Two Discussion Question

Discussion Question 1

In the course text, read case 4 -1 on pages 98 (bottom) to 101. On page 102, what is your response to question #4? Justify your response.


In 1997, the Office of Minority Health (OMH) in the U.S. Department of Health and Human Services began work on national standards for culturally and linguistically competent health care. The stated goal was to help reduce health disparities. OMH published draft standards in December 1999 and solicited public comment through a variety of channels over a 4-month period. On December 22, 2000, it published the final standards. Although the standards are primarily directed at health care organizations, OMH encourages their use by individual providers as well as by policy makers, accreditation and credentialing agencies, purchasers, patients, advocates, educators, and the health care community in general (OMH, 2001).


Standard 1

Health care organizations (HCOs) should ensure that patients/consumers receive effective, understandable, and respectful care from all staff members that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2

HCOs should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

Standard 3

HCOs should ensure that staff members at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.


Standard 4

HCOs must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact in a timely manner during all hours of operation.

Standard 5

HCOs must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to received language assistance services.

Standard 6

HCOs must assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7

HCOs must make available easily understood patientrelated materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.


Standards 8–13 are guidelines for activities recommended by the Office of Minority Health for adoption as mandated by federal, state, and national accrediting agencies. Standard 14 is suggested for voluntary adoption by HCOs.

Standard 8

HCOs should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

Standard 9

HCOs should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.

Standard 10

HCOs should ensure that data on individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.

Standard 11

HCOs should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Standard 12

HCOs should develop participatory, collaborative partnerships with communities and use a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.

Standard 13

HCOs should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

Standard 14

HCOs are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information (OMH, 2001).

From page 102
What would you change about these regulations if you were in charge at the U.S. Department of Health and Human Services?

Discussion Question 2

In the course text, read case 6-1, pages 171 through 175. What is your response to question #5 on page 176?



Blue Ridge Paper Products, Inc. (BRPP) in Canton, NC is a paper company making predominantly food and beverage packaging. It was the largest employer left in Western North Carolina in 2006, with 1,300 covered employees in the state and 800 elsewhere. Started as a Champion Paper plant in 1908, it was purchased by the employees and their union (a United Steelworkers local) in May 1999 with the assistance of a venture capital firm and operates with an Employee Stock Ownership Plan (ESOP). To purchase it, the employees agreed to a 15% wage cut and frozen wages and benefits for seven years. From the buyout through the end of 2005, the company lost $92 million and paid out $107 million in health care claims. It became profitable in 2006. Maintaining health benefits for members and retirees is a very high priority item with the employees and the union, although retiree medical benefits have been eliminated for salaried employees hired after March 1, 2005.

BRPP employees are “predominantly male, over 48, with decades of services and several health risk factors. They work 12-hour, rotating shifts, making it extremely difficult to manage health conditions or improve lifestyle” (Blackley, 2006). The ESOP has worked hard to reduce its self-insured health care costs. Health insurance claims for 2006 had been estimated at $36 million, but appeared likely to hold near $24 million, which is still 75% above the 2000 experience. A volunteer Benefits Task Force of union and nonunion employees worked to redesign a complex benefit system. After two years of 18% health care cost increases, the rate of growth dropped to 2% in 2003. It was 5% in 2004 and a negative 3% in 2005.

Programs initiated in 2001 included a plan offering free diabetic medications and supplies in return for compliance and a tobacco cessation plan with cash rewards. In 2004, the company opened a full-service pharmacy and medical center with a pharmacist, internist, and nurses. In 2005, it began a Population Health Management program. Covered employees and spouses who completed a health risk assessment were rewarded with $100 and assigned a “personal nurse coach.” The nurse coach assists those who are ready to change to set individual health goals and choose from among one or more of 14 available health programs, which may include “cash rewards, waived or reduced co-pays on over 100 medications, free self-help medical aids/equipment, educational materials, etc.”

Where BRPP could not seem to make headway was with the prices paid to local providers. Community physicians refused deeper discounts. Even banding together in a buying cooperative with other companies could not move the local tertiary hospital to match discounts offered to regionally dominant insurers. This hospital was not distressed and had above-average operating margins.

Articles on “medical tourism” in the press and on television attracted the attention of benefits management. Reports were of high quality care at 80% or less of U.S. prices with good outcomes. BRPP contacted a company offering services at hospitals in India, IndUShealth in Raleigh, NC, and began working on a plan to make its services available to BRPP employees.


IndUShealth provides a complete package to its U.S. and Canadian clients, including access to Indian superspecialty hospitals that are Joint Commission International accredited and to specialists and supporting physicians with U.S. or U.K. board certification. It arranges for postoperative care in India and for travel, lodging, and meals for the patient and an accompanying family member—all for a single package price. For example, it represents the Wockhardt hospitals in India, which are Joint Commission International accredited and affiliated with Harvard Medical International. Other Indian hospitals boast affiliations with the Johns Hopkins Medical Center and the Cleveland Clinics.

Mitral Valve Replacement

One of the first cases considered was a mitral valve replacement. IndUShealth and BRPP sought package quotes from a number of domestic medical centers and could get only one estimate. That quote, from the University of Iowa academic medical center, was in the $68,000 to $98,000 range. The quote from India was for $18,000 including travel, food, and lodging for the patient and one companion. Testifying before the U.S. Senate Special Committee on Aging, Mr. Rajesh Rao, IndUShealth CEO, (2006) cited the following costs.


Typical U.S. Cost

India Cost

Heart bypass Surgery

$55,000 to $86,000



$33,000 to $49,000


Hip replacement

$31,000 to $44,000


Spinal fusion

$42,000 to $76,000



To encourage employee participation, BRPP prepared a DVD on its medical tourism initiative, which it called Global Health Coverage. It outlined the opportunities and described the Indian facilities and credentials. The next step was to be a trip by an employee “due diligence” committee to India to inspect facilities and talk with doctors. Then they would discuss how to handle the option in the next set of union negotiations.


On June 27, 2006, the U.S. Senate Special Committee on Aging held hearings entitled “The Globalization of Health Care: Can Medical Tourism Reduce Health Care Costs?” Both BRPP and IndUShealth presented together with others.

When testifying to the Senate subcommittee, Bonnie Grissom Blackley, benefits director for BRPP, concluded:

Should I need a surgical procedure, provide me and my spouse with an all expense-paid trip to a Joint Commission International-approved hospital, that compares to a 5-star hotel, a surgeon educated and credentialed in the U.S., no hospital staph infections, a registered nurse around the clock, no one pushing me out of the hospital after 2 or 3 days, a several-day recovery period at a beach resort, email access, cell phone, great food, touring, etc., etc. for 25% of the savings up to $10,000 and I won’t be able to get out my passport fast enough.


The test case under the new arrangement was a volunteer, Carl Garrett, a 60-year-old BRPP paper-making technician who needed a gall bladder removal and a shoulder repair. He reportedly was looking forward to the trip in September 2006, accompanied by his fiancée. A 40-year employee approaching retirement, he would be the first company-sponsored U.S. worker to receive health care in India. The two operations would have cost $100,000 in the United States but only $20,000 in India. The arrangement was that the company would pay for the entire thing, waive the 20% co-payment, give Garrett about a $10,000 incentive, and still save $50,000.

The United Steel Workers Union national office objected strongly to the whole idea, however, and threatened to file for an injunction. The local district representative commented, “We made it clear that if healthcare was going to be resolved, it would be resolved by modifying the system in the U.S., not by offshoring or exporting our own people.” USW President Leo Gerard said, “No U.S. citizen should be exposed to the risk involved in travel internationally for health care services” and sent a letter to members of Congress that included the following (Parks 2006):

Our members, along with thousands of unrepresented workers, are now being confronted with proposals to literally export themselves to have certain “expensive” medical procedures provided in India.

With companies now proposing to send their own American employees abroad for less expensive health care services, there can be no doubt that the U.S. health care system is in immediate need of massive reform

The right to safe, secure, and dependable health care in one’s own country should not be surrendered for any reason, certainly not to fatten the profit margins of corporate investors.

The union also cited the lack of comparable malpractice coverage in other countries. The company agreed to find a domestic source of care for Mr. Garrett, but may continue the experiment with its salaried, nonunion employees. Carl Garrett responded unhappily, “The company dropped the ball …. people have given me so much encouragement,” he said, “so much positive response, and they’re devastated. A lot of people were waiting for me to report back on how it went and perhaps go themselves. This leaves them in limbo too” (Jonsson, 2006, p. 2).

This is the Question from 176
How might state and national governments respond to this expanding phenomenon?

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