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PRINCIPLES REGARDING HEALTH-CARE DELIVERY AND DELIVERY SYSTEMS

The American Medical Student Association:

1.             SUPPORTS a coordinated, cohesive health-care delivery system that maximally meets diverse health needs and efficiently achieves such needs, and within such a system, SUPPORTS a multiplicity of approaches to delivering health care and ENDORSES structuring services to meet local needs, including special needs arising due to geographic, cultural, economic, social and/or historical differences between areas;

2.             In regard to managed care:

a.             OPPOSES the concept that fee-for-service practice, in the context of medical care as a market commodity, is the only system to provide the highest quality and availability of medical care;

b.             SUPPORTS the concept of prepaid group practice as a model able to increase the quality of health-care delivery to all people;

c.             SUPPORTS the establishment of a community-based, community-controlled health-care system, publicly financed through general revenues and progressive taxes, employing a full range of health workers and providing complete health services;

d.             OPPOSES the current profit-based fractionalized health-care delivery system. (1989)

3.             In regard to primary care, community and public health care:

a.             URGES that an emphasis be placed on the development of primary care, ambulatory care and mental health facilities to increase access to and availability of needed health-care services, with such facilities serving as patient health education centers with extensive programs in health education for the public as teaching bases for health professional students;

b.             SUPPORTS the concept of Area Health Education Centers, i.e., regional medical centers established by academic medical centers that work in conjunction with both community groups and regional health planners;

c.             BELIEVES that states must increase efforts to evaluate and, if indicated, divert offenders with long-term medical problems to alternate forms of confinement, such as halfway houses, work releases, educational releases or group homes, to more effectively deal with their medical problems;

d.             ENCOURAGES development of adequate screening, maintenance and emergency health-care facilities in jails, prisons and rehabilitation centers, and that medical schools should be instrumental in developing these programs;

e.             SUPPORTS the maintenance and improvement of public sector health-care with the aim of eliminating any disparity in the quality of care between the public and private sectors, and further, SUPPORTS the use of the public health-care sector, when possible, by publicly elected officials as an incentive toward upkeep of the public health system;

f.              BELIEVES that hospitals and other health-care institutions, physicians and other health-care workers have an historical and continuing obligation to meet the needs of the communities in which they are located.  This obligation stems from:

1.             their membership in the community,

2.             the benefits and support they derive from belonging in the community, and

3.             the humanitarian origins of the health-care profession. (1986)

g.             SUPPORTS a patient initially accessing a subspecialist physician of his/her choice only through primary care physician referral; (1994)

h.             calls for the integration of health services with social welfare and community resources, including housing and employment opportunities for the persistently mentally ill, under the umbrella of community mental health services; (1997)

i.              URGES that state mental health agencies enforce minimum standards of care based on peer reviewed psychiatric criteria in order to insure that private HMOs do not provide substandard care to Medicare and Medicaid populations.  These minimum standards of care should be guided by the principles of accessibility to care, continuity of care and prevention as well as rehabilitation; (1997)

j.              SUPPORTS legislation to require parity for mental health benefits such that co-payments, deductibles and degree of coverage for mental illness be comparable to physical illness; (1997)

k.             SUPPORTS legislation to require coverage for preventive mental health-care services such as counseling for at risk pregnant mothers and in school counseling for at risk teenagers. (1997)

4.             In regard to quality assurance:

a.             SUPPORTS the concepts of peer review and quality assurance as embodied in Section 249F of Public Law 92-603 (Professional Standards Review Act) as effective and beneficial means of improving the quality and decreasing the costs of medical care with the following recommendations for improvement of the existing statutes:

1.             more flexibility and local innovation be allowed so as not to restrict alternative, unique and innovative systems that could equally well accomplish the review objectives;

2.             measures be incorporated to ensure that the administration of the program and its guidelines not be dominated through control of federal monies;

3.             continuing education be given greater emphasis than punitive controls;

4.             efforts be undertaken to ensure that implementation does not compromise quality medical care in favor of cost control or administrative efficiency;

5.             physicians-in-training be included at all levels of planning and implementation;

6.             sufficient evaluation of the hospital-based Professional Standards Review Organization (PSRO) system and its impact on cost, personnel, consumers, and quality of health-care delivery be undertaken before any extension of the PSRO concept to private office practice;

b.             URGES the Department of Health and Human Services to periodically undertake special investigations into increases in surgical procedures such as, but not limited to, hysterectomy, Cesarean section, mastectomy and forced sterilization;

5.             In regard to patient rights:

a.             SUPPORTS health care as a basic human right for all people regardless of ability to pay. (1986)

b.             URGES all health care institutions to seek improved ways to limit access to patient records, especially with regard to computerized record systems where retrieval controls are often inadequate;

c.             OPPOSES any local, state, or national legislation that would deny health care, education, or social services based on real or perceived immigration status. (1996)

d.             OPPOSES

1.             the denial of health or life insurance based on a history of domestic violence; (1996)

2.             the denial of coverage for injury or illness incurred through domestic violence. (1996)

6.             URGES that reimbursement policies of private health insurance carriers and federal health-care programs, such as Medicare and Medicaid, be revised to include provisions for:

a.             prepayment on a capitation basis;

b.             equivalent reimbursement for services rendered, regardless of geographic locale of the practitioner;

c.             equivalent reimbursement for performance of identical services by all physicians;

d.             direct reimbursement of properly trained and supervised health-care professionals, such as physician assistants and nurse practitioners, or the clinics for which they work;

7.             OPPOSES the accrual of profits by health-care-related industries and providers at the expense of medically indicated quality patient care;

8.             In regard to access:

a.             SUPPORTS an individual’s unrestricted access to the provider, clinic or hospital of his/her choice in an emergency situation; (1994)

b.             OPPOSES the requirement of health professionals to identify and report any patient believed to be an illegal immigrant and further opposes the requirement of health professionals to ask any patient their immigration status in order to deny care. (1995)

c.             STRONGLY URGES that health-care legislation for all persons, regardless of immigration status, include provisions for: (1996)

1.             emergency care and treatment;

2.             pregnancy related services, including but not limited to family planning, prenatal care, labor and delivery;

3.             preventive services, including:

a.             immunizations,

b.             infectious disease screening and treatment, especially for tuberculosis,

c.             sexually transmitted diseases, including voluntary and anonymous HIV testing,

d.             breast exams,

e.             pap smears.

9.             In regard to funding for medically underserved and indigent:

a.             URGES that in the establishment of priorities for health-care funding, resources be allocated to maintain services for the economically deprived;

b.             SUPPORTS federal legislation, such as Medicare disproportionate share adjustment, which will provide financing to allow increased opportunities for hospitals to provide care to those unable to pay. (1986)

c.             SUPPORTS efforts by state legislatures to consider and implement bills designed to increase health-care access for the medically indigent,  through:

1.             development of a state all-payer system,

2.             taxation of hospitals to develop uncompensated care pools,

3.             requirement of specific levels of indigent care for Certificate of Need approval. (1986)

10.           In regard to Certificate of Need (CON) legislation:

a.             SUPPORTS the concept of Certificate of Need (CON) legislation as mandated in the National Health Planning and Resources Development Act of 1974 (PL-93-641); and, ENCOURAGES the continued future support by the DHHS of statewide implementation of the law, including:

1.             development by the Secretary of HHS of a uniform National Health Policy Statement, incorporating the medical care priorities outlined in PL-93-641;

2.             insurance that Health Systems Agencies are declared the primary implementers of the policies set forth in the National Health Policy Statement.

b.             SUPPORTS the inclusion of physicians’ offices in CON legislation with the following provisions:

1.             that Certificate of Need review be mandatory for capital expenditures of $150,000 and over by physicians for their private facilities which involves only the acquisition of a unit of major medical equipment used in patient diagnosis and/or treatment;

2.             that Certificate of Need review of private physician offices for such capital expenditure takes into serious consideration the geographic proximity of the physician’s offices to any other clinical facility, for it is important to note that the location of physician offices (e.g., rural/isolated areas vs. numerous clustering of urban facilities), in addition to the clinical capacities of already existing medical facilities in the area, are two critical determinants of the potential for expensive and inefficient duplication of medical services;

11.           In regard to health care costs:

a.             SUPPORTS efforts to eliminate unnecessary health care expenditures, and SUPPORTS voluntary efforts to limit increases in health care costs.

b.             URGES that the impact on the individual, community, and the nation of non-medical factors, such as life-style and the environment (physical, social, occupational, and economic), should be reflected in the allocation of fiscal and other resources available for health;

12.           ENDORSES efforts to provide older Americans with special health maintenance programs such as, but not limited to, home health services, visiting nurses, therapists, nutritional services and other alternatives to institutional care;

13.           SUPPORTS public and private funding of preventive, as well as remedial, health-care services for all age groups;

14.           In regard to portability:

a.             URGES the guaranteed continuation of health insurance coverage regardless of change in health status or change in family relationship to the initial health insurance liaison or place of employment, such that all individuals initially covered may retain desired coverage and be notified of the necessity of making new payment arrangements at least 30 days before coverage may be discontinued;

15.           CONDEMNS health-care fraud, specifically the mispromotion of remedies, and calls for:

a.             increased enforcement against fraud at all levels of government;

b.             increased criminal penalties for promoters of such medical quackery;

c.             the establishment of a national, public clearinghouse on inappropriate remedies for illness and disease. (1985)

16.           In regard to transferring a patient:

a.             SUPPORTS “antidumping” legislation, which requires that patients not be transferred unless stabilized, including adequate evaluation and treatment to reasonably assure that transfer will not result in death, or loss or serious impairment of bodily parts or organs. (1986)

b.             URGES that, in cases of inappropriate transfer of a patient in a life-threatening emergency or active labor, where screening and stabilizing treatment are not carried out, civil monetary penalties be imposed against both the hospital and the responsible physician. (1986)

c.             SUPPORTS the involvement of a third party to act as a patient advocate in this process. (1986)

d.             CONDEMNS as inappropriate any and all patient transfers that do not meet the following guidelines as developed by the American College of Emergency Physicians.

1.             The patient should be transferred to a facility appropriate to the medical needs of the patient.  The facility should have adequate space and personnel available to care for the patient.

2.             A physician or other responsible person at the receiving hospital must agree to accept the patient transfer prior to the transfer-taking place.  An acceptable “other responsible person” should be medical personnel who are designated by the hospital and given the authority to accept the transfer of the patient.  The patient transfer should not be refused by the receiving hospital when the transfer is indicated and the receiving hospital has the capability and/or responsibility to provide care to the patient.

3.             Communication between responsible persons at the transferring and receiving hospitals for purposes of exchanging clinical information should occur prior to transfer.  Ideally, this communication should be physician to physician.

4.             Once a patient is accepted for transfer, an appropriate medical summary and other records should be sent with the patient.

5.             A patient should be transferred via a vehicle that has appropriately trained personnel and life-support equipment. (1986)

17.           RECOGNIZES that a significant influx of sick and injured people may occur after military confrontations, natural disasters, or unforeseen emergencies, and REALIZES that hospitals, including the Veterans Administration, are often unable to adequately serve such an influx of patients, and therefore URGES: 

a.             volunteerism by physicians-in-training as health-care providers for use in such special and exceptional situations; (1991)

b.             the hospitals, in need of support, to allow medical student to serve in roles consistent with their level of training; (1991)

c.             the deans of medical schools to support their students in this initiative, and to allow for a wider latitude of attendance and participation in school-related activities (lectures, night-call, etc.). (1991)

18.           SUPPORTS the establishment of a national health care budget, as part of a coordinated approach to effectively and equitably constrain health-care costs, thereby setting enforceable expenditure targets for health-care services. (1993)

19.           In regard to employer-based insurance:

a.             SUPPORTS a universal health insurance system in which insurance status is not linked with employment status; (2006)

b.             URGES all employers to provide health insurance to all employees in the absence of such a universal health care system.  This health insurance should be affordable, comprehensive, and available to all employees and their dependents, spouses and domestic partners immediately upon hiring, regardless of  full-time or part-time status; (2006)

c.             OPPOSES increasing the employee portion of health insurance premiums from year to year; (2006)

d.             SUPPORTS measures that maximize the portability of health insurance, such that individuals do not experience interruptions in coverage when they are between jobs. (2006)

20.           In regard to neonatal patients:

a.             STRONGLY URGES the federal government to require health insurers to provide hospital care for neonates and their mothers for a 48-hour period postpartum after a normal vaginal delivery and for a 96-hour period postpartum after a c-section. (1996)

21.           In regard to physician gag-rules:

a.             OPPOSES any law, contract provision, or incentive that prohibits physicians from disclosing all available medical options for a patient. (1997)

b.             OPPOSES any law, contract provision, or incentive that prohibits physicians from disclosing all financial incentives, which affect the physician's practice. (1997)

c.             SUPPORTS and ENCOURAGES federal, state and local legislation that prohibits health plans from prohibiting physicians from disclosing all available medical options for a patient and/or prohibits physicians from disclosing all financial incentives that affect the physician's practice. (1997)

22.           In regard to health-care system guidelines and incentives:

a.             STRONGLY URGES that private and public health-care system guidelines serve the interest of the patient and the ethical practices of medicine; (1997)

b.             OPPOSES private and public systems that employ guidelines, apply pressures, or institute salary incentive programs that promote negligent health-care practices; (1997)

c.             SUPPORTS the due moral and legal accountability of any party who devises or enforces such guidelines, applies pressures, or institutes salary incentive programs, which are directly proven to cause negligent patient care. (1997)

23.           In regard to consumer-driven health plans:

a.             RECOGNIZES that consumer-driven health plans establish tax-exempt investment health savings accounts that primarily benefit healthy individuals, discourage preventive care, discriminate against sick and low income individuals, constitute an unfair and regressive tax subsidy for high income individuals, serve little benefit for low-income or uninsured individuals, reduce the overall level of insurance in the population, increase the fragmentation of the health insurance risk pool, and decrease the affordability of traditional, comprehensive health insurance. (2006)

b.             OPPOSES the creation of high-deductible health plans that shift the cost of health care to consumers, many of whom cannot afford such a deductible;  (2006)

c.             URGES employers to continue to offer traditional health insurance for employees and to refrain from offering consumer-driven health plans, including plans with health savings accounts and variations of health savings accounts.  (2006)

d.             URGES the repeal of health savings account provisions from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. (2006)

24.           STRONGLY URGES that all insurers fully cover rehabilitation for the purpose of optimizing adaptation to and improvement of cognitive deficits. (1999)

25.           In regards to hospital billing of the uninsured: (2005)

a.             SUPPORTS the establishment of free care provisions for un- or underinsured patients up to at least 200% of the Federal Poverty Level (FPL), and partial free care (sliding scale fee schedule) for un- or underinsured patients up to at least 400% FPL;

b.             SUPPORTS limitations on charges for the uninsured above 400% FPL that do not exceed either the actual cost of care or the negotiated price for insured patients, whichever is lower;

c.             SUPPORTS community oversight and transparency into the administration of free care to the uninsured;

d.             ENCOURAGES hospitals and health care providers to enhance their outreach and publicity regarding free care funds and programs for the uninsured;

e.             SUPPORTS a free care application process that is easily understandable, language accessible, and efficient;

f.              OPPOSES the use of aggressive debt collection tactics, including, but not limited to, body attachments, garnishment of wages, and the placement of liens on homes of the uninsured who are unable to pay their medical bills;

g.             OPPOSES the accruement of interest on involuntary medical debt incurred due to illness.

26.           In regard to the individual insurance market:

a.             URGES private insurers to ensure that plans on the individual market are affordable; (2006)

b.             URGES private insurers to offer coverage to all individuals regardless of health status or pre-existing conditions; (2006)

c.             OPPOSES the practice of excluding coverage for health care related to a patient’s pre-existing condition; (2006)

d.             BELIEVES that proposals to expand access by building on the individual market, such as tax credits for the uninsured or individual mandates, are inferior to proposals that institute a comprehensive national health insurance system. (2006)