 Good morning everyone it's it's unusual to get a little bit of silence before it ran rounds and that is that's definitely our cue to start off so this is this is our semi-annual ethics conference this is taking just a little bit different shape this is a topic obviously near and dear to many of our hearts in this building and yet was not a topic that was suggested by anyone in this building it was actually something that's been the front of the mind of our moderator and talented guest J Jacobson J Jacobson emeritus professor of internal medicine practice infectious disease and is and I forget the exact title forgive me of your role in in medical ethics I just consider him to be the medical ethics guru for the health sciences he'll be joined today by dr. Avni Shah most of you should know dr. Avni Shah she's been here a year although been here is maybe not the accurate term she has been a fellow for the past year but she's been traveling all over the world representing Moran and building collaborations as our global fellow so with that turned over to J Jacobson for ethics epidemiology and health policy what's the macula and thank you for coming Paul Bernstein just so that we can answer this question thanks Joe well I'm very flattered I haven't been called a guru before but I'm guessing maybe that's an age criteria but my connection with ethics was we established the division of medical ethics actually very exciting because not every medical school had one in 1988 and many of them were not led by physicians often they were people with a background in theology or philosophy so it's really really exciting but backgrounds are important and my background is infectious disease which also does epidemiology and public health so I think I've always had a focus on the larger community and how to keep that community healthy and prevent illness and that's actually not an unusual transition I think to things like ethics and particularly policy so that's a good way and again whenever I speak with your group I think in terms of ophthalmology book vocabulary so think of my lens as the lens that includes public health so when I see individual cases I can't help but see all the cases that are around them right the ones that transmitted to them and the potential for them to transmit to others so it's a it's a rather large view I mentioned that I always think about your vocabulary when we talk and I think the background for this is pretty straightforward the progress in medicine over the last let's say 70 years has been extraordinary and I think that a lot of that is about technology and clinical skill and the direction of that is incredibly positive always more always better I think on the other hand from that public health view we've actually also made some progress in the U.S. it's kind of almost stumbling or iterative it's a little bit of progress sometimes some steps back and then some more progress but we're at a very unusual point right now we seem to have stalled and I think that many people are concerned about the next step in terms of health care in the United States and I think many people are troubled by it and I think the thing that I hear about government and policy is the phrase what's the matter so as I was just saying to one of you you could think of this as a typo the real question of course is what's the matter but in terms of your vocabulary I really thought a lot about that I think that you could describe some of our policy as say near-sighted or myopic you might want to call it far-sighted or maybe that's desirable but I have to say when I'm thinking about 2020 when this whole country is likely to be talking about policy and law and change I'm actually now a little worried as I think of Donald Trump and the leading Democratic contenders Bernie Sanders and Joe Biden that maybe the problem we presbyopia so anyway what what to say the reason that I picked the macula is I think the macula is it's not just a metaphor it's real about keen clear straight-ahead vision and that's exactly what we're going to need to do better in terms of health policy and health outcomes and so we'll talk about several things today I'm going to bracket that and talk a little bit about ethics and health policy and Avni is going to talk about something that's even more real she's going to talk about this health issue but from the standpoint of ophthalmology literally about eye health where you are how we compare to others and maybe what the direction is of the state of vision health in the United States and so that's kind of something that will ground you but I hope that you will leave thinking about what would be the policy at the national level state level and maybe the Moran level that you would like to see going forward so we continue to make progress so ethics usually about what you should do it's about the right action on epidemiology is about what's out there and what makes it the way it is so we look at not only incidents and prevalence but we look at association as kind of a hint at cause and that's also if we understand causes we may understand if we understand causes or problems we may understand solutions and then finally health policy unlike ethics is not always about what you should do it's often about what you must do or what you must not do and it often guides how you manage to do that so for example in terms of insurance and funding policy is kind of both an enabler but it can be a crippler so all three of these are really really important so you know what the macula is and this image is our US Capitol that's actually a statue of George Washington and he's standing in the rotunda looking up at the dome of the Capitol and I was actually struck by how analogous that image was to what you all see when you look into the eye George Washington actually spoke in some very relevant metaphors this is what he had to say no more and ever dawn more favorable than ours did and no day was ever more clouded than the present wisdom and good examples are necessary at this time to rescue the political machine from the impending storm leadership is not only having a vision but also having the courage the discipline and the resources to let you get there when there is no vision there is no hope so I think that's a really nice foundation for kind of starting off and I think this picture of the Capitol where we all would like clarity and clear vision and kind of getting through the clouds to where we want to be so these two images actually pretty well depict the steps that we've taken in health care in the United States on the left is president Johnson turning over his presidency which established two terribly important programs in American health care Medicare and Medicaid and also one that I think we often forget about which was a Children's Health Initiative interestingly enough that was a Democratic president turning the reins over to a Republican one but those programs have actually endured so since 1968 we have had Medicare and Medicaid so what Johnson said was no longer will older Americans be denied the healing miracle of modern medicine no longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years no longer will young families see their own incomes and their own hopes eaten away simply because they're carrying out their deep moral obligations to their parents better health for our children all of our children is essential if we have are to have a better America so he said I propose a child health program that's in addition to Medicare and Medicaid to provide over the next five years for families unable to afford it access to health services from prenatal care of the mother through the child's first year when we do that you will find it is the best investment we ever made because we will get these diseases in their infancy we will find a cure and a great many instances that we can never find by overcrowding our hospitals when they are grown so you have that transition and that pro those programs all of them have endured and in fact there's a question right about expanding Medicaid in our present era to include more people so those programs have remained viable the picture on the right of course is Barack Obama and Barack Obama both famous and notorious in our country for moving the agenda toward what was formerly called the affordable care act but because of his link to it often referred to as Obama care let me tell you what he had to say he said I'm here for my mother and all the Americans who are forced to spend time arguing with health insurance companies instead of focusing on getting well I'm here for the millions of lives that will be touched and in some cases saved by health insurance reform I'm here for the small businesses who are forced to choose between health care and hiring I'm here for the seniors who are unable to afford the prescriptions they need he went on to say we're unique among advanced countries that we don't have universal health care my hope Obama speaking was that I was able to get a hundred percent of people health care while I was president we didn't quite achieve that but we were able to get 20 million people health care who didn't have it before and obviously some of the progress we made is now imperiled because there's still a significant debate taking place in the United States and I think you know really in the presence and shortly toward the end of this year and in 2020 health care and health care reform will in fact be the largest focus of the debate for the presidency in the middle of that period a Republican president actually initiated a health reform policy for the country and this is now a very unusual picture there are eight people standing behind President Reagan four of them are Democrats they're in the center and four of them are Republicans so a very fair question is what is there about health policy that may also be political and so the background for Medicare obviously technology was advancing there were more drugs more treatments more expensive older people were not working they didn't have work related insurance and they were sicker so they had greater need for more expensive care and they couldn't meet it so in response to that you get Medicare on the other end you have again people who are not working for any reason or who are working at low-paying non-union jobs don't have insurance in the country and that policy was designed to address it so what about this policy so M. Tala you know about that emergency medical treatment and active labor act signed by a Republican president the background would be dumping so as medical care became more expensive and people without insurance were showing up in emergency rooms hospitals were transferring them to other hospitals often with fewer skills right so-called public hospitals and as a result their treatment was delayed some got no treatment at all some obviously died and the treatment that some got was inferior to what they would have gotten in a hospital with full resources if they had committed to it so call that a crisis that kind of grew out of both progress and medicine and the cost well how did this bill work and get bipartisan support well for the people that were being dumped this bill made it illegal to do that it said that the hospital in which they appear must take care of them so that's why the Democrats are in the picture they would be advocating as they have for a long time for very broad-based health care why are the Republicans there this was not a federally funded program so while the hospitals were obligated to provide the treatment the government had no obligation to pay the support so this was in a sense a program that took the financial responsibility off the government shoulders and put it out actually on the medical community particularly on hospitals and potentially on insurers because as you can see those hospitals that were moving away expensive care by dumping patients were now obliged to provide it and somehow they needed to pay for it and the only solution available was to transfer the cost to other patients who could and would pay so patients with means or patients insurance so I think you can see the bullet points there and I think a good thing to remember is that while I've said it shifted the cost to the institution it also shifts the cost to the individual so an individual who's not insured but is treated is in fact billed usually for the treatment provided some of that treatment can be incredibly expensive and as you well know trying to pay for medical care or being obliged to pay is one of the largest causes of bankruptcy in our country so interesting to take a look at this policy which met some needs but also had some significant consequences so this is a way of looking historically at what I said was kind of the stumbling progress that we've made so we've talked a little bit about Lyndon Johnson and Medicare and Medicaid what you want to appreciate is before that bill one in four Americans had no insurance so the uninsured rate was about 25% with that particular set of programs Medicare Medicaid Children's Health you can see that it fell to about 12 or 13 and it continued to fall as that program was implemented and sort of steadied out somewhere around 14 to 15 percent and then you can take a look at the right President Obama came into office first in 28 and by 2012 had succeeded almost entirely with one party to pass the Affordable Care Act right and that didn't really go into full effect until about 2014 but you can see the incremental fall again down to about 8% that's the 20 million people that President Obama talked about a really good thing to recall is who those people were so you know they weren't the elderly because there were no changes for people over 65 in some states they weren't the very poor because some states chose to leave Medicaid exactly the way it was what it changed were middle-aged and younger people who did not have insurance that actually is going to turn out to be really important for you because that's the period of time other than early childhood where you're going to recognize the beginning of many important eye diseases at a point where they're treatable and or preventable so that's the group that really constitutes the 20 million so that's the story just through about 2015 if you look at this a little more closely just more recent periods from 2008 which is Obama coming in and then you can see the improvement in the percent uninsured right after 2014 what you must also appreciate is that things are going back the other way so the proportion of our country uninsured even toward the end of the Obama administration was creeping up and now it's almost back to where we started about 14% and you know what's happened right so you have a Congress that hasn't offered a new proposal but has been eviscerating the very heart of this particular program which was the mandate that's actually what made insurers willing to do this that is they were covering people who before could not be covered people with pre-existing conditions they wanted to collect more premiums from people who didn't need care think of that young healthier population without insurance and the government stood behind them again this is very different than the Reagan program instead of you can't pay that premium will pay it so we're heading back that way and I think that's the direction we're likely to be in unless something changes so for today what I'm hoping to do are the first three of these quickly and they will be quick it's asking the question what do our professional organizations require of us but particularly with reference to what do they require of us in terms of caring for people who might otherwise be unable to afford care so that's that's the key question what do we expect of ourselves you're gonna answer that I will ask you about that in sort of a gated way and with some scenarios and then we can proceed to what Avni will do is talk about well wow once you decided what your targets are and what your goals are she's gonna show you in a way what those targets look like obviously she also will give you an idea and I'll just say right now how federal health policy is shaped access to eye care is exactly the way it's shaped access to any other care so for emergencies something like Imtala has actually made more eye care available to more people in excellent institutions where they go for help after an injury for example it doesn't address the payment for that treatment but in terms of getting an emergency treated no question better off also just insurance for non acute reasons to visit the hospital insurance is often what provides access for people if they're contemplating even a routine care visit which from their standpoint seems expensive a huge difference is made by whether that will be paid for completely or not even something as simple as glasses whether they're paid for or not makes a very big difference to many people whose vision at risk Avni will talk about that and why what are we doing to meet our goals and what changes in policy would optimize eye care I think my goal for you is that after today hearing what I have to say and particularly what Avni has that as you hear people roll out some of these rather arcane really broad policy proposals you will look at them with macular vision you will look to see whether a universal health plan even covers vision insurance just so you know not everyone does Canada has a system that we point to as a model system but it doesn't provide coverage for routine eye care so you want to look for that and then be looking at the kinds of programs that will actually serve the communities that Avni tells you need your help so this is kind of the standard conjunction of overlapping circles ethics that I explained to you policy and law right so should must and how to do it it's really more complicated than that and I think that top circle is the one where you can contribute tremendously most of the people who have been offering health care proposals do not have an ophthalmologist at their site trust me many of them don't even have practicing clinicians at their site so people who have experience in how medicine works literally where the rubber meets the road have to be a part of this debate and so you could at least be discerning voters but even better would be for you to share your advice as a group as people who advocate for good vision in America you could be informing these policies as they develop so we had never talked about this kind of ethics at this meeting much of American medical ethics is grounded around something called deontology rules of behavior you will see that in codes of ethics you will hear it in the way hospitals talk about how physicians should behave it's very very rule based some ethics is consequential we always ask the question of what's the greater good as we look at any problem we ask you know if I do it this way will it be better for more people than if I do it the other way those are two very different ways of approaching ethics here's a third this is called virtue base that what physicians or other people in responsible positions do is actually a moral imperative that comes from what it is they're doing or even where they're situated let's make it really easy imagine a guy at the beach someone is hundreds of yards off from shore the wind has picked up and they're obviously flailing and drowning a very skilled swimmer very motivated rather heroic might strike out and attempt to save them let me add untrained however a lifeguard sitting in a chair spending most of his time just protecting his skin with sunblock sees that and has an obligation that's a duty of station and you would immediately judge that lifeguard good bad appropriate inappropriate responsible irresponsible by what the lifeguard did in that situation that's their job so one of the questions to think about is what are the duties and obligations that go with being a physician and that's something that we're gonna think about for the next remaining time you know some special ones you know that the duty of station for a priest in Catholicism is to listen to everyone who wishes to confess to keep that information confidential and to grant absolution that goes with the territory if a priest declined to do that in many ways they wouldn't fully be a priest they wouldn't be a virtuous priest by this definition we never really have had much of a discussion in America about what are the constitutive duties that go with being a physician so that pretty much summarizes what we've had to say and I think what I'm gonna share now is what our organizations have had to say about our duties and remember what I said they're usually phrased in terms of rules and they take a lot of account of things like law and policy so the first one I'm only gonna show you a few the first of these is that it's actually your job to respect the law but also your responsibility to seek some changes in the law which might be contrary to the best interests of a patient so obviously in that one rule you have two things going on you have kind of an allegiance or an obligation to patients but similarly an obligation to the law so there is a problem for you if you're living in a situation where the law is not what's best for the patient what in fact should you be doing you must follow the law that's the first part but how does that feel if you're following a law which you believe is not best for the patients you serve the next one is that in providing care and notice this one except in emergencies I need to let you know that was written after the mtala act was in place so even though it doesn't specify a law here law is looming very large in the background except in emergencies be free to choose whom to serve so that's actually also a really fascinating and very American kind of codification of the idea of independence liberty and autonomy but it's fair to ask whether that comports with the obligation of a physician you go very early way back third century BC to Hippocrates you really don't have that idea of being free to choose the idea there was if they were sick and they came to you or even you went to them the obligation was to treat so it's a very large obligation but in a very different world with very little to offer and very little that was so expensive so I think worth remembering that one the next one is a physician should recognize a responsibility to do things that lead to the improvement of the community and the betterment of public health so it's a little soft in the sense you should recognize the responsibility they stayed away from words like you should or even you must but I think that's an important thing to think about that our larger umbrella organization thinks that we should be at least looking I'll use a visual looking at what's going on that might improve the community and then finally and this is the most recent addition of physicians shall support access to medical care for all people so again that's actually a response to things that were happening in the country the Medicare Medicaid bill the mtala bill and it preceded the affordable care act but try to think carefully now as you know about policy that access was supported by the mtala act more people literally could get in and stay in emergency rooms in hospitals than before the act but it didn't handle how that would be paid so as you think about access you now have to think about it in a complex way it not only means ability to get through the door but it has to have a strategy for how that is supported your own academy it's in its kind of preface to the code of ethics says that an issue of ethics I presume they mean a problem or a dilemma and ophthalmology is resolved by the determination that the best interests of patients are served so there's a theme through medical ethics historically and in very recent times it's very clear that we give at least verbal attention to the best interests of patients what's not as clear as how you wrestle with the best interests of patients and your own best interests or the institution's best interest or maybe even the best interests of the country if you think about it fixing everything might take more than what we have might be best but if you can't do it all there are some people that won't be fixed so best interest is pretty complicated it's the best interest of whom when and how what it does say more specifically is that your services and please notice there is nothing here about an obligation to treat people who cannot pay but it says the services must be given with compassion respect for dignity honesty and integrity and the closest it comes to talking about what you charge or what you receive is that fees must not exploit patients or others and then it like the American Medical Association says there's also a community responsibility to improve the health and well-being of the patient and it adds in a cost effective way which I think is fine and I think you should be thinking about that when you think about policy thinking about policy from just our perspective making people healthy ignores the fact for example could we do it the same at the same quality but for less money or if we do this what is it that we're giving up that's actually what your congressman have to face and what any president will have to face so as you're thinking about policy you want to be thinking about arguments that you would make that would make preventing visual impairment improving it treating it etc. why is that important and why might that be more important than some of the other things that will be competing for public support in in this special issue of seminars and ophthalmology I think I saw the farthest reach for ophthalmology that is most of the things I read obviously I don't read what you do but reviews are about the progress that's made in a new drug or technical treatment or a diagnosis this is a focus on who has the eye disease and what should be done so you can see what I highlighted eliminating first of all that's a really strong word in my field that's we use that word because we've eliminated smallpox we've almost eliminated polio and I'm talking now in a frame that you understand I'm talking about around the world this is for our country that we're talking about today or for your state or for your community but eliminating is a very strong word right and for an individual practitioner that's a huge responsibility so if you want to think about eliminating you obviously have to think about how do we do this I mean I can't do this alone so what do I engage eliminating racial sex and gender and regional variations in health disease and outcomes as a stated goal of the Institute of Medicine the National Institutes of Health and at least during the Obama administration the US government and that could come back again it could be a goal to eliminate a certain disease we had that goal with measles I just share with you from my field it's the same problem I'm talking to you about we made a lot of progress and we're slipping back but policy and law will help us to get back to where we were so there's this new initiative called iris right intelligent research in sight the field of ophthalmology this obviously your field and I was excited to see that is in a position to take a more quantitative look at disparities in outcomes and we've talked before about AI and big data that will also help you if you choose to to take a patient centered by that I mean designing your treatments that acknowledge why people are not coming to you or what beliefs they have that are impeding their seeking of care or maybe following good regiments so that you could take a patient-centered approach to patient perceptions of unmapped access and disparities so here's the questions that can kind of frame on what of me is going to say I'm going to ask you actually to maybe raise your hands and then I might ask some of you to give a reason so here are three choices three things that I'll ask you to raise your hands about a is to prevent preventable visual impairment in some people the key word here some and if we have a minute we'll ask well who are the people you're going to prevent it in and how will you do that be is the same thing prevent that kind of preventable impairment but in most people and the third one is in all and so let's go back to that ambitious goal right which is kind of complete right do you want to be complete so thinking about yourselves and if you wish thinking about your larger community of ophthalmologists so for the academics you can be thinking about the private practice community private practitioners can think about that if you wish you can think about the public health that's available in our state so that's the frame how many of you believe that the duty we're back to duties of station that it is your duty to prevent visual impairment in some people okay you want to keep that in mind and you want to keep in mind what you are doing right and Avni is going to tell you that that is the data show that you prevented in some most or all but you're telling me you don't think your duty is to prevent it in some let's try the next one is that your duty to prevent the preventable in most people this is very striking and Avni and I didn't know but do I have someone that would take that position well sure look I have two so let me start with Jeff and then go behind you well I think I'm just I mean we're we're trying to do but you can't do everything that's I think so that's why I'm kind of not going for C so first a very logical answer and very defensible and it's just true that you can't do everything I just tell you I accept that now keep thinking about the lifeguard so what's the lifeguard's duty and let's all acknowledge that he can't do the impossible right this is pretty clear on a day when seven people are drowning each of them a hundred yards from the other right there's almost no way one life there's I'm sure there's no way that one lifeguard could save all seven was it his duty yes actually it was but we understand why he failed in that duty so that's a pretty straightforward one and it does it helps you really get into that you know what the duty is now but you know that having a duty doesn't make you able to do it all the time so if there was one person drowning and he didn't go we're pretty clear right the reason we're upset is that it was his duty and he could have done it so let me that's really helpful Paul Jeff I think in a way depending on the scale you're looking at their position level what you can do and some and and so on and so forth depending on how far you expand that so I think it really depends on what the question is duties of all collective ophthalmologists in our state versus in our practice in our community or in your one person practice so again I were you able to hear Jeff's point his point is that they're all true at the level of performability that is it just begins with the truth that Paul pointed out no one doc can do it all but then it's a question for you about this idea of duties of station for example there could be more than one lifeguard on the beach if there were two they would be able to do more and they would be the two people with that responsibility so one of the questions for you to think about is is this in fact inherent in being an ophthalmologist if you're at Moran and you have a large faculty all around you with different skills obviously you do as much as you can but you probably feel good if you're looking at these that your colleagues are amplifying that so together you're doing more I'm kind of inviting you I think to think that way to to really take that on that you it's a large community of ophthalmologists and actually growing right it's actually one of the fields it's very attractive to young physicians so a growing field and so think about it in terms of just duty right and the duties could be fine that is for a plumber for example I don't think any plumber feels that it's plumber's job to fix the pipes in everybody's home I don't think we think about that I think we think of that as a trade or a craft and we think he should do a good job for the people that pay him to do it so we don't condemn the universe of plumbers for coming up short but I think we haven't thought that way about ophthalmologists okay I'm up to three how many of you think that it's the duty that's the word we're using of ophthalmologists to prevent preventable impairment in all people I have a lot of abstainers if you abstained just raise your hand on this one if you agree then I'll ask you about the other so here's what I saw I didn't see hands before I saw some hands here when I asked the abstainers I saw more but I want to give the abstainers another choice I don't have a right answer for this it's a question does anybody want to raise their hand for A or B actually Paul explained his reasons for that and we have that clear it not being able to do it personally is not a reason to you know choose right it's what you believe does anyone believe that the duty of ophthalmologists is less than preventing all preventable disease well that's this is important for you to know and Avni is going to tell you what's undone and then you'll have to come back and talk about strategies obviously none of us expect any one of you to go out and do all of this all right the how is going to be very important for you and also which ophthalmologists have which obligation um here are three quick scenarios and this is my next the last slide so Medicare has a medical and a patient Medicare patient has an indication for cataract surgery and Medicare I was liberal here pays less than half of the usual charge for cash patients so here's another ABC for you and another choice so A is proceed do the procedure and accept Medicare's payment B is proceed and bill the patient for the balance C is tell the patient you're cash only sorry and D is actually checked with administrators and we have one here so that pretty clear it's about somebody where insurance is going to give you less than what you would get if you were taking care of another full-pay patient and those are your choices how many of you would proceed and accept the payment that's a and again don't abstain but vote for each one so that's a maybe a third something like that how many of you would proceed and build a patient for balance so it's great so someone said it's illegal and Brent is here and he knows that but I just want to show you what an interesting thing that that might be your choice but your choice is constrained by law remember we talk about law policy etc so here's a case where the law tells you you might want to do that but if you do there are consequences see tell the patient you are cash only can you do that are there some private practice talks here first of all you can so and Brent is helping so again some constraints you can do that but you would it's interesting if you're a cataract surgeon you're giving up an awful lot of people that have the disorder you can treat and the payer that will pay you but some communities would have plenty of older people with cataracts who could pay cash so that's an option um let's see check with administration do you need to and if you're at Moran I'm guessing that this is literally habitual right that you do this pretty much every day and so you no longer need to check and if you did check about balance billing administration would tell you you can't do that okay second one this is an emergency an ER doc asks you to see an uninsured patient with an eye injury do you refuse see them repair and don't bill see them repair them bill and send that to collections or check with administration how many of you would refuse to see this patient so once again we're constrained by law by the way just so you know the answer to that was not infrequent before mtala so I mean that was real it was a choice that some I don't know data about ophthalmologists I will tell you that surgeons declined to treat trauma patients before mtala was in place so it really does happen uh did happen be uh see them and repair them but don't bill them does that sound good would any of you do that Brent what about that one no why because our obligation is to bill the collection is different so by the way for any of you that have practiced for a long time seeing a patient and not billing was not unusual that was something that doctors did it's worth remembering that is some doctors thought it was their obligation to do charity care or care they knew wouldn't be reimbursed and they didn't generate a bill that's actually illegal if you accept Medicare funding fair enough uh see that was that one check with administration so I think most of you would take care of that patient and you would be obliged to bill the last one is something that company is going to talk more about your local physician refers an uninsured non-medicare eligible 59 year old Hispanic diabetic with cataracts AMD for indicated treatment on this one would some of you decline to see the patient no would you proceed but not bill we don't need to repeat that you know you can't do that proceed and bill that's actually probably what most of you would do tell me if I'm wrong on any of these and then finally check with administration do you have any questions about this one that an administrator could answer do you think you know what the law requires you to do it's not an emergency that's really important Brett can you tell them what the legal choices might be here well legally let's look at the patient Hispanic diabetic with cataracts and AMD the definition of stable is not in jeopardy of life of them imminently I don't think so stable that was their obligation do they need to do anything else not for the law okay yeah let's talk about that but did everyone hear the question was that wonderful question about policy what if the patient was an illegal immigrant so I showed you president Reagan signing Mtala do any of you know what Mtala says about whether someone is a citizen or not remember it says a lot about emergently ill a medical condition that is not stable and the obligation is to get as far as stability what about an illegal or undocumented individual ideas Brett do you know go ahead I think it's silent to the okay so it's silent but it says there's an obligation and legal analysis has said regardless of citizenship so just so you know that's again unfunded and not likely to be funded because Brett and his team for your other unfunded patients will try to find help for Medicaid other sources etc you're not going to find that for an undocumented the obligation against the obligation imposed on us not by us but it's there so in this one you could decline the 59 year old Hispanic individual within the law I'm going to leave it for you to decide whether that's appropriate inappropriate whether you have a duty to that person let's leave the law aside for a while think about that Dr. Jacobson this is yeah could I add one point so we think about Mtala usually about emergency departments but we have a triage clinic here and Mtala is actually broader than just emergency departments and it also if you put yourself out as someone who receives emergency care and we are very close to that line with our triage center and so from our institutional standpoint we look at our own triage center as needing to comply with Mtala just like we would the emergency room and I think what again I hope you heard Brett and as you picture yourself more like an emergency room publicly available skilled provider for certain conditions you're kind of holding up the sign that says if you have this we're here for you the key issue is if you have this emergency we're here for you so that's really really helpful I kind of frame for you what Avni will fill in and she's going to start with this which is kind of our first look at how are we doing if the goal or obligation was to take care of all preventable disease and prevent it this is the reality Avni you want to pick up so thank you Dr. Jacobson for that awesome introduction to this topic I'm Avni Shah I'm the global fellow for those of you that don't know me like Dr. Petty said it might be because I've been abroad for most of the year but it's been really fun coming home and looking introspectively at what we've been doing in Utah especially for this talk so you know like Dr. Jacobson said this is kind of moving now in the direction of now that we've established these are the current policies we feel our obligation is this how are we performing under the current policies and how are we performing relative to what we think our obligations are and who's getting missed specifically and how do we reach them and so I want you to kind of think about this you know in the framework of what is our obligation but does it matter are we thinking regionally are we thinking here just at Moran is our obligation extend to the state of Utah does it extend to the country and you know we also work internationally so sort of what what framework for that obligation and then does it matter if the patient that comes to us as a U.S. citizen does it matter if that patient seeks care actively or not so those are just some things to think about as we go through so these are just some statistics basically about the U.S. and how we're doing in general 20 or sorry 12 million people over the age of 40 have vision impairment 1 million are blind 8 million have uncorrected refractive error and the amount of people experiencing blindness and visual impairment will double by 2030 the annual economic impact and this is really important here is more than 145 billion dollars in the U.S. and so that includes both what the cost is and also what we're losing by those patients not being in the workforce by others taking care of them and not able to contribute and half of 61 million high risk adult Americans did not seek care in the last year and that major reasons are due to lack of awareness costs and lack of health insurance so this is from the IAPB global vision atlas this is actually a really helpful resource looking at prevalence of blindness and visual impairment across the world and this map is specifically looking at moderate severe visual impairment which is defined as 2060 to 2400 and you can see the U.S. compared to the rest of the world is doing pretty well we're in that lowest category of zero to five percent but kind of just barely it's at about 4.6 percent for this particular category and the best country I could find was France at around three and a half percent and then for blindness it's another 0.6 percent or so prevalence in the U.S. with the best country being Iceland at about 0.3 percent within North America these are the reasons for moderate or severe visual impairment you could see almost half or more than half of that is uncorrected refractive error also cataract and D diabetic retinopathy and this is the proportion that's preventable or curable so that's pretty striking when we think about you know what we're doing in our own country and then a lot of people have seen these this is sort of risk factors definitely race is one of them and black Americans tend to have higher prevalence rates of blindness by most age groups until you get into the very elderly can you go back for a second so male female just the scale is different on the two and women have higher rates of I mean you may get to this but blindness and visual impairment consistently are you going to be addressing just question was it a question just gendered yeah yeah so I'm not really going to talk about why that is we can talk about that as part of the discussion but yeah that has been consistent in my research as well and this I thought was pretty striking to me so this is looking at the causes of blindness by race and you can see here for for white patients you know and D is more than half other whatever that sort of nebulous category is this is cataract glaucoma diabetic retinopathy things that we say are definitely preventable or curable it's this smaller wedge of the pie whereas when you look at black patients it's almost two-thirds or more and Hispanic patients it's more than half so just kind of thinking about who's at risk and you know what we can do those patients really have more proportion of preventable or curable disease than white patients in our higher risk this map shows the moderate or severe visual impairment not correctable with refractive error correction and it's comparing each individual state so the proportion here in utah is 1.8 percent this is 1.8 per hundred patients that have moderate or severe visual impairment and it's actually one of the best in the country so it was in the top three and then we're looking ahead at 2050 so this is 2015 and you see that all of the states get worse and utah goes to about 2.8 percent and this is for blindness here and again utah 0.56 percent that's again in the top three and it's actually the best in the lower 48 states so not too bad in comparison and of course getting worse as well in 2050 and here is kind of this male and female breakdown here as well that Dr. Petty was talking about that in almost all these categories you see higher prevalence of these you know reasons for visual impairment and blindness in utah but that's also in the entire country as well here by race and kind of what I want to highlight here is the cost of vision problems just here in utah is one billion dollars so when we think about our moral obligation and our professional obligation there's also this economic component as well that we have to keep in mind so looking at this you know and thinking about the fact that a lot of people raise their hand to say that we need to be preventing all visual impairment that it's preventable who's not being served in utah and sort of what should our targets be the system has historically been set up to most care for white wealthy and working patients and I would add urban to this especially in this state where there are a lot of very very rural patients and the patients that aren't really getting the care are patients that don't have good physical access to care based on locations of clinic transportation issues minority race lower socioeconomic status lack of insurance these are all common things that most of us know and so this map shows the percentage of people 18 or older with severe vision lost by county and this is self reported based on a survey do you have a lot of difficulty seeing even with glasses on so this is actually really helpful and here's utah here and you can see that the darker blue is the higher prevalence and you can see where exactly we have the most problem here and this is sort of a blown-up version of this looking at adults over the age of 40 you can see these southern counties here as well as here is sort of where we have the most unmet need and where we might want to focus if we think about moving ahead of course this is San Juan County and the Navajo nation is right over here and we do work there and this is an interesting map so it's taking the first map and it's super imposing family income below the poverty level and so this is areas where these counties are both in the top quartile for severe vision loss in the bottom quartile for socioeconomic status for income and San Juan County is one of those and this is actually this map was completed in 2013 which is the same time that we started working in Navajo unfortunately there's not good data of this kind that's been published since then to really know if there's a change that we see in that county specifically so looking at race you know more than 50 percent American Indian in this county there and then this is just showing uninsured patients in the rural county specifically and you can see between 10 and 20 percent uninsured in these rural counties this is a map showing a location of optometrists darker green is more optometrists white means no data can we extrapolate that that means there are less or no optometrists maybe i'm not sure but helpful data to know and then specifically for children so um overall we think between one and five percent of preschool age children have vision impairment but that's more than five percent when you look specifically at African American or Hispanic preschoolers and this is the the number of preschool aged children with visual impairment by race and you can see over time this Hispanic white is going up pretty much every race is going up except non-Hispanic white this is again preschool age children prevalence of visual impairment and this is per thousand so it's not 11 percent it's really one percent here's how utah is doing relative to the rest of the country and it is projected to go up this is the state policy for vision screening in children basically all it says is that when a child enters the utah public school system they need a document saying that they've had one eye exam by a physician optometrist or other health professional and that they don't have any visual problem and there's no law about continuing vision screenings throughout school that sort of left up to the schools and then last thing here being a member of family who lives below the federal poverty level nearly doubles the likelihood that a child will be visually impaired compared with children whose income is greater than 200 percent so that sort of brings us to you know now we we know the scope of the problem in utah we know who remains to be served and we want to serve everyone that's what we all raised our hands to say so what are we doing here at the Moran for patients that that we see here how are we a safety net hospital for patients that can't pay and then we'll talk about what we're doing in terms of outreach and so kind of touching on some of the questions that Dr Jacobson had and we're lucky to have Brent and Matt Bow here to help us sort of navigate what our policies are specifically because this is our financial assistance policy which is a little bit vague it does talk about only emergency or medically necessary care so not elective cases like cataract surgery it says we use a sliding scale for assistance based on income no patients over 300 percent of the federal poverty level are eligible for this program and these are the things you have to submit and the hospital CFO or medical director has the authority to approve or deny but it doesn't really lay out exactly who will be covered by this policy who won't and how we decide these things and i think this is important for us specifically as physicians at the Moran because when we have that patient sitting in our chair and we want to give them the right expectation for what we think we'd like to do for them and what their financial obligation is going to be it's important for us to have a sense of of what that'll be and who will be covered and how by these type of policies question Brent I know you need to leave before you step away can you comment on that policy and the prioritization of Utah citizens versus out of state versus non-us citizens in the past it used to be that you we we had to be domiciled in the state of Utah really to get access to the University of Utah's charity care fund if you will that's not the case anymore now it's just based on federal poverty level and a percentage of that and there's actually more detail behind this and Matt can speak to that after I leave but I think an interesting point to as you look at you know how you prioritize all of this is last year the University hospital spent $118 million in charity care activities you think I don't know what their top dollar is I think it's like 1.2 billion or so but if you do the math there you're looking almost 10% of that that top dollar went into some charity care kind of activity and so that's what the University hospital is doing in the community outside of what we do in outreach and here at Moran we had over a million dollars of costs that went to charity care not counting what goes into our specific outreach division and so you know not quite you know 10% you know it's less than 5% for us but in terms of scale you know that's what we are doing for using our resources for for charity care can I just ask a cross question to Brent if Utah had passed the expansion to Medicaid what effect do you think that would have had on the budget you just described it would have definitely it would have reduced the charity care contribution for for you have all of the examples what part of it might go in or what proportion then yeah I don't have okay that's fine yeah interestingly though is that when when when you know the Obamacare Act was implemented that we actually had more access to patients so we did at that point we had a drop in our charity care contributions so thank you and if you could maybe sort of clarify for us in these particular situations which are all different and these are patients that are here showed up to our clinic you know or in an attendance clinic you know one patient has neovascular glaucoma needs an emergency tube a patient who just came in with a symptomatic complaint is getting an exam getting a facility fee in a clinic might need a diagnostic procedure or a patient who's fine but would benefit from an elective surgery that could prevent or cure a blinding condition what is the process what are the options for these patients within the system that we have now here at the Moran at the U and kind of touch on what percent of patients that you know apply for this policy actually benefit and and who are those patients that benefit who decides medical necessity what's included any of those things if you could clarify for us it'd be great that's the best person to do that i just got more of a global view unfortunately i don't have specific tumor man but just this morning the numbers came from may 2018 to may 2019 university the patients that applied for this financial assistance policy was just over 5 000 people that had were approved for this assistance either full charity or partial was just over 4 000 so about 80 percent of those who apply go through this process are approved and i was actually relieved to see that number so high but then my mind went immediately to well what about the other 20 percent what happened and i don't have the data immediately available right now to why you know what happened to the other 20 percent was it incomplete you know applications or you know why were they denied but i like i said i was i was pleasantly surprised to see you know that 80 percent and the key take home message i think from me is we should be putting them through this process as soon as possible we have in-house patient financial advocates we're fortunate to have that at the moran not all organizations departments have that in-house and so when you come across these patients who could benefit from this financial assistance policy the best thing to do is is set up an appointment with that patient financial advocate so they can help the patient get started on this process the sooner the better because once they're approved they're approved for a six-month time period it is a little backwards in the sense that it's retroactive so they have to have a claim out in order to be approved but it can't be retroactive going back to that first if the application is complete so Matt just to be clear they can't get the answer of how much will be covered before it's done correct they have to have it done and then and then just one other question elective cataract surgery through this mechanism is never rarely ever approved i don't have a direct answer to that is my understanding that that because it's an elective kind of purely elective procedure regardless of vision that this is not a mechanism that they have ever forgiven for cataract surgery after the fact or a portion of it do you know how much of that figure that Brent quoted is attributable to patients that have gone through this process as opposed to people who just obtained care and then decided not to pay for it i don't i know that specific to maran i don't know i don't have the number of people who apply for financial assistance through this program specific to maran but i do have a number who are approved and that's 270 patients in that year but i don't i don't have that broken down by that million dollars okay so thank you so much for that that's very helpful um so now sort of moving outside of you know the immediate maran premise and moving to what are we doing as an institution in our local community we do have these community clinics many of you know about we have a homeless clinic refugee clinic a couple times a year the fourth street of Malie and and people's health clinics where we go monthly um these are the the number of patient visits in 2018 um and just for reference based estimates based on other sources these are the amount of uninsured in these counties and the amount uh that would have severe visual impairment so we can kind of look at those numbers and who we're getting out to see and the Navajo Nation um we work down here so there's a very very small part of the Navajo Nation here in Utah and actually only 7,000 of the 170,000 Navajo patients are here in Utah but we do see patients from the entire Navajo Nation in 2018 these are the numbers in terms of patient visits surgeries procedures glasses um i will mention there is an optometrist who serves that area Dr. Kirk who we've been working closely with so even when we're not there there is follow-up care happening and there will be um optical shop opening down there and training for the optical staff um upcoming um operations site we do this twice a day charity surgery day most of us know about this these are specifically for patients that are referred from these community clinics um and are not otherwise eligible for insurance or discounts so the first thing we do when these patients come is make sure that they can't benefit from Medicaid or or the financial assistance policy and if they can't they get put on a list um sometimes they do wait up to nine months for surgery just because these this is twice a year that this happens uh last calendar year we have 51 patients and that's at Moran as well as at some of our partners in the community that did some of these surgeries as well they were all FACO surgeries one makes surgery and from what i understand that's sort of the policy for these surgeries is that they have to be a topical case so how is this set up um normally happens on a Saturday the staff donate their time industry their Alcon or AMO will donate the consumables for the surgery either there's no facility fee generated or it's generated and written off and maybe you can clarify that for me um outreach actually will buy medications in bulk and um A.S.C.R.S foundation will pay um a small sum per patient back to outreach and just to get a sense for an entire charity surgery day we did 30 patients the cost of all of the medications that outreach bought directly from the pharmacy and then gave back to the patients was $217 so not not really very much so it it works well um can you comment on the facility fee okay okay um and so i wanted to take just a little bit of a look at other programs around the country and obviously this is just brief um and i talked to other people that have come from other institutions about their experiences so here are two examples this is Henry Ford um University of Miami these are their financial assistance policies they're a little more direct than ours is in terms of exactly who's going to be covered and who's not they both do also mention medical necessity and emergency and so it's a little bit less clear what they'll do for an elective case like a cataract surgery um and so you can see this is income less than 250 percent of the federal poverty level for 100 percent um discount and then if it's above that they may qualify for a 30 uh for medical debt being reduced to 30 percent of household income which is still quite a bit um this is University of Miami they'll give full assistance to patients that qualify up to 400 percent of the federal poverty level and this all just depends on sort of local funds and politics and policies at the U where i did my residency it's actually quite bad so this is what they have on the website very very vague if you think you can't pay talk to a financial counselor there's no other information about who would be covered by a financial assistance policy and from working there uh there basically is no safety net for patients in Aurora County at the University Hospital and it's a problem um this is a dark myth something they've done to try and access their rural populations that they found weren't coming in for care um they basically sent medical students out to community clinics and some rural communities they trained them how to do a basic screening and then they referred the patients um back to uh dark myth essentially to be seen and they did pretty well so 72 percent of the patients they saw were referred most of them attended their appointments 88 percent had abnormal findings although some of these include things like glaucoma suspect ambliopia um basically they were given free care for their first visit they were given a $50 voucher for glasses the question then being for you know these glaucoma suspects and other patients you know what's done for them long term after this one visit hard to tell um but they said you know the patients hadn't sought eye care for about seven years before that so it's at least getting people plugged in and that's how they sort of dealt with their the problem of rural patients not being able to access care so you know in in doing this research and looking around and talking to people what i've concluded is that we're actually doing quite well here at the University of Utah in terms of what we're able to achieve for our patients here what we're able to do in our communities um and that's and that's hugely important and that's do a no small part to everyone's efforts um along the way over the last several years to get to where we are now um and as you know an institution where one of our core missions is outreach and we all raised our hand saying we want to prevent all preventable blindness and as leaders in this field you know we should really ask can we raise the bar even higher could we do better should we do better what does that look like and what are our barriers to achieving that vision and that's sort of where we're going to go from here these are some of the things that i could think of and we'll open up the discussion and talk about other barriers or how to kind of get past these obviously there's geographical issues here cultural issues you know there's some sort of a funding cap for indigent care even here at the university we can't pay for everyone to do everything human resources you know there are some places where residents will do a satellite rural rotation where they'll go out into a rural area for a few months and they'll see patients there or a couple once or twice a week something like that and they'll sort of refer patients back to the main site you know a medical student screening clinic kind of like what dartmouth did and then institutional and regular regulatory barriers which can be a big one you know do we need to negotiate on a different level with administration other departments here at the hospital and then where exactly should we focus and what should we target we need to be very targeted in our approach if we're going to try and expand this is something that was done in chicago they basically created a hotspot map for undiagnosed diabetic retinopathy so you know they used patients that came into the clinic based on where they came from their physical address and their demographic to then plot you know where areas that that have the most need in terms of diabetic retinopathy and so they now know exactly where to go and so that could be something that we could look into doing in Utah. Medicaid expansion did pass and so I just want to briefly touch on what that means this is where we are right now this is the bridge this will eventually expire and one of these plans will take effect this bridge means that we go up to the 100 percent federal poverty level and who's covered by Medicaid but it is otherwise a bit restrictive and what Utah wants to pass permanently is this per capita cap it has to be approved by the federal government first and this is also restrictive it's still only 100 percent of the federal poverty level there's these self-sufficiency work requirements there's caps and so it's not as expanded as some of the most expanded programs however if this waiver is not granted by the federal government and if this next slightly less restrictive plan is also not granted we will automatically go into full expansion and that's up to 138 percent of the federal poverty level and less restricted so that sort of will keep an eye out on what's to come with this here we'll treat an additional 70 to 90,000 patients in Utah and if we go to full expansion that's an additional 40,000 patients so where do we go from here this is my last slide and then I really want to open it up to discussion and Dr. Jacobson if you wouldn't mind moderating the beat excellent but this is just kind of you know some thoughts going forward and kind of everything we could think of here you know do we focus on areas with the high prevalence of blindness or high risk here in Utah and who's there and what are we seeing do we know exactly you know are there do we know where all the optometrists and ophthalmologists are can we ask them what do they see in their clinics and if we don't know should we do some type of screening survey is it mostly a refractive error cataract things that are easy to treat if there's a lot of diabetic retinopathy should we start setting up some telemedicine this idea of more operation site days or maybe integrating it into work days is something that's being discussed right now you know outreach right now with donor funded and you know do we need more funds directed towards things like this would that ultimately be a change in policy and that's sort of what we're getting back to and then this is kind of important too you know I think we have to take a step back and look at this from a public health perspective of is it worth it and and this idea of justice if we're going really really deeply into the rural community to find a couple patients and bust them all the way back to the Moran and treat them we'll feel good about what we did but are we using our resources wisely and I think the only way to know that is to really do some sort of a pilot study on the economic impact of doing something like that and so first of all thank you Avni and my hope is that some of that was valuable for you I certainly didn't know this level of detail about visual impairment in Utah and I think that everything that Avni shared was really helpful to me as I said right in the beginning if you have a better idea of the causes of a problem or a situation you have a much better opportunity to think about solutions the only thing that I want to add about the comments that Brett and Matt helped us out with is maybe the best examples there are the micro and macro vision for the most part charity within a hospital setting focuses on the patients who present and as Brett mentioned it's actually the ones who actually get treated so an interesting example there is you treat the ones you must for sure so the emergencies that show up do get treated and then the charity care is a way of addressing that unaddressed issue in the Reagan rule the mtala law so we got that the macro side is what proportion of any problem are you actually seeing that comes to the hospital I'll just tell you that for infectious disease for example we often use multipliers of one to ten or one to a hundred so in other words a good example currently you could think about a case of measles that comes to the hospital it's actually extraordinary it's around one in a thousand cases of measles that develop meningitis or encephalitis that child will go to the hospital but if I see a child with encephalitis due to measles that pretty much tells me there are thousand children that I haven't seen and I think that's again where ovni slides are really helpful to you that is even when you talk about the proportion of charity care that's given you want to keep those caveats in mind a lot of that is addressing you had a legal obligation to provide and the emergency was often the catalyst that brought let's just use the accident victim that's going to happen somebody injured it works seriously automobile accident they will be brought to you that's often not a volitional thing the bigger problem is actually volitional and what you want to remember is for elective disease people that are uninsured are actually unlikely to present they're unlikely to present for screening exams and a positive screening exam may leave them unlikely to present for treatment I'll just share that with you where I live as an internist a woman may not go for a screening mammogram because she's not insured if she finds the money to go for a mammogram and they find a tumor she may not go for surgery or for further treatment because it's going to be unfunded and it may not be provided again just back to this amtala rule if it's not an emergency people may not be under the obligation to do it and she will stay away so one of the things that Jeff asked Avni's research and some of mine getting ready helps to answer to the best of my knowledge I don't think we see the gender difference in children in terms of refractive errors etc but you asked about women it's adult women and so things to think about that are very peculiar in our country it's worth thinking about how they are in Iceland or countries with universal health care women have historically been less likely to be employed that actually means in our country less likely to be insured fair the next one is studies of Hispanic women in particular and on her slide the blue arrow pointing straight up with incidence increasing with age was in Hispanics it's more in Hispanic women than men couple of reasons from epidemiologic studies one is they're not so aware that conditions diagnosed early can be prevented secondly they have a prevalent cultural beliefs it's not all but more prevalent in that community that what happens is kind of faded that seeing doctors and doing things doesn't really change very much this was meant to be so that's a deterrent the next one is of course money and uninsured and many of them are in situations now where they're undocumented but their children are documented and they're extremely hesitant to even apply for insurance or show up at an emergency room or a clinic yet another deterrent the last one is within their culture they're very preoccupied with caring for others and less preoccupied with caring for themselves so those are some hurdles that you know they're all outside there are things that keep people from seeing you and I think Avni's example is a really interesting one of geographic targeting and then using low-cost individuals like mid-levels or medical students to do the screening that wouldn't otherwise happen but if you want it to follow through you need a program to provide the care so that's just introductory micro macro what do you all think now that you've kind of seen both what you're doing and what's undone about anything that you would want to see in policy either at your own hospital the state or the federal level that could make you feel better that is I was looking at numbers like in the tens or hundreds of thousands and interventions that are addressing hundreds or thousands so there's a big need out there what are your thoughts have you seen a program or a policy that you actually like or even you have a reason to dislike yeah on a policy level I mean I think a tax increase a sales tax increase pretty minimal that county voted on to approve and it goes into a public health trust that defunds uninsured or lower income patients and the lower income is actually fairly generous a lot of the residents and fellows actually qualified for it especially if they had one two or more children so it was actually much more encompassing than even Medicaid or Medicare for patients in the younger angel engines and it provided care at any of the county hospitals or facilities which included if they didn't have a specialty they would partner so that's how the University of Miami would become a partner of that county public health trust and it basically you could get I mean even though when they had to try to see treatment came out there was about $90,000 there was controversy in the county because patients could receive that as a part of it whereas there was fully insured patients you know who were unable to because insurances weren't willing to cover that $90,000 so it was a it was a pretty successful program and it was at a government or policy level was a democratic decision and it's a county program is that right yeah so that was the one buried world one of the barriers you run into was one you had to have some form of proof of residency so a totally illegal person without any paperwork was excluded but you didn't have to be a citizen and then anybody who lived outside the county wasn't included as well so those were the main barriers we faced as providers two minutes one minute one minute so thank do you know if that plan covered vision health I don't know if it included like refractive health but if you came through the ophthalmologist yes so right you we we provided full eye care vision care as a part of it and you would get a refraction as part of it so you get a normal eye exam for you but I don't think it covered the glasses for example some understanding so those are actually very very important points that you're making you also make a great point that even a geographic um political bounded area like a county can take an initiative and then thinking back to Avni slides that's actually a really interesting idea whether you go to a county it's not going to look good here at the county level because the disease is going to be in your poorest counties so it's going to be hard for the county to raise the funds to take care of the problem but it wouldn't be a problem for state government to allocate but only to one county the other thing I think you learned through this is you get a lot of bang for your buck it's actually kind of interesting um with some of the impairment which is as easy to correct as refraction the cost of improving vision could be very low and I think we need more studies to back up ovnis which actually show the other side what are the benefits that are gained from preventing blindness and improving vision and my guess is that you would be able to make a really strong case so that's a really lovely idea the other one I think we're going to be out of time is to think about either volunteerism or that language from your own code which was cost effective care there's so many things that you could be thinking doing think about the geographic so some sort of telemedicine outreach or volunteer students or or mid levels going to an area and then referring up would really be a good idea and wouldn't it be exciting to have Avni back in about five years and look at the data that she showed you now and just to feel like you're actually moving closer again we're all limited by possibility but there's no reason we couldn't move closer to doing a better job for the unmet need last comment I assume that's all written off do physicians here actually have the ability to wave our physicians freeze preemptively and if so how does that work and is there any ability for physicians to write off fees since the university is obviously benefiting from that financially what happens for a physician if you choose to do that case by case case so if we say we don't wave our feet it's not guaranteed correct we can't tell the patient that honestly yes and even that's been taken out of our hands directly in the building to do that you may think you're waving your fee when on the back end of fee is actually added and so that's why it actually needs to go up through administration to make sure that the patient doesn't receive this this bill so you may be telling them hey I'm not going to charge or on the back end it is through the documentation that bills be added so it's important to communicate those situations so it's actually a lovely thing to end up first let me thank you for your comment and your question as you're looking at policy or talking to a candidate something that you might want to consider is bringing up the issues that you think need to be corrected so for example that very question about could a physician's donation of services count as a charitable act that's allowable for many many other professions so it's something to talk about and you also want to think about the cost shift in that if it is allowable and you get a benefit back it means the government is taking on some cost for the care provided but i'll tell you the cost of a tax deduction might actually be a lot less for government than the cost of the full procedure so that's a clever idea please look for whether vision is covered in any policy that you look at and consider in a plan that's going to be a menu plan by the way oragon had that for their under and short it's like these services are covered and these are not i think you could make tremendous arguments that taking better care of vision is a cost effective choice thank you so very much for your time and attention