legislatures Immigration Policy Project. Washington, D.C. Retrieved D.C. Retrieved February 5, 2009, from February 5, 2009, from http://www.ncsl.org/programs/immig/6ImmigEnactedLegis3.htmhttp://www.ncsl.org/programs/immig/6ImmigEnactedLegis3.htm

Sherman, A., Greenstein, R., & Parrott, S. (2007). Poverty and share of Sherman, A., Greenstein, R., & Parrott, S. (2007). Poverty and share of Americans Americans without health insurance were higher in 2007 and median without health insurance were higher in 2007 and median income for working-income for working- age households was lower than at bottom of last age households was lower than at bottom of last recession. recession. Center on Budget and Center on Budget and Policy PrioritiesPolicy Priorities, Retrieved February 2, , Retrieved February 2, 2009, from2009, from

http://www.cbpp.org/8-26-08pov.pdfhttp://www.cbpp.org/8-26-08pov.pdf Volunteers in Medicine. (2008). Volunteers in Medicine Institute. Retrieved Volunteers in Medicine. (2008). Volunteers in Medicine Institute. Retrieved

Jan 31, Jan 31, 2009, from 2009, from http://www.volunteersinmedicine.org/http://www.volunteersinmedicine.org/