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Position Statement
Access to Care
November 10, 2002
This position statement was originally released in 1995 under the title of "The American Health Care System." It was updated, reviewed by the membership and the Board of Directors, and published on the Academy Web site in 2003 under the title: "Access to Care." This statement replaces and supercedes the 1995 statement.
The statement below is not to be construed as dictating an exclusive course of action nor is it intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. The above statement reflects clinical and scientific advances as of the date of publication and is subject to change.
Abstract: The American Academy of Allergy, Asthma and Immunology asserts that the system for provision of health care to Americans must be reconfigured so as to expand access and choice while preserving and enhancing the quality of care provided to all. This care should be administered in accordance with the six principles of care outlined by the Institute of Medicine. That is, care should be safe, effective, patient-centered, timely, efficient and equitable. Further, issues related to the administration of care, such as reimbursement, liability, and claims, must be reexamined and also reconfigured to appropriately and cost-effectively support the principles outlined above.
Background
In 2001, the Institute of Medicine (IOM) released "Crossing the Quality Chasm: A New Health System for the 21st Century"1. In that report, the IOM detailed the inequities in access to care, type of care, and considerations for changes in health care delivery provided to various segments of the U.S. population. Further detailed were inadequacies in the health care system's ability to address broader issues of care such as the increasing complexity of medical science, an aging population, increasing numbers of persons with chronic diseases, and an increasingly diverse population. The IOM report called on all stakeholders to commit to a "national statement of purpose" for the health care system.
Thus we respond. The American Academy of Allergy, Asthma and Immunology (AAAAI), an association of health care professionals directly involved in prevention, assessment, treatment, education and research issues surrounding allergies, asthma, and other immunologic diseases, publicly affirms the tenets of the IOM study and, in the context of this statement, further articulates elements essential in the provision of access and effective health care for all Americans.
Access to Care
The AAAAI affirms the principle that all Americans are entitled to preventive and basic health care and that society has an obligation to provide access to quality care at an affordable price. The AAAAI supports a broad, basic benefits package that emphasizes prevention and education, which are key elements in the successful identification and treatment of all diseases, including those of an allergic, asthmatic, or immunologic nature. The Academy supports public education on this issue so that wise selections about care can be made.
Freedom of Choice
In defining benefits, the Academy supports the principles of freedom of choice that allow patients to select their doctors and health plans. People must be able to choose professionals who can understand and monitor the constellation of symptoms/illnesses they may encounter.
To meet the needs of all Americans, the AAAAI believes that the public must be offered a wide variety of health care plans. We believe it is in the best interest of the public that there be a single basic health care plan given to everybody, whether it is federally funded, or privately or employer funded, and then there should be a menu of additional benefits which could be purchased by the individual based upon their perceived need and their ability to pay.
We believe that universal access to care in the private sector requires that community ratings be established. Also, because of basic changes in our economic structure, people change jobs more than previously. Portable health care coverage would eliminate prior existing disease exclusions.
Health Care Provider Accessibility
The provision of care goes beyond insurance, whether privately or publicly provided. Studies have shown that even when coverage is statistically controlled for, differences exist in the type of care sought and received by minorities. While the reasons for this are varied, a discussion of real access to care for patients must include education, professional culturally competent health care, accessible interpreters, and physically accessible health care facilities.
Physical accessibility is an issue not only for those in urban underserved areas, but also for those in rural underserved areas. Approximately 30% of the U.S. population live in rural areas. It is essential that points of care be broadly dispersed so that diverse and unique needs can be identified and met.
Medication Accessibility
We recognize that some patients are unable to afford all drugs necessary for their care. Therefore we support the inclusion of coverage for drugs and biologicals (such as vaccines, blood products, and allergenic extracts) in the basic benefits plan with an appropriate co-payment or deductible, which could be waived for patients and families with income below appropriately identified categories. Restrictions on the provision of drugs or biologic agents must only be based on properly developed parameters of care.
Parameters of Care
While access to care should be universal, it is acknowledged that universality does not translate to the provision of all possible tests or treatments. As the pool of health care resources is finite, prudence and judgement by health care professionals must be applied. Tools such as evidence based care and outcomes studies must be consulted for insight into best practice options that optimize cost-effectiveness.
Type of Care Provided
The health care system should be structured to provide care adherent to the six principles of care outlined by the IOM1:
- Safe: patients should not be subject to potentially injurious care.
- Effective: care provided should be evidence-based with services provided based on scientific knowledge.
- Patient-centered: care provided should be respectful of and responsive to individual patient preferences, needs, values. These preferences, needs, and values also guide all clinical decisions.
- Timely: care should be provided in a timely manner.
- Efficient: care provided should efficiently utilize technology, equipment, supplies, ideas, and energy.
- Equitable: care provided should not differ in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.
The AAAAI further asserts and reinforces the importance of the following points.
Cultural Competency
Patients should have access to physicians and medical/nursing professionals who are culturally competent. This will allow for enhanced exchange between patient and provider.
Health Care
We believe the public is best served by the availability of trained professionals. Health care decisions should be made by health care providers who have a broad knowledge of biological science, pathophysiology, differential diagnosis, and disease presentations, in partnership with patients and their families.
Specialist Accessibility
Allergist/immunologists are first trained in the primary care specialties of pediatrics or internal medicine and then receive specialized training in the delivery of care to patients with asthma, allergic, or immunologic diseases. We believe the public should have unfettered access to these trained specialists.
We support programs to increase the basic knowledge of asthma, allergies, and other immunologic disease mechanisms and their management by primary care providers. We also believe that improved training and appropriate referrals to allergist/immunologists will improve patient outcomes. Barriers to specialist referrals should be minimized or removed so as not to conflict with patient need or quality of care. All health plans should provide access to qualified allergist/immunologists for their patients. To ensure the appropriate availability of specialists, each specialty should monitor workforce needs and create plans to meet current and future demands.
Continuum of Care
Care should be provided along a continuum, rather than only in response to acute episodes. This will be facilitated by ongoing access to responsive primary care professionals who support an orientation that: 1) focuses on wellness and 2) serves as a point of coordination for the total care of their patients, integrating specialists as needed or recommended by guidelines/outcomes studies.
Guideline-based Practice
Health care providers should be encouraged to offer care within established guidelines. Expert guidelines, when available, must be adapted into formats that meet the needs of patients and providers and then be disseminated. Significant changes in clinical practice depend on the influence of physicians and other health care providers who provide state of the art care to their patients and communicate to their peers the importance of doing the same. Provision of care in this manner should ensure protection of the patient without limiting health care provider freedom of thought.
When scientifically-based outcome studies are available, health care providers, health care plan administrators, and patients must be aware of the results and recommendations.
Appropriate Testing of Therapies
The testing process for all potential therapies, including generic drugs, should involve individuals who are representative of all ages and patient populations who may use these medications or regimens. These medications should be proven bioavailable or therapeutically effective by a proper scientific method. In research, in clinical studies, and in medication development studies, all ages and minorities must be adequately represented to ensure that the results regarding dose, efficacy, and side effects are adequately generalizable.
Patient Education
Patient care must involve not only prevention and treatment of presenting ailments, but ongoing education and patient involvement in management and follow-up. Adherence to treatments is complex, and resolution will not come about unless education is a prominent piece in any prevention and treatment plan.
Mechanisms to Sustain Quality Care
The cost of delivering health care is impacted by a variety of factors, including inflation, characteristics and size of the population, patient demands and expectations concerning testing and treatment, new technology, the emergence of more serious diseases, excess capacity in the system, waste, violence, drug abuse, nonessential paperwork and professional liability.
Although there are identifiable, practical measures to control both paperwork and inappropriate professional liability expenses, other factors are societal and not subject to control by the health care delivery system. We believe that health care costs can be controlled only by paying for health care that falls within properly adopted guidelines or parameters of care, ultimately validated by scientifically performed outcome studies.
Fee Restrictions and Price Controls
We oppose price controls, which establish budgets for health care expenditures that limit reimbursement for the proper care of legitimate diseases. Price controls placed on insurers, physicians, and hospitals will not improve the quality of health care.
We believe in a system that allows fair reimbursement for appropriate services rendered. These services should be consistent with current standards of care, guidelines, and scientific studies, or should be properly justified if outside these parameters. We support a process that allows the marketplace to function. Within this marketplace, we also strongly support the rights of health care providers to choose the health plans in which they wish to participate.
We believe that interested patients should have reasonable access to health care provider fee schedules. This is necessary so that patients have the proper information to make informed choices on the basis of both quality and price. We believe that fee restrictions for proper care will limit the access of patients who require that care and therefore are not in the patients' best interest. Finally, we support and would like to contribute to any legislative and national policy efforts that make quality health care more affordable.
Professional Liability
The Academy affirms that some of the increasing cost in the current health care system is due to excessive professional liability insurance premiums. The Academy supports the American Medical Association's position calling for major liability reforms to control costs. Specifically, we support the following tort reforms:
- Limitations for non-economic damages
- Collateral source offset when computing injured patient compensation
- Periodic payment of future damage awards
- Reasonable limitations on statutes of limitations for both adults and minors
- Required certificate of merit from a board certified health care provider practicing in the same specialty as the defendant health care provider as a prerequisite for the filing of claims.We oppose the idea of enterprise liability. We believe that enterprise liability will create inappropriate adversary relationships between the health care provider and either the hospital or the carrier, which will result in increased costs or limitations of access for patients with certain conditions whose treatment poses a risk of injury. We believe that the control on the independent thought processes of the health care provider, which will result from fully implemented enterprise liability, will decrease quality of care.
Administrative Concerns
The process of claims submission is cumbersome and may impede the ongoing application of best practice care. Unnecessary administrative costs are incurred because of the variety of carrier requirements, forms, claims, and review procedures. We believe that:
- There should be a single, uniform claim form.
- All claims should be submitted electronically with a single electronic format.
- Claims, procedures, and review practices should be standardized, simplified, and fair. Health care providers should be immediately aware of claims denials and reasons for such denials and should be allowed immediate telephone or written appeals to knowledgeable reviewers. Claims appeal and reimbursement policies should be standardized across all states and payors.
- There should be a review board that includes practicing health care providers who constantly monitor the system for unnecessary red tape and hassle and who have the authority to make reasonable changes to eliminate both. Health care providers, patients and their families should be able to report unnecessary red tape and hassle directly to this review board without fear of reprisal.
- Health care professionals must not be subject to civil penalty for occasional, unintentional, incorrect coding errors. Penalties should be imposed only when a pattern of repeated, intentional abuse is proved.
Conclusion
The health care system is both complex and critical. Strategies must be determined and implemented to contain the increasing cost and decreasing access to quality care. The AAAAI believes that adherence to the principles outlined in this Position Statement and implementation of the recommendations herein will be a positive step toward "crossing the quality chasm" and creating an accessible, affordable, and quality health care system for the 21st century.
References
1. Crossing the Quality Chasm: A New Health System for the 21st Century, Committee on Quality of Health Care in America, Institute of Medicine, March 2001, National Academic Press, Washington, DC
2. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Institute of Medicine, March 2002, National Academic Press, Washington, DC
2002 revision was drafted by:
Karen Huss, RN, DNSc, FAAAAI
Andrea Apter, MD, MS, FAAAAI
Michael Schatz, MD, MS, FAAAAI
George Green, MD, FAAAAI
Donald Aaronson, MD, FAAAAI
And reviewed by the membership, legal counsel and the 2002 Board of Directors.
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