Executive Summary - Dr Vipin Kalia

COMPREHENSIVE COMMUNITY HEALTHCARE PROJECT: EXECUTIVE SUMMARY

PROPOSAL OUTLINING:

· This is a multiphase approach to finding comprehensive healthcare needs and beyond for the community.
· This proposal outlines mechanisms on how to provide primary care.
· How to fund complicated healthcare.
· How to find humane ways for helping vulnerable people, elderly, disabled, chronically sick, culturally challenged, linguistically, educationally, and transportation challenged.
· This also provides an opportunity for everyone to get involved and organize comprehensive community healthcare.
· We can use time and monetary from everyone.
· If you have any skills, like doctor, nurses, lab workers, allied healthcare workers, computers skills, driving skills, read/write English, Hindi or other language and are wiling to donate four to eight hours.
· If you are an Engineer, Professor, I.T. professional and are willing to donate four to eight hours per month, we can use your skills for building this organization.
· Obviously if you think healthcare for your own community is a worthwhile cause, your donations are tax deductible.
· I would also encourage all the local religious, secular and ethnic/regional organization to throw their weight behind this project and support in terms of talent and money can expedite this process.

COMMUNITY HEALTHCARE PROJECT

PROBLEM:

As we know there are about 47 million uninsured and probably another million who are underinsured or partially insured people in our country. Many of them live in Central Indiana. The challenge that underinsured, uninsured, and partially insured face on daily basis is seen in all hospitals and healthcare settings. This population faces challenges of access to healthcare, cost of healthcare, bankruptcy from healthcare and a daily struggle of balancing the cost of living versus cost of medical care. As a result most of preventive health care is not sought and then those preventable diseases compound to become much more serious and expensive leading to catastrophic health conditions. These catastrophic health outcomes are usually far more expensive, life threatening and financial future threatening leading to medical cost associated bankruptcies. The problem obviously is not hidden, it is lived by about 1/6th to 1/7th of population on a daily basis and there challenges are seen in every healthcare setting on a daily basis and there is almost daily coverage by the media of this problem.

SOLUTION COMPREHENSIVE:

Unfortunately the solution is far more complex for multiple reasons. It would have been ideal if there was a universal access to health care government sponsored solution.
However, it has been lacking and not forth coming as of 2008. The other complex issue is even in populations which have 100 percent of there healthcare bills paid by government insurance programs, still a multitude of a medical associated problems remain uncovered.
Those are defined as problems of being vulnerable. Those problems of vulnerability include things like being elderly, disabled, and chronically sick. Even when patients have
100 percent health insurance coverage including things like Medicare, Medicaid and or VA benefits the chronic care required by elderly, disabled and chronically sick is not covered. In the solution proposed in this community health care project, our approach is to look for a comprehensive solution that not only that addresses the needs of uninsured, underinsured, partially uninsured but also the needs of vulnerable population which include elderly, disabled, and chronically sick.

IDEAL SOLUTION:
The ideal solution would be if we had complete funding of about 2.5 million dollars we could resolve this complex issue, we could find solution to this complicated problems at least to a limited extent. However, at this point there are no obvious sources of funding even at a minimal level to get this project off the ground. Therefore a multistage approach will have to be taken.

PHASE-1

Phase 1 of this approach would include starting a monthly clinic at India Community Center. In the beginning the clinic over there would meet once a month. The medical expertise, doctor care would be provided by Dr. Vipin Kalia, MD on a volunteer basis. Dr. Kalia will donate about four hours once a month of his time seeing patient and another 12 hours a month in providing organizational, logistical support. Out of four hours of clinic time about four to eight hours of lab follow-up, medical records follow-up and other logistical details would be needed. Another four to eight hours on monthly basis would be needed trying to arrange for volunteers, arrange for phase two, three and four. In this phase the clinic would recruit volunteers and they would play the roles of receptionist, transcriptionist, educators, coordinators, medical records people, fundraisers, health techs, nurses, and pharmacist. We would also form a subcommittee to recruit more healthcare personnel especially doctors, nurse practitioner, physician assistants, nurses. As and when more personnel become available we would increase the frequency of this clinic. Our hope is that we would have enough volunteer physicians and other volunteers in the community that we can open this clinic 5-6 days per week even on a part-time basis.

FREE PHARMACEUTICAL SUPPLIES:

We would recruit volunteers who would seek free pharmaceutical samples, medications at either free and/or subsidized cost. The legal and logistical challenge of importing drugs from other third world countries would be explored to see if the medications can be imported at a cheaper price and either distributed for free or subsidized price. Other cost in primary care clinic comes from labs, X-rays and other paramedical services. Our subcommittee of volunteers will try to contact lab services to see if they could donate their services and also to radiographic services to see if they could donate their services for free as well.


PHASE 2:

Our phase 2 would include a little better physical infrastructure of the clinic however still largely run by the volunteers. Our phase 2 would comprise of a house, an old house located at any main road which is allowed to be zoned into commercial zones and then convert that house into a clinic. That house probably should have 4 to 5 bed rooms and the overall cost probably to buy such a house on a main busy street would be less then $100,000 and if you add a cost of modifying it into a clinic that would be another 50,000 so probably a total cost of $150,000. Once the house is modified into a proper clinic then we would hire one fulltime coordinator to coordinate the activities of volunteer clinic. This clinic would still largely be based on volunteer activities. We would still need volunteer nurses, health techs, receptionist, transcriptionist, billing people, volunteer physicians, volunteer lab services, donated pharmaceuticals, however this would at least guide the users of free and or subsidized healthcare to a proper location and also give a proper location to the volunteers who would be helping out. The anticipated cost of this phase 2 project is probably than 200,000. $150,000 of that would go to infrastructure cost and $50, 000 or so would be in terms of the cost of hiring a manager/coordinator.

Phase -3

Functional or architectural structure of the clinic would contain about 10 exam rooms each measuring about 15 by 12 feet or 180 square feet and between in those will be hallways etc measuring that about 1200 square feet and two waiting rooms 1200 square feet each and then a office space of another 1200 and lab area and a area for social concerns of the patients. A total of about 10 to 12000 square feet of space would be needed to locate phase 3 of the clinic. The total structural cost is anticipated at about 1.2 million dollars. The cost of land based on location would be anticipated at about 1 million dollars and cost of building would be about 1.2 million dollars and cost of furnishing would be about 400 thousand and first year operational cost would add 600 thousand dollars in term of labor etc. Total anticipated cost for phase 3 would be about 3.2 million dollars. Once phase 3 is functional we anticipate to have enough money for first year’s operating expenses since, we anticipate about 60 to 70% of patients with insurance and remainder either free or subsidized. Revenue from there should help us expand labor-force in this phase. By middle of phase 3 we should have enough revenue to hire two full-time doctors, one to two full-time nurse practitioners. We would again encourage recruiting volunteer doctor, nurse practitioners, nurses and cadre of other volunteer for other kinds of services there would continue to provide varied services at this clinic. However, once phase 3 is fully functional, about 80 percent of the population that is served would be expected to have health insurance. And those people who have insurance, their insurance would be billed and full amount would be collected for the service provided. 20 to 30 percent of services provided at the clinic would be either completely free and or subsidized based on the income of the consumers based on the sliding scales. The amount of free healthcare and total amount of healthcare would fluctuate based on the resources present at that time.
1 Exam Room
180 Square feet
Cost of Building
$1,200,000
10 Exam Room
1800 Square feet
Cost of Land
$1,000,000
Hallways
1200 Square feet
Cost of Furnishing
$400,000
2 Waiting Room
2400 Square feet
Cost of Labor
$600,000
Office
1200 Square feet


X ray/labs
2400 Square feet


Social Work Area
1000 Square feet


TOTAL
10,000 Square feet
TOTAL
$3.2 million

FUNDING FOR PHASE 3:

Multiple sources of funding will be sought for Phase 3. In phase 2 a small fee would be charged in the clinic to cover the cost of operation of Phase 2 and also to collect money for expansion to Phase 3. Donations would be encouraged from those patients and their family members seeking healthcare in the free or subsidized clinic of the IAI. Every effort would be made to seek general community donations and also corporate and business donations. All those businesses where these community members spend their money would be encouraged to donate money for the Phase 3 of this clinic. Grants from various endowments and government agencies will be sought for funding of Phase 3 of this clinic. Fund will also be generated by sale of bricks and plaques. All the exterior bricks and stones will be made with custom names and or initials. People in the community would be encouraged to buy as many bricks as they like with their names on it so their contribution can be permanently remembered. Inside of the building, there will be plaques of various sizes throughout the waiting room and the exams room listing various sources of funding. This would include individual donors and corporate donors. Different members in the community will be asked to sponsor either plaques, stones, bricks, signs or different facades. Wealthy donors can sponsor entire exam room, waiting room, lab, X-ray facility etc.

PHASE-4

In phase 4, we will try to address the problems of vulnerable population in our community. The vulnerable people are defined as people who are elderly, disabled, and or chronically sick, and who require on going logistical support to carry on their activities of daily independent living. At this point regular health insurance, VA benefits, Medicare, Medicaid either does not cover the logistical support of activities of daily living for vulnerable population at all or if it is covered at all it is covered to a very minimal extent maybe 5 to 10%. The other challenge we see is the people, who are linguistically challenged, culturally challenged and challenges of transportation. All those challenges are compounded in vulnerable population to various degrees. We would also try to address the various challenges of vulnerable population. A computer database network of volunteers could be compiled. Once the volunteers are determined to be free of criminal records and not seeking any secondary gains those would be matched to help our vulnerable population in their logistical challenges of their activities of daily living, linguistic challenges, cultural challenges and transportation challenges. Those patients who get free and or subsidized healthcare in our clinics would definitely be expected to do something in return for vulnerable population. A point system would be established where the dollar amount for which these patients are provided free and or subsidized healthcare and those dollars would be converted into some point system. Each activity of daily living multiplied by its hourly content would have a quantifiable point system. Based on this system, those people who received free and or subsidized healthcare would be expected to turnaround and provide assistance of similar or more points to our vulnerable population. Those patients who are paying customers who are paying either through out of pocket expense or insurance would also be encouraged to be good citizens and donate some of their time as a good will gesture to assist the vulnerable population and also to continue donating time, services, money to help the vulnerable population and also to help this free clinic in growing the community where more patients can be provided free and or subsided healthcare. Those patients who are providing services and or donations or money to our vulnerable population they too would also accumulate on point system. Those continued points are obviously good for giving recognition awards to the people who are providing the services but also if and when those patients who have been active participants in donating time, money, services would be given preference should they ever become vulnerable themselves in terms of becoming elderly, disabled, chronically sick, linguistically, culturally, transportation wise challenged.

PHASE -5

Since our goal is to provide free healthcare or subsidized healthcare to as many people in community as possible, there will be an ongoing need for funding. All the previously mentioned funding source will be continuously sought on an ongoing basis which would include small fee in the clinic, insurance billings and collections once the Phase 4 is complete, continued encouragement of donations, general community donations, grant for funding and ongoing sale of plaques and bricks out side the clinic. However, even despite all the sources, the demand of free services is far likely to exceed the supply of services. The next level of funding will be sought by encouraging all members in the community who utilize our services whether insured or uninsured to join community buying pools. Those people who are getting free and or subsidized care they would definitely be mandated to buy their groceries, insurances, gas and all other goods and services they use in life from preferred vendors. These preferred vendors would be expected to donate 1 to 5% of their gross receipts for the continued support and expansion of this healthcare project. However, the fully insured people who are paying full fee for their services will be encouraged to join the buying pool as well. They would be encouraged on moral grounds that when they purchase their goods and services from preferred vendors for example grocery stores like Meijer and Kroger’s, refunds somewhere from 2 to 3% of for community projects if the groceries are bought from them. This reimbursed money for all the goods and service will be utilized for ongoing healthcare associated projects. For those people who are fully insured and paying 100% of their health care bill might not see a need to participate in this program. However a moral force would be exerted on them to educate them in their participating in bulk buying of goods and services the rebates that would come back and would help us provide free and or subsidized healthcare to the members in their community who are less fortunate and do not have access to healthcare, health insurance and or otherwise vulnerable. (Vulnerable people again include elderly, chronic sick, disabled, linguistically, educationally, culturally, transportation challenged.)

PHASE-6

Once phase 5 is fully functional and the healthcare clinic is self sufficient and self sustaining and extra revenues are available adjoining child care center would be open. The idea behind the child care would be to provide subsidized high quality childcare for members of the community who otherwise could not afford the childcare. Second center for daytime eldercare for elderly, disabled, chronically sick in the community would also be offered for vulnerable people who are usually living in isolated lonely condition in their homes. They would be offered free or subsidized transportation to the elder care center for the community activities and social events on daily and ongoing basis. Along with that homeless shelters also would be associated somewhere from 4-6 homeless shelters because when you come across a large variety of varied socioeconomic status population invariably homelessness is part of the problem that is encountered on daily basis in a healthcare setting. Under the present healthcare delivery model the homeless have to transfer far away and there are always inadequate homeless shelters. A limited numbers of homeless shelters would be also built on premises. Number of homeless shelters would vary based on demand. Phase 6 would also involve nursing homes, this nursing home would be for patients who require 24 hours a day, 7 days a week, care around year in an inpatient facility especially elderly, chronic sick, disabled for whom independent living is no longer possible. The benefit to these patients in our own nursing home would be, that these would be the people who already graduated through outpatient community healthcare center and have also been associated with eldercare center and also on the ground would have daycare and childcare center so there would be a continued interaction of various socio economic, ethnic background, cross-section of age, culture, education, on a ongoing inpatient-outpatient setting in one facility. Our community members would not have to go to strange nursing homes. Nursing home care is quite expensive and is usually self funded, long-term care insurance funded or funded through Medicare/Medicaid. Again this can be used as for sources of revenue. That revenue can be used to subsidize who can not afford nursing home.

PHASE-7

Once one of these facilities is fully functional then clearly three more would be replicated to a total of four facilities in each of the quadrants of the city of Indianapolis one on the North East side, one on the North West side, one on the South West side and one on the South East side. In the long term, having to travel more than 12 miles to reach one of these facilities would not be practical on a daily basis. If you locate 4 facilities in each quadrant of the city Indianapolis, then you can serve people within 12 miles of their residence.

PHASE-8

This phase is based on the land availability and preplanning definitely in second, third and fourth phase is necessary for this purpose. Ample land should be purchased in advance because if funding situation should improve by the second or 3rd phase, there should be adequate land for expansion. In the second, third, fourth and may be even in the first facility another wing would be added for assisted living, independent living, and full nursing home as mentioned before. Independent living would be for patients who are elderly disabled, chronically sick who want to be near the institution where help can be available if they so choose and or on as needed basis for example: nursing help, activities of daily living help, but otherwise those patients are largely functionally independent. So a wing for independent living would be made and then a second wing for assisted living would be made. Assisted living would for those patients who require minimal help with their activities of daily living, transportation etc. However the healthcare and the common dining facilities would be available on the premises. Of course the third wing would be full nursing home where full facilities are needed including nursing, assistance etc for 24 hours around the clock assistance with the daily activities. The benefit of a full nursing care would be that funding by the state, through Medicaid and or long term care insurance dollars so they would provide a source of revenue as well. All theses different phases would be funded through all mechanisms mentioned before like small fees clinics, nursing home, assisted living facilities etc encourage donations in general, community donations, and grants for funding and then of course continued selling of named bricks, flags, signs etc. The hope is that it would become self-sufficient and fully functional self-sustaining entity where no body would be turned down for primary healthcare, extensive healthcare, and nursing home regardless for capability to pay because there would be multiple different source of funding available at all time.

THE FINAL PHASE OF THIS PROJECT WOULD INVOLVE UNIVERSAL
HEALTHCARE

PHASE-9

Once we have achieved the level of large community interest where people are willing to donate their time, effort and money then we will be in our final phase. Those people who are already accessing free healthcare from us and those who are interested in helping we would choose preferred vendors for them for all their goods and services. For example if you are getting ready to buy a house then we would have preferred realtors and builders from which you can buy the house and hopefully same way for home insurance, cars, car insurance, other services and along with that goods for groceries, furniture etc we would have a list of common preferred vendors. Once all the community members who participating in this project purchase their goods and services in bulk from preferred vendors then 2 to 5% discount can be obtained from vendors. This discounted amount can be rebated back to this community healthcare project. With that rebate amount our hope is to buy catastrophic insurance for everybody in the community. Question one may ask, why is catastrophic insurance necessary for everybody in the community and secondly why should this be our responsibility? The reason it is necessary because about 2 to 5% of the uninsured people who are otherwise living comfortable, middle, upper middle level life but do not have health insurance come upon complicated expensive healthcare expenses. Whenever that happens usually their financial futures and all other aspects including income are wiped-out clean. It can be a tremendous amount of challenge to those families. So if we are assuming that it happens to about 2 to 5% people of the community lets take conservative number of 2%. And if there are 4 to 5 thousand ethnic Indian families in this Central Indiana, again let’s take conservative number of 4 thousand. Therefore, 2% of 4 thousands would be 80 families a year. That is a large number of people who are going to face catastrophic healthcare expenses on their own. From the experience of the founder of this organization I have seen bills as high as 250 thousand dollars or even higher in certain cases. Those kinds of bills clearly are unaffordable for most middle, upper middle class people and usually lead to financial ruin, bankruptcy etc. Once we raise enough money then money needs to be spent to buy catastrophic insurance. However we certainly can raise the money in the community today and do not have to wait for final phase to buy catastrophic insurance for everybody. That 2 to 5% catastrophic healthcare number and healthcare dollars are going to be spent. Whether you spend those thru out of pocket expense and face financial ruin or you collectively plan and purchase catastrophic insurance and purchase by raising money through rebates etc. The healthcare expense is going to remain same. However, our biggest hurdle is educating people in the community that it is important to plan for catastrophic healthcare expenses while they are young, healthy, working and have money to buy insurance. However that educational challenge has remained to be the biggest challenge in this project therefore we are not optimistic that it would be accomplished in near future. We do anticipate an inflation of about 5% annually for all our estimated expenses and for catastrophic insurance also. While we are planning for all these things we need to add about 5% annual inflation for catastrophic expense as well. Once we have catastrophic insurance for everybody in the community who can not, will not afford insurance and then have primary healthcare clinic then we can say that we have universal healthcare in the community. Even though this is a goal which can be and should be accomplished rather quickly however we are not optimistic this is going to happen in the near future and we do anticipate 2 to 5% of the people in the community meeting financially ruinous expenses on annual basis for quite some time.

Insurance works thru the model of spreading the risk. Which means when people are healthy, walking, talking, earning, they deposit a small sum of money on annual basis into a large pool. Should there be any unplanned healthcare expense, then that large pool of money covers the expense. Risk of big healthcare expense is spread to large healthy population base.

However, this assumes that large numbers of young, healthy, walking, talking, earning people would be willing to pay into this pool of money. For some people it is truly un-affordable to buy insurance. Others see no need for this expense. In the experience of this author, a large percentage of people start their research while having a heart attack, stroke, bleeding on “where to get healthcare, how to pay for it and then how to deal with states of vulnerability that invariably follow.” We are developing a BLENDED MODEL of how to pay for healthcare and state of vulnerability. Blended model means, if you can’t pay for it with money, you can pay for it with effort or SWEAT EQUITY. However, all 3 models of paying for healthcare/ vulnerability assume:-Either work hard/or inherit money and pay for it cash upfront. Secondly, pay into insurance pool on an ongoing basis, while you are healthy. Then there is our blended model, where you can pay with effort (sweat equity) + small amount of cash. Either way some effort has to be made for in advance of healthcare crisis or state of vulnerability. In the experience of this author, the LARGEST CHALLENGE is to educate young, healthy people who do not anticipate any healthcare crisis or state of vulnerability to engage. First by planning and then building this infrastructure and secondly to maintain it with effort and/or money.

Since I have had following discussion dozens of time with people in the community- “I am having chest pain or/and my face is weak on one side or I have a lump or I have a tumor that is bleeding.” My answer always is “Go to ER.” In variably I hear back- “ER’s are very expensive and we do not have insurance. Last time either when I went there, friend or family went there it was very expensive.” I always feel like saying “ER’s/Hospitals/Doctors/Labs/X-rays and pharmaceutical companies have not jacked up prices because you are coming; they have always been expensive and are going to remain expensive. I do not have any cheap, inexpensive magic pill that can cure all the problems. For last 15 years, whenever I have tried to engage young, healthy, walking and talking people to get engaged in building infrastructure for healthcare crisis or states of vulnerability the response is always underwhelming.

I still think it is an important enough cause that we should continue trying. However, the largest challenge I have experienced is “General Apathy and lack of willingness to engage while people are healthy and have time to plan for SPREADING the RISK.” Risk of healthcare cost and states of vulnerability can only be managed by spreading it over large population group. The largest challenge is educating people to engage in this endeavor. Therefore, this is as much educational endeavor (to educate people to engage and plan for healthcare crisis and state of vulnerability that inevitable comes to large percentage of people) as it is to build infrastructure for healthcare and to deal with states of vulnerability.

No new magical sources of funding are likely to come either. As far as I can see sources of funding have always been and will be:
· General donations
· Corporate sponsorships
· Sale of plaques
· Grants from:
Endowments
County
State
Fed government
· Seeing paying patients thru self pay or insured patients
· Getting discount/Rebate on bulk of goods/services that large population base consumes.

Anyone interested in the community in being part of this project, please do not hesitate to call me at (317) 414-4439.

Authored by Dr. Vipin Kalia, MD.
Assistant professor of clinical
medicine@i.u.medcenter



Phase

INDEX


Pg. #




1
The approach would include starting monthly clinic at IAI. The medical expertise, doctor care would be provided by Dr. Vipin Kalia, MD on a volunteer basis.

3
2
This phase would include a little better physical infrastructure of the clinic however largely run by the volunteers. Our phase 2 would comprise of an old house with 4 to 5 bed rooms. The anticipated cost of this phase 2 project is probably less then $200,000. $150,000 of that would go to infrastructure cost and $50, 000 or so would be in terms of the cost of hiring a manager/coordinator.

3
3
Functional or architectural structure of the clinic would contain about 10 exam rooms. Total anticipated cost for phase 3 would be about 3.2 million dollars. Once phase 3 is fully functional, about 80 percent of the population would be fee for service expected that is served at this clinic and would have insurance. And those people who have insurance, their insurance would be billed and full amount would be collected for the service provided. 20 to 30 percent of services provided at the clinic would be either completely free and or subsidized based on the income of the consumers based on the sliding scales. The amount of free healthcare and total amount of healthcare would fluctuate based on the resources present at that time.

4
4
We will try to address the problems of vulnerable population in our community. A point system would be established where the dollar amount for which these patients are provided free and or subsidized healthcare and those dollars would be converted into some point system. Each activity of daily living multiplied by its hourly content would have a quantifiable point system. Based on this system, those people who received free and or subsidized healthcare would be expected to turnaround and provide assistance of similar or more points to our vulnerable population.

5
5
The next level of funding will be sought by encouraging all members in the community who utilize our services whether insured or uninsured to join community buying pools. Those people who are getting free and or subsidized care they would definitely be mandated to for example to buy their groceries, insurances, gas and all the goods and services they use in life from preferred vendors. These preferred vendors would be expected to donate 1 to 5% of their gross receipts for the continued production of this healthcare project.

6
6
Adjoining child care center would be open. The idea behind the child care would be to provide subsidized high quality childcare for members of the community who otherwise could not afford the childcare. Second center for daytime elder care for elderly in the community who are usually living in isolated lonely condition they would be transported to the elder care center for the community activities and social events on daily or ongoing basis. Along with that homeless shelters also would be associated somewhere from 4-6 homeless shelters.

7
7
Once one of these facilities is fully functional then clearly three more would be replicated through a total of quadruplicate facilities of four facilities in each of the quadrants of the city of Indianapolis one on the North East side, one on the North West side, one on the South West side and one on the South East side.

7
8
This phase is based on the land availability and preplanning definitely in second, third and fourth facility that is built for this purpose. Ample land would be purchased in advance because if funding situation should improve by the second project, therefore adequate land would be purchased from the very beginning. Independent living quarters would be for patients who are elderly disabled, chronically sick who want to be near the institution where help can be available if they so choose or need on as needed basis.

7
9
Once all the community members who are participating in this project purchase their goods and services in bulk from preferred vendors then 2 to 5% discount can be obtained from vendors. This discounted amount can be rebated back to this community healthcare project. With that rebate amount our hope is to buy catastrophic insurance for everybody in the community.


8