Instructions Texas Directive To Physicians And Family Or: Fill & Download for Free

Q. What jobs can I do with an MD without a residency? I want to take a year off before residency.A. NON CLINICAL DOCTORSJOBS FOR PHYSICIANS WITHOUT RESIDENCYCertification and training options for MD’s without residency training/ medical licenseThere are other health related jobs that that MDs can get with some additional training or certification. Most of these options cost money for course tuition and examination fees. Starting salaries for these jobs are generally lower than the starting salaries of residency trained physicians, but they can offer full time employment in the health care field and a stepping-stone to leadership positions and promotions and even entrepreneurial opportunities in the future.*Research is a competitive field that requires experience and completion of a post doctorate-training program. Most post doctorate-training programs will pay you a stipend while you train in a research lab. In general, they do not require residency and they are usually filled outside of the match.*Medical informatics is a growing field that is open to physicians. This field involves working with electronic medical records and implementation of technology. Find information about certification here.*Naturopathic medicine is an option that would allow you to see patients. Naturopathic medical practice requires a license. You can take courses and then sit for qualifying examinations. Find more information about licensure requirements here, about board requirements here and about educational programs here.*Lifestyle medicine is an option that incorporates working with patients on issues such as weight loss and addiction. Find information about courses and certification here.*Preventative medicine is an area that offers the opportunity to gain certification. Information can be found here.*Genetics counselors also see patients and are generally paid through patients’ insurance plans. Most large medical systems and academic hospitals have genetics counselors. Find more information about training, certification and licensing here.*Acupuncture is a field that would allow you to see patients and perform procedures. Find more information about certification and examinations here. More Information about eligibility requirements here.*Cosmetic enhancement with procedures such as botulinum toxin injection require training and certification. More information here.*Aesthetic medicine involves a variety of procedures that range from hair removal to fillers. Find information about licensing here.*Electrodiagnostic medicine technicians work in electrophysiology labs. Find information about eligibility here and learn more about the work of an electrodiagnostic technician, the training and certification process here.*Ultrasound technicians and lab directors need to obtain training, courses and certification. Information can be found here.*Sleep medicine is a post residency specialty, but there are also certifications for non MDs and non residency trained professionals. See eligibility requirements here.*Personal trainers work with people who need fitness counseling and coaching. Fitness trainers must take courses and obtain certification. Find more information here.Job options for MD's without residency trainingTechnical writing/scientific writingWriting is an option for physicians who want to work for pharmaceutical companies or medical media companies to write grants, clinical trials reports, basic science studies, applications for approval of new medical products and safety inserts, among other assignments. Writing should be impeccable and sometimes fluency in another language or translating capabilities are a plus.Medical editingMedical textbook publishers and medical journal publishers often employ writers and editors with a health background for copywriting and editing assignments. These jobs do not require residency training or a medical license.Pharmaceutical industryPharmaceutical companies have jobs for physicians who are not licensed or board certified. These jobs are in the areas of clinical trials, basic science research, product development, marketing, administration and finance.Pharmaceutical sales and pharmaceutical liaison positions generally do not require an MD and there are international medical graduates who find jobs in pharmaceutical sales or pharmaceutical liaison.BusinessFinancial firms that have investments in healthcare companies hire MD's to review and report on investments. These are generally full time jobs that require travel and can provide opportunities for executive level promotions.Health/medical instructionTeaching at the medical school or university level is another career path for physicians. Most science departments in research universities employ full time faculty primarily for research and allow limited time for teaching courses, with research as the primary focus.Researchers in major universities are usually required to obtain funding for research projects through grants. This requires research experience and proficiency with grants. Some colleges employ faculty for teaching jobs without a research obligation. Community colleges, nursing schools and chiropractic medicine schools are among the colleges that have full time and part time teaching positions for doctors without a research requirement.Non-clinical job options that are usually not open to MD’s without residency trainingBesides clinical practice, there are some non-clinical healthcare jobs that generally require a medical license or residency or board certification.They include :*Medical-legal work- usually requires clinical experience, licensing and board certification.*Health writing for the general public typically requires specialization and clinical experience in a prominent medical center.*Chart review jobs, including healthcare utilization review and disability review, require board certification.Of course, there are exceptions to every rule and there are numerous examples of physicians who have achieved exceptional success without residency training.For more instructions on how to find a non-clinical job, explore Nonclinicaldoctors.com or see Careers Beyond Clinical Medicine, available at most http://booksellers.To find links to companies and job websites, visit the useful links page.What if Clinical Medicine Is No Longer Rewarding?1. Move Into Hospital Administration2. Become a Physician Advisor at Your Hospital3. Start a Practice Management Consultancy4. Become a Career Coach5. Work With Computer Technology6. Review Insurance Claims7. Work at a Management Consulting Firm8. Become a Financial Planner9. Work for a Venture Capital Company10. Get Involved in Retail or Manufacturing11. Get a Job in the Pharma Sector12. Become a Physician Recruiter13. Become a Freelance Writer14. Produce CME Presentations15. Become a Teacher16. Start an 'Encore Career'ReferencesWhat if Clinical Medicine Is No Longer Rewarding?If you're thinking of quitting clinical medicine, you're not alone. A 2010 survey[1]by The Physicians Foundation found that 40% of doctors planned to drop out of patient care in the next 1-3 years, either by retiring or seeking a nonclinical job.Doctors who decide to stop seeing patients are usually glad they did -- and in many cases, they're earning as much money as they did in clinical medicine, according to Steve Babitsky. Babitsky is an attorney who runs SEAK Inc., a Falmouth, Massachusetts-based company that trains physicians, including those who want to switch careers."Most, if not all, of the doctors who switch to a nonclinical career are happier," Babitsky said, adding that replacing clinical income is easier than you might think. "Look at what you're earning per hour of work," he said. "You may be getting less than plumbers, electricians, and landscapers."As sobering as that may be, don't take a switch lightly. Finding a new career is a big decision that requires a lot of soul-searching, said Heather Fork, MD, a physician coach at Doctor's Crossing in Austin, Texas. When deciding, "it's important to create some space in one's busy life for something new to come in," she said.Dr. Fork added that in many nonclinical jobs, it's possible to continue clinical work on a part-time basis. Indeed, some jobs require keeping one foot in clinical medicine. Also, clinical assignments, such as working for a locum tenens agency, can provide extra income as you build up your new career, she said.Here are 16 options for second careers, but before we get to them, let's first examine what kinds of doctors switch careers -- and for what reasons.Who Switches, and Why?Doctors have different reasons for leaving clinical care, depending on the stage of their career, their gender, and their specialty.Joseph Kim, MD, who runs a Website for doctors called Nonclinical Jobs, said physicians tend to leave clinical medicine at distinct stages in their careers. In the first wave, a small group of young doctors leaves clinical medicine right after medical school or residency, or just when they start practicing.Dr. Kim is one of them. Graduating from an internal medicine residency, he realized that he didn't want to practice. He instead worked for a consumer health company and then for a continuing medical education (CME) company, MCM Education in Newtown, Pennsylvania, rising to his current position of president.Typically, these doctors didn't plan to leave medicine. "They don't tend to have an entrepreneurial interest," Dr. Kim said, "so they might go into medical writing, medical communications, or pharma at various levels."On the other hand, another group of newly minted doctors never intended to practice medicine at all. "They might get a dual MD/MBA degree, which has really flourished," Dr. Kim said. "They can be very ambitious and very driven, and are willing to put in long hours." These young doctors might focus on financial careers, such as consulting or raising venture capital.Most doctors who leave clinical medicine, however, do so in mid-career, when they're in their late 30s or 40s -- the second wave, if you will. "These physicians have been in practice for a number of years and are getting burned out. They tend to be very disenchanted about the changes in healthcare," Dr. Kim said. "They want to find greener grass. They might go into pharma, health insurance, managed care, or health resource utilization."But the transition into a new career can be very difficult. "They've spent much of their career practicing medicine and haven't been developing other skill sets," he said. "It's hard for these doctors to convince a prospective employer that they have something to offer besides being a clinician."A third group of doctors switches jobs at or near retirement age. In this case, "someone age 50 or 55 years decides to take on a completely different career," Dr. Kim said. This strategy, called an "encore career," involves something the physician may always have been interested in, such as painting or working outdoors. "This isn't the predominate trend, but it became bigger in the recession," he said.Career changing also differs by gender. Women are more likely to exit clinical medicine to deal with family responsibilities. They may work part-time or not at all while their children are young. When their children are older, however, they have a chance to rethink their careers and may choose a job outside of clinical practice. A study[2] by the American Medical Group Association found that 44% of female physicians were working part-time in 2011, twice the level of male physicians.No one has pinpointed which specialties change careers the most, but we do know which specialties report the most burnout, which is a factor in career changes. A 2013 Medscape survey[3]found that the highest incidence of burnout was among physicians in emergency medicine, critical care medicine, anesthesiology, and general surgery, as well as in all major primary care fields except pediatrics.Specialty can also be an impediment to career change. Primary care physicians with high medical-school debts and low practice income may be less willing to exit clinical care because they can't afford to lose the income. On the other hand, specialists with high incomes are likely to have a harder time finding nonclinical work that matches their current income.Despite the risks, however, plenty of doctors still decide to make the leap. Are you ready to consider something new? If so, here are the 16 options for second careers.1. Move Into Hospital AdministrationHospital administration is a long-standing option for physicians, and the opportunities are expanding as hospitals try to align more closely with their doctors. For a practicing physician who is no longer feeling challenged by patient care, here's a chance to make a big difference across a whole institution and still earn a good living.Although chief medical officer is the traditional role of physicians, more key positions are opening up. These include chief operations officer; chief integration officer; chief administration officer; and chief strategy, innovation, or transformation officer.Typically, any of these career paths first involves serving on hospital committees for a few years. Once appointed, you may be able to rise through the ranks. But you'll need to deal with business issues that you might not be familiar with, and you'll run the risk of having some colleagues who won't view you as one of them anymore.Philippa Kennealy, MD, became Chief Executive Officer (CEO) of UCLA Medical Center, Santa Monica, in California in the late 1990s. She took the traditional route -- serving on hospital committees in order to build her reputation. A practicing family physician, she initially volunteered for a committee because she wanted to help out after an earthquake hit the area. Then she began to relish the role. "I realized I was unhappy in my own practice," she said. "I decided there was a lot more that I could contribute in administration." She initially left her practice in 1996 to become Hospital Medical Director before later becoming CEO.Dr. Kennealy thinks her experience as a practicing doctor made her a better executive. "Another physician really does understand the physician's point of view," she said. On the other hand, "it's a tricky role, because there are physicians who think you've moved over to the dark side."There are many opportunities for administrators these days. Eight in 10 healthcare organizations have at least one doctor in senior management, according to a 2010 survey.[4]However, whereas multihospital health systems and academic medical centers were most likely to have several physicians at the top, more than one half of community hospitals did not have any physicians in key roles.As Dr. Kennealy has experienced, MD or DO leaders can bridge the gap between the administration and physicians, the hospital's most important resource. A 2011 survey[5] revealed that 56% of physicians on hospital staffs didn't trust the administration as partners because of a lack of physician leadership, and 50% cited too little communication with the administration.Physician leadership is linked to the more highly regarded hospitals. A 2011 research study[6] found that specialty hospitals headed by physicians rank about 25% higher on U.S. News and World Report's Best Hospital list than those run by nonphysicians.At many hospitals, however, you won't be able to stop practicing altogether. A 2011 survey[7] found that more than two thirds of physician executives at hospitals continue to see patients, even if it's only half a day per week, and more than one half said it was a job requirement.Pluses: This is a relatively easy transition, and the income is good.Minuses: Former colleagues may distrust you in your new role.2. Become a Physician Advisor at Your HospitalOne job in hospital administration that has seen a lot of growth recently is that of the physician advisor. The position involves working closely with doctors to improve documentation of hospital charges, as well as making sure they adhere to quality and safety regulations. You may also interface with Medicare's recovery audit contractors and other regulators.Once a part-time position for physicians nearing retirement, the physician advisor is now usually a full-time gig filled by doctors in mid-career. Dr. Heather Fork, the career coach, expects a lot of growth in this field. Although only one quarter of hospitals currently have the position, most will have it in the near future, she said. Growth is driven by the need for alignment with physicians, the shift to Accountable Care Organizations, and increasing use of performance data.Physician advisors are chosen from within the hospital staff; these folks have earned their colleagues' respect and understand evidence-based medicine. "The physician advisor is a clinical educator, diplomat, and tightrope walker," Dr. Fork said. "This role is only for a certain type of physician who is able to handle conflict and deal with different personality types."Bernard H. Ravitz, MD, has been physician advisor at the 300-bed MedStar Good Samaritan Hospital in Baltimore for 10 years. Beforehand, he had served as an emergency physician at the hospital for 15 years.A key part of his job is to monitor admissions. "If even one hospital day is denied, that means we're still caring for the beneficiary but not getting paid for the care we're providing," he said. Working closely with physicians, he sees himself as an educator, helping with documentation and offering feedback to reduce denials and improve care."You have to be able to get along with the medical staff," Dr. Ravitz said. "You have to have people skills."Dr. Ravitz was a speaker at the 11th Annual Physician Advisor Summit in March and is a founding member of the American College of Physician Advisors, which was launched in May. He said there are roughly 50-100 founding members out of hundreds of physicians in the field. The college plans to provide assistance to doctors interested in this career.Pluses: This is challenging work for those interested in evidence-based medicine.Minuses: You'll have to deal with pushback from physicians.3. Start a Practice Management ConsultancyThousands of physicians have started practice management consultancy firms, based on a skill they learned when they ran a practice, such as coding, claims processing, or practice efficiency. "This is good for people who are self-starters," Babitsky said.For example, David Zielske, MD, an interventional radiologist in Tennessee, founded a company that addressed the difficult coding requirements of his specialty. "The coding for interventional radiology is unusually complex and error-prone," he said, but he enjoyed the challenge. "I've always had a passion for coding."In 2000, Dr. Zielske took his coding skills and cofounded ZHealth in Brentwood, Tennessee, to help physicians and hospitals deal with interventional radiology coding. For a while, he operated out of his home and had to continue practicing for a few years to keep up his income. The transition was "a very expensive, long-term process," he said. "You can't just quit and think you can be successful right away."The company has prospered since then, branching out into coding for vascular and cardiac care, and Dr. Zielske has also written books, hosted webinars, and given speeches and seminars on coding.Some physicians who start consulting firms keep practicing medicine. For example, L. Neal Freeman, MD, a practicing ophthalmologist in Melbourne, Florida, is President of CPR Analysts, coding and physician reimbursement analysts.The work can build on basic skills learned in clinical care. "Consulting is like the problem-solving you do in medicine," Dr. Fork said. "You have to take a project from beginning to conclusion."Pluses: You can build on a skill you learned in running your practice.4. Become a Career CoachLots of physicians stay busy these days serving as career coaches for their colleagues. And considering the high percentage of doctors in The Physicians Foundation survey who reported that they wanted to change careers, demand for this new field may not yet be fully tapped.In addition to counseling on career change, coaches help physicians upgrade their current careers, brush up on their management skills, and develop new sources of income for their practices. They may work with clients one-on-one, speak to small groups, or give seminars and speeches.There are even courses and certification programs for career coaches, who can earn six figures once they've established themselves.Dr. Kennealy left her post as hospital CEO in 2002 to start her own coaching company in Los Angeles. First she taught leadership skills to physician executives, department chiefs, and medical staff presidents. Now, in a business called The Entrepreneurial MD, she coaches physicians who want to start their own business. "It was a natural fit for me, because it allowed me back into the helping relationship that I enjoyed when I practiced medicine," she said.Dr. Fork decided to become a career coach after leaving her dermatology practice in 2004, and Francine Gaillour, MD, has been working in the coaching field for 18 years. In the past five years, Dr. Gaillour has coached more than 300 physicians in one-on-one and group settings, as well as through teleseminars, according to her Website.In 2003, Dr. Gaillour founded the Physician Coaching Institute, which has graduated more than 50 certified physician development coaches, including Dr. Kennealy. Enrollees take a six-month program that includes 12 live training teleseminars, other coaching sessions, and modules on specific skills.Pluses: Demand for coaching is high, and the income can be good once you get established.Minuses: You'll have to work hard to build up a client base.5. Work With Computer TechnologyIf you have expertise in computer technology, you'll have a variety of careers to choose from, including advising an electronic medical record (EMR) company, working for a hospital, creating software applications, and perhaps even launching a technology start-up company.In the flawed launches of EMRs and other systems in hospitals, physicians have blamed non-MD chief information officers (CIOs) for not understanding their needs. As a result, hospitals have started hiring physicians as chief medical information officers (CMIOs). These doctors serve as a liaison to the medical staff and apply a clinician's insights into developing computer technology.The Health Information Management Systems Society (HIMSS) recently stated[8] that the number of physicians who reported working with a CMIO has almost doubled, from 22% in 2012 to 40% in 2013. "When you think about the physicians and CMIOs coming on, they bring in this culture [of] connectivity and analytics," Lorren Petit, Vice President of Market Research for HIMSS, told EHR Intelligence magazine.[9]A model for this approach is John D. Halamka, MD, who has been CIO at Beth Israel Deaconess Medical Center in Boston for many years. He also writes the Geek Doctor blog and puts in time practicing emergency medicine.Similarly, physicians can offer useful input into improving EMR design. A company called Modernizing Medicine, based in Boca Raton, Florida, seeks to bridge the gap between doctors and software engineers by teaching physicians computer coding and having them design specialty-specific EMRs. The physicians even go on the road to market their product, even as they continue to practice medicine.Beyond EMRs, physicians can play a role in developing a variety of new software applications, ranging from at-home patient monitoring to providing doctors with quick access to best practices. For example, Thomas Osborne, MD, a radiologist in Vista, California, has been reading scans for vRad, a large telemedicine company. Recently, he was named the company's medical director of informatics. To demonstrate his abilities and get the job, he did IT work and volunteered for a company project. "My successful involvement has in turn put me in a position to be involved in other areas of the rapidly expanding business," he said.Some physicians dropped out of medicine to work on software even before they completed their residency. Scott Zimmerman, MD, CEO of Xola Booking and Marketing System, a travel Website based in San Francisco, said he became interested in software coding while in medical school and left a neurology residency program at Stanford to devote himself full-time to the company."People told me I was crazy," he said. "I only had $10,000 in the bank and nearly $200,000 in student loans, with a six-figure salary just in reach." But the new company raised $2 million from several investors.Pluses: A variety of career paths are available to those who are computer-savvy.Minuses: Most physicians don't have a strong enough background for these jobs, and additional learning and experience would be required.6. Review Insurance ClaimsThere's a growing demand for physicians to help payers with utilization review (UR). "The health insurance industry is just booming right now," said Steve Babitsky, citing the mandate under the Affordable Care Act requiring all Americans to have coverage.Although some physicians may view this as working for the wrong side, it's "actually a chance to do good," Dr. Fork said. "Your role has to do with stopping overuse of services within the healthcare system and helping to provide quality care for value."The advantages are that you can use your diagnostic skills as a physician; you're often able to work out of your home; and, if you work full-time, it may be possible to make as much money as you did seeing patients, although many UR physicians work part-time.Heidi Moawad, MD, a neurologist in Cleveland, served for several years as a UR physician, working part-time out of her home while raising her young children. Working with a radiology review company that contracted with several health insurers, she dealt with preauthorization requests for radiology from fellow neurologists.Contrary to her trepidations going into the job, she felt under no pressure to deny payments and felt little resistance from the physicians whose requests she was reviewing. In fact, many of them would even ask for her guidance. "They would tell me, 'This is the story; what do you think?'" she recalled. "When I said the test was unnecessary, they were actually relieved." The job helped her get on the Practice Guidelines Committee of the American Academy of Neurology.When her kids got older, Dr. Moawad switched to a teaching job, but she looks back fondly on her UR career. However, she thinks UR physicians are now under increasing pressure to closely follow practice guidelines rather than follow their own reasoning.Amy E. Odgers, MD, an internist in Chicago, also switched from clinical practice to UR work. Initially she worked in a call center, handling physicians whose charges were being challenged. "At times, the work can be contentious," she said. "Doctors don't like to be questioned about why they're ordering tests."After 9 years of reviewing claims, she now has a new position at the same company, studying ways to improve workflow. Working just 20 hours a week, she said she doesn't make as much money as clinical care physicians, but she isn't in debt either. Plus, she has time to pursue gardening and ceramics. "I love the balance I have between work and other things," she said from a cell phone while in her garden.Pluses: Reviewing claims pays relatively well, and in many cases, you can work part-time from your home.Minuses: The work is becoming more and more regimented.7. Work at a Management Consulting FirmA management consulting company might be a good fit for ambitious physicians who like problem solving and working in teams, but expect to put in long hours and don't mind having to be away from home a lot.Many doctors work for such companies as Accenture, Boston Consulting Group, Deloitte, McKinsey & Company, and Milliman. The work involves making in-depth studies on behalf of clients that include hospitals, government, and insurers. Salaries at the top firms start at around $150,000, with the chance to earn raises each year.Consulting firms often recruit doctors directly out of medical school, but also hire them in mid-career. McKinsey has a Webpage to answer questions from physicians and other people with advanced degrees looking for jobs there.Dr. Fork said assignments can last months, during which consultants usually work on-site for most of the week. "In many cases, you're traveling four days a week and putting in long hours," she said. This makes it impossible to work in clinical practice even at a minimal level.In 2001, Michael P. Ennen, then a senior medical student who had accepted a position with McKinsey, wrote an article[10] about the career in JAMA. Physicians attracted to this work often cite a "fear of reaching a professional plateau," he wrote. They like "the challenge of continually working on new problems and shaping new industries as a source of professional satisfaction."He emphasized the need to adjust to a team approach. "To be successful, physicians must modify their expectations about their role in a hierarchy, their individual input, and the service being provided to clients," he wrote.Pluses: The work is challenging, and the pay is good.Minuses: You'll work long hours and travel a lot.8. Become a Financial PlannerPhysicians who are successful in financial planning can use some of the skills they honed as clinicians and attain previous earning levels, but building the business involves hard work over several years.Joel Greenwald, MD, was a practicing internist in the Minneapolis area for 11 years before switching to financial planning. "I was in my mid-30s, and I said to myself, 'I can't feel like this for 30 more years,'" he recalled. He was always interested in financial planning, which he says is a lot like practicing medicine: Clients come to him with problems; he asks questions, comes up with solutions, and develops a program for them.But the switch took years. First came the required classes and an exam to become a certified financial planner (CFP), which he completed while still in practice. Then he quit practicing to launch his new business, Greenwald Wealth Management. But during the first three years, he wasn't allowed to represent himself as a CFP and didn't have many customers.When he could finally hang his CFP shingle, Dr. Greenwald realized that his best clientele would be other physicians. Very focused on their work, they often don't have time to tend to their finances. "Free time away from your practice is a precious commodity," he said. And because of the MD after his name, Dr. Greenwald could gain their trust, which is necessary when handling someone else's money.Dr. Greenwald has worked hard to get new clients, writing articles on his new profession in major publications and speaking before physician groups. But even with all of the effort he's put into his second career, he thinks the work is a lot simpler than running a practice. "I serve 80 households of clients, and I have two employees," he said. "All I need to do is make them happy." Now that he has a busy practice, "I make more money than I would as a general internist," he said.Pluses: This path is a good fit for physicians who have financial skills, and in time you can potentially match your clinical income.Minuses: You need to have a knack for managing finances, and it takes years to establish the business.9. Work for a Venture Capital CompanyWant a chance to earn millions? Then take a closer look at a second career at a venture capital firm. There, you'll often find greater challenges and even greater risks, with a shot at a huge income if you succeed.In this line of work, physicians closely analyze start-up companies in healthcare -- in such areas as software, drugs, and medical devices -- and help determine whether the venture capital company should invest in them. The work is best suited for doctors with strong analytical skills, an aptitude for finances and statistics, and a willingness to take risks on largely untested start-ups.Companies are often looking for young physicians with MBA degrees, but they also hire physicians who have proven their chops as consultants. Doctors can work full-time directly for the venture capital company or be hired as a freelance consultant.Physicians even start their own venture capital companies. Marlene R. Krauss, MD, left an ophthalmology practice many years ago to start KBL Healthcare Ventures in Manhattan, after working for 8 years at an investment bank, according to the company Website.Dr. Fork said physicians consulting with venture capital firms earn $300-$500 per hour. Working directly for a firm pays about $150,000 a year for entry-level positions, whereas some in the upper echelons can potentially earn millions.Pluses: Competitive physicians with strong analytical skills can earn as much or more (way more) than they could in medicine.Minuses: It's hard to break into this field -- and it's a real pressure cooker once inside.10. Get Involved in Retail or ManufacturingSome physicians enter businesses that have little or nothing to do with healthcare and do quite well, thanks in part to skills and temperament learned in practice. In business, "you need to be a smart, hard-working person who can stay focused," Babitsky said. "Those are things that physicians do quite well."Babitsky recalled a doctor who opened a bagel shop near him on Cape Cod. It was a shrewd move, because there were still no bagel shops in the area. The doctor worked hard and the business flourished. It wasn't a sure thing, because many restaurants and other retail businesses fail, especially when the economy sags.Similarly, Daniel E. Kohn, MD, an emergency physician in Baltimore, switched from practicing in an emergency department to running a manufacturing company full-time. Like many physicians, he had for many years been investing in real estate, buying old buildings and rehabbing them, when in 1997 he came across a dilapidated factory.The factory housed a shirt company that was about to go out of business. Dr. Kohn decided to buy the company, called Aetna Shirt, and bring it out of bankruptcy. "It was kind of a fire sale," he said. "The price was reasonable, and there was a book of business already there."As an emergency physician, Dr. Kohn had experience bringing back patients from near death, but rescuing a whole manufacturing concern proved to be a greater challenge. "I didn't understand how relentless the financial needs of this kind of enterprise can be," he said, "but I was determined to make it work."He left the emergency department and introduced a new product he knew intimately: white lab coats. "I never found a decent lab coat," he said. He set about producing a sturdier product that could also be custom-tailored to create a more fashionable look. The lab coat business, called On Call Medical Coats, now makes up 70%-80% of sales.After 17 years in business, Dr. Kohn still hasn't recovered his full investment, but the company is firmly in the black. To find customers, he used to go to 20 medical meetings a year, but he cut back that schedule as business improved. "It's still a work in progress," he said. "I want to continue to grow this company."Pluses: A successful business can provide a great deal of satisfaction and financial rewards.Minuses: You'll have to work hard, and failure is a very real probability.11. Get a Job in the Pharma SectorPhysicians can easily develop a side income by speaking about a drug to colleagues on behalf of a pharmaceutical company, but full-time work in pharma is more difficult to obtain. Although a few physicians work on the marketing side, most are involved in research and development. Even here, the field is hard to break into, in part owing to a complex set of rules and regulations not found anywhere else in medicine.Experts on pharma trends point to somewhat greater demand for full-time physicians in prescription-heavy specialties, such as oncology, cardiology, gastroenterology, neurology, and psychiatry. It also helps to have experience with drug trials or to have worked for the US Food and Drug Administration (FDA) for a few years. FDA pay is quite low, but the experience can be a springboard to a career at a drug-maker, where salaries start at $130,000 and top out at about $500,000 plus bonuses.Another way to share in the storied wealth of the pharma industry is to start an independent company that contracts with drug companies. For example, former plastic surgeon Mike McLaughlin, MD, cofounded Peloton Advantage, a New Jersey-based medical communications company that works with pharma, biotech, and medical device companies.Dr. McLaughlin also runs a side company, Physicians Renaissance Network, which provides information for physicians seeking a career change. "I quit clinical care all at once," he recalls. "I wouldn't recommend doing that, because it's important to test the waters to make sure it's a good fit."Pluses: Being a physician can help open some doors, and successful employees can match their old clinical income.Minuses: Landing a position often takes a lot of networking.12. Become a Physician RecruiterOne unusual but financially rewarding job is to recruit physicians for various jobs, such as clinical research, hospital employment, and group practice. As with many other jobs that require interaction with a lot with doctors, it helps to be a physician and understand what makes them tick.John Goldener, MD, runs a company that recruits doctors for drug trials. Although it took years of hard work to get Goldener Executive Search Associates, in Bryn Mawr, Pennsylvania, off the ground, he said he's now making more money than he did in clinical medicine.In 2000, Dr. Goldener traded his lab coat for a position with an executive search company that worked with pharma companies. It meant giving up clinical work, because "if a client calls and wants to talk to me, they don't want to hear that I'm seeing patients," he said. Three years later, he founded his own company, but a noncompete clause in his contract meant he couldn't solicit any of his old employer's clients. "I had to start at the bottom," he said.That meant making cold calls to pharma executives asking to do their physician searches and driving up to New Jersey to meet with them. "I'm rather introverted, so I had to learn how to call people one after another," he said. It took him six months before he landed his first search.As with any job that involves working with physicians, it helps to be one of them and demonstrate that you understand medical concepts, Dr. Goldener added.Pluses: Physicians who are willing to be patient and work their contacts can earn a high income.Minuses: It can be a tough field to break into.13. Become a Freelance WriterDo you like to write? If so, and you can prove that you have a talent for it, there are countless clinical writing and editing opportunities with pharmaceutical companies, marketing agencies, CME contractors, quality and performance improvement initiatives, and medical publications. In most cases, the work is done on a freelance basis, which means you have to build up your business.Once you have an established set of clients, however, your income can reach primary care levels. Dr. Fork said freelancers' average income is $70,000-$130,000 a year, and the starting salary for in-house clinical writers ranges from $75,000 to $180,000; the higher end of the range is usually reserved for those with an advanced medical degree."If you have the skills, it's not a big transitional hurdle," Dr. Fork added. Characteristics of good medical writing include thorough research, accuracy, logical organization, clear thinking, and readability, according to the American Medical Writers Association.This has been a growing field. According to a report[11] by CenterWatch, which studies the pharma industry, the medical writing market more than doubled in value from 2003 to 2008, increasing to almost $700 million. CenterWatch reported that pharmaceutical companies cut many in-house writing jobs, meaning there's more work available for freelancers.Diane W. Shannon, MD, MPH, a freelance healthcare writer in Brookline, Massachusetts, writes on performance improvement in healthcare as well as other topics. Her exit from general internal medicine in the early 1990s was an act of "self-preservation," she recalled. "I was less immune than others to the stresses of practicing medicine."First, she worked as editor and staff writer for a medical communications company for three years. As a freelancer, she's making more money than when she was working in clinics. "Leaving a relatively low-paying job probably made it easier to walk away from clinical medicine," she said, adding that she uses a variety of medical skills in writing, such as interviewing patients, having to be well-organized, and breaking down very complicated material.Mandy Armitage, MD, also moved from medicine to writing. In an article on Dr. Fork's Website, Doctor's Crossing, she said she stopped practicing sports medicine and rehabilitation after a year, and "I haven't missed it a bit." She initially enrolled in a six-week online writing course and then started a freelance company, collecting such assignments as conference coverage, medical news, and feature stories."What I love most about freelance medical writing is that I cover fields outside of my own specialty, so I'm always learning something new," she wrote. "Plus, I can set my own schedule, and this work is much less stressful."Pluses: Physicians who can write well have good prospects in this field.Minuses: It may take some time to get established, and for specialists especially, income is relatively low.14. Produce CME PresentationsDoctors can help organize and write presentations for companies that host CME for doctors and other health professionals, an industry that generates more than $2 billion in annual sales.These companies must meet a demanding set of requirements from the Accreditation Council for Continuing Medical Education (ACCME), such as documenting their target audience, stating course objectives, explaining how the course fills gaps in knowledge, and testing participants afterwards.Talented doctors can rise fast in the CME industry. For example, Dr. Kim joined MCM Education, a small CME company in Pennsylvania, in 2006 and is now President, making an income similar to that of physicians in clinical practice.Dr. Kim said he brought skills in both writing and computer software to the company. As an MIT undergraduate, he wanted to combine his interest in technology with population-based health, so he enrolled in medical school and trained in internal medicine but didn't go into practice."I just felt I could apply my skill set better somewhere else," he said. So he went to work at a consumer health company, where he helped build some computer-based education modules. But he preferred writing for doctors, which brought him to CME. He's currently studying for an MBA. "A lot of doctors have to learn executive skills to be successful in business," he said.According to the ACCME's 2012 Annual Report, the latest available, the total income for accredited CME providers exceeded $2.4 billion in 2012, a 5% increase over 2011. Accredited CME providers differentiate themselves from medical communications companies that work with pharmaceutical companies to provide seminars to doctors. Although CME companies still derive some income from pharma companies, the ACCME report said those payments fell by more than 10% in 2012.Pluses: Physicians with writing and computer skills can thrive at CME companies.Minuses: The production process is often cumbersome, because it must meet a variety of accreditation requirements.15. Become a TeacherMany doctors dream of becoming teachers, and for a lot of them, it's a good fit in many ways. Physicians know how to talk to patients about complicated medical concepts in simple terms, and they have had to speak in front of small groups. However, opportunities are limited to part-time work at colleges, and the pay doesn't match what can be made in clinical care.Despite the financial drawbacks, doctors have a surprisingly strong interest in teaching. In the 2011 Medscape Physician Compensation Report,[12] physicians who wanted to drop clinical medicine chose teaching as one of their top three alternatives. Indeed, teaching is regarded as a relatively stable refuge from the disruptive modern workplace. Among 14 categories in the Gallup-Healthways Well-Being Index,[13] teachers rank second.Dr. Moawad was satisfied with the move from her UR job to working as a college science teacher. After 4 years in the job, "I'm really, really happy," she said. The work draws on her skills dealing with patients. "Doctors are used to talking to people who don't know about the subject matter and have a limited interest in wanting to learn more about it," she said.She's an adjunct professor at John Carroll University in University Heights, Ohio, teaching two courses on human physiology and global health. The hourly pay is about the same as in clinical practice, but she works just 10-25 hours a week. Only full-time professors get 40 hours, she said, adding that fewer hours are a good fit for physicians raising a family or in semi-retirement. Her work schedule also puts her in sync with her school-age kids' vacation schedules."College teaching is the best teaching opportunity," Dr. Moawad said. Teaching high school science pays too little, and medical school also isn't an option, she said. Dr. Moawad, who served on the faculty at Case Western Reserve University School of Medicine in Cleveland, said there aren't any nonclinical teaching jobs for physicians who are not full-time faculty.Pluses: A good fit for physicians raising families or entering retirement.Minuses: Opportunities are limited to part-time, relatively low-paying positions at colleges.16. Start an 'Encore Career'The "encore career," the job switch made by older doctors, which Dr. Kim explained earlier, typically doesn't pay very well but may answer some personal calling. Dr. McLaughlin said he knows of plastic surgeons who have taken up sculpture full-time, and Dr. Moawad knows a physician who quit practicing to open an aromatherapy and jewelry shop.The Medscape Physician Compensation Report included responses of "chef" and "musician," which could represent doctors beginning encore careers. Steve Babitsky said one of his clients always wanted to work in the outdoors, so he found a job as a park ranger. "The job only paid $30,000-$40,000 a year, but that's what he really wanted to do."Michael Alberti, MD, gave up a job as an emergency physician in Scottsdale, Arizona, to become a portrait photographer. Working in a busy emergency department, "I was losing my love of medicine," he said. Then two things happened: He got a digital camera as a gift in 2001, and his wife had a baby four years later. "It rocked my world," he said.Having already mastered Photoshop, he began taking lots of pictures of his new baby, and within two years he had opened a portrait studio. By 2009, he had acquired a steady customer base in his affluent hometown, and he cut back on his emergency department shifts. In 2010, he was diagnosed with cancer, and by the next year he had quit medicine altogether.He isn't making as much money as in clinical medicine, but his wife, also a doctor, makes up for that. "Giving up my old salary was not easy," he said, "but I don't do this to make money. I do this because of the love I have for it."Pluses: This is a chance to pursue a personal passion while heading into retirement.Minuses: Income from these jobs is generally low.

HelloThe U.S. health care system is unique among advanced industrialized countries. The U.S. does not have a uniform health system, has no universal health care coverage, and only recently enacted legislation mandating healthcare coverage for almost everyone. Rather than operating a national health service, a single-payer national health insurance system, or a multi-payer universal health insurance fund, the U.S. health care system can best be described as a hybrid system. In 2014, 48 percent of U.S. health care spending came from private funds, with 28 percent coming from households and 20 percent coming from private businesses. The federal government accounted for 28 percent of spending while state and local governments accounted for 17 percent.[1] Most health care, even if publicly financed, is delivered privately.In 2014, 283.2 million people in the U.S., 89.6 percent of the U.S. population had some type of health insurance, with 66 percent of workers covered by a private health insurance plan. Among the insured, 115.4 million people, 36.5 percent of the population, received coverage through the U.S. government in 2014 through Medicare (50.5 million), Medicaid (61.65 million), and/or Veterans Administration or other military care (14.14 million) (people may be covered by more than one government plan). In 2014, nearly 32.9 million people in the U.S. had no health insurance.[2]This fact sheet will compare the U.S. health care system to other advanced industrialized nations, with a focus on the problems of high health care costs and disparities in insurance coverage in the U.S. It will then outline some common methods used in other countries to lower health care costs, examine the German health care system as a model for non-centralized universal care, and put the quality of U.S. health care in an international context.In Comparison to Other OECD CountriesThe Organization for Economic Co-operation and Development (OECD) is an international forum committed to global development that brings together 34 member countries to compare and discuss government policy in order to “promote policies that will improve the economic and social well-being of people around the world.”[3] The OECD countries are generally advanced or emerging economies. Of the member states, the U.S. and Mexican governments play the smallest role in overall financing of health care.[4] However, public (i.e. government) spending on health care per capita in the U.S. is greater than all other OECD countries, except Norway and the Netherlands.[5]This seeming anomaly is attributable, in part, to the high cost of health care in the U.S. Indeed, the U.S. spends considerably more on health care than any other OECD country.The OECD found that in 2013, the U.S. spent $8,713 per person or 16.4 percent of its GDP on health care—far higher than the OECD average of 8.9 percent per person.[6] Following the U.S. were the Netherlands, which allocated 11.1 percent of its GDP, then Switzerland also at 11.1 percent, and Sweden, which allocated 11 percent of its GDP to health care in 2013. In North America, Canada and Mexico spent respectively 10.2 percent and 6.2 percent of their GDP on health care.On a per capita basis, the U.S. spends more than double the $3,453 average of all OECD countries (see chart[7] below).[8]Health Expenditure per capita, 2013 (or nearest year)Drivers of Health Care Spending in the U.S.Prohibitively high cost is the primary reason Americans give for problems accessing health care. Americans with below-average incomes are much more likely than their counterparts in other countries to report not: visiting a physician when sick; getting a recommended test, treatment, or follow-up care; filling a prescription; and seeing a dentist.[9] Fifty-nine percent of physicians in the U.S. acknowledge their patients have difficulty paying for care.[10] In 2013, 31 percent of uninsured adults reported not getting or delaying medical care because of cost, compared to five percent of privately insured adults and 27 percent of those on public insurance, including Medicaid/CHIP and Medicare.[11]While there is no agreement as to the single cause of rising U.S. health care costs, experts have identified three contributing factors. The first is the cost of new technologies and prescription drugs. Some analysts have argued “that the availability of more expensive, state-of-the-art medical technologies and drugs fuels health care spending for development costs and because they generate demand for more intense, costly services even if they are not necessarily cost-effective.”[12]In 2013, the U.S. spent $1,026 per capita on pharmaceuticals and other non-durable medical care, more than double the OECD average of $515.[13]Another explanation for increased costs is the rise of chronic diseases, including obesity. Nationally, health care costs for chronic diseases contribute huge proportions to health care costs, particularly during end of life care. “Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, much of it going toward physician and hospital fees associated with repeated hospitalizations.”[14] The National Academy of Sciences found that among other high-income nations the U.S. has a higher rate of chronic illness and a lower overall life expectancy. Their findings suggest that this holds true even when controlling for socio-economic disparity.[15] Experts are focusing more on preventative care in an effort to improve health and reduce the financial burdens associated with chronic disease.[16] One provision of the Patient Protection and Affordable Care Act, commonly referred to as simply the Affordable Care Act (ACA), implemented in 2013, provides additional Medicaid funding for states providing low cost access to preventative care.[17]Finally, high administrative costs are a contributing factor to the inflated costs of U.S. health care. The U.S. leads all other industrialized countries in the share of national health care expenditures devoted to insurance administration. It is difficult to determine the exact differences between public and private administrative costs, in part because the definition of “administrative” varies widely. Further, the government outsources some of its administrative needs to private firms.[18] What is clear is that larger firms spend a smaller percentage of their total expenditures on administration, and nationwide estimates suggest that as much as half of the $361 billion spent annually on administrative costs is wasteful.[19] In January 2013, a national pilot program implemented under the ACA began. The aim is to improve administrative efficiency by allowing doctors and hospitals to bundle billing for an episode of care rather than the current ad hoc method.[20]Health Insurance in the U.S.: Uneven CoverageWhile the majority of U.S. citizens have health insurance, premiums are rising and the quality of the insurance policies is falling. Average annual premiums for family coverage increased 11 percent between 1999 and 2005, but have since leveled off to increase five percent per year between 2005 and 2015.[21] Deductibles are rising even faster. Between 2010 and 2015, single coverage deductibles have risen 67 percent.[22] These figures outpace both inflation and workers’ earnings.The lack of health insurance coverage has a profound impact on the U.S. economy. The Center for American Progress estimated in 2009 that the lack of health insurance in the U.S. cost society between $124 billion and $248 billion per year. While the low end of the estimate represents just the cost of the shorter lifespans of those without insurance, the high end represents both the cost of shortened lifespans and the loss of productivity due to the reduced health of the uninsured.[23]Health insurance coverage is uneven and often minorities and the poor are underserved. Forty million workers, nearly two out of every five, do not have access to paid sick leave. Experts suggest that the economic pressure to go to work even when sick can prolong pandemics, reduce productivity, and drive up health care costs.[24]There were 32 million uninsured Americans in 2014, nine million fewer than the year prior. Experts attribute this sharp decline in the uninsured to the full implementation of the ACA in 2014.[25] Of American adults who had health insurance in 2014, 73 percent had one or more full-time workers in the family and 12 percent had one or more part-time workers in the family.[26] Just 49 percent of American adults reported getting health insurance from an employer in 2014.[27]Coverage by employer-provided insurance varies considerably by wage level. Firms with higher proportions of low-wage workers are less likely to provide access to health insurance than those with low-proportions of low-wage workers.[28]In 2014, 11.2 percent of full-time workers were without health insurance. However, the percentage of part-time workers without insurance was 17.7 percent, a significant decrease from 24 percent in 2013, thanks in part to the Affordable Care Act. The uninsured rate among those who had not worked at least one week also decreased from 22.2 percent in 2013 to 17.3 percent in 2014.[29]Smaller firms are significantly less likely to provide health benefits to full or part-time workers. Among all small firms (3-199 workers) in 2015, only 56 percent offered health coverage, compared to 98 percent of large firms.[30]After the Affordable Care Act allowed for many young adults (19-25) to remain on their parents’ health plans, there was a statistically significant increase in the percentage of insured young people from 68.3 percent in 2009[31] to 82.9 percent in 2014.[32] Over the same period, the percentage of young people aged 26-34 with insurance increased from 70.9 percent to 81.8 percent.[33]Minorities and children are disproportionately uninsured. In 2014, 7.6 percent of non-Hispanic Whites were uninsured, 11.8 percent of Blacks were uninsured, 9.3 percent of Asians, and 19.9 percent of people of Hispanic origin were uninsured.[34] The Kaiser Family Foundation has found that about 80 percent of the uninsured are U.S. citizens.[35] Among children, six percent were uninsured in 2014.[36] These children are 10 times more likely than insured children to have unmet medical needs and are five times as likely as an insured child to go more than two years without seeing a doctor.[37]Women in the individual market often faced higher premiums than men for the same coverage. Beginning in 2014, the Affordable Care Act banned this practice, as well as denying coverage for pre-existing conditions.[38]In 2014, 19.3 percent of the population living below 100 percent of the poverty line ($23,550 a year for a family of four) was uninsured.[39] According to the Kaiser Family Foundation, 90 percent of the uninsured have family incomes within 400 percent of the federal poverty level. This makes them eligible for either subsidized coverage through tax credits or expanded Medicaid eligibility under the Affordable Care Act’s state health exchanges. [40]Rising Healthcare PremiumsHealth insurance premiums in the U.S. are rising fast. From 2005 to 2015, average annual health insurance premiums for family coverage increased 61 percent, while worker contributions to those plans increased 83 percent in the same period. This rate of increase outpaces both inflation and increases in workers’ wages.[41]In 2005, the average annual premiums for employer-sponsored health insurance were $2,713 for single coverage and $8,167 for family coverage. In 2015, premiums more than doubled to $6,251 for employer-sponsored single coverage and $17,545 for employer-sponsored family coverage.[42]A growing number of workers face a deductible of $1,000 or more for individual plans. In 2015, 46 percent (compared to 38 percent in 2013 and 22 percent in 2009) of workers were enrolled in a plan with an annual deductible of $1,000 or more. Employees at small firms are more likely than those at large firms to have a deductible greater than $1,000.[43]The Union Difference: Union workers are more likely than their nonunion counterparts to be covered by health insurance and paid sick leave. In March 2015, 95 percent of union members in the civilian workforce had access to medical care benefits, compared with only 68 percent of nonunion members. In 2015, 85 percent of union members in the civilian workforce had access to paid sick leave compared to 62 percent of nonunion workers.[44] At the median, private-sector unionized workers pay 38 percent less for family coverage than private-sector nonunionized workers, according to a 2009 study.[45]Across states, there are significant disparities in both the availability and the cost of health care coverage.In 2012, Medicare reimbursements per enrollee varied from $6,724 in Anchorage, Alaska to $13,596 in Miami, Florida.[46] Annual premiums are similarly disparate. In 2015, the average family premium in the South was $16,785 while the same coverage averaged $18,096 in the Northeast.[47]Firms in the South were less likely to provide coverage for an employee’s domestic partner than other regions. In the South, 41 percent of firms reported providing benefits for same-sex partners (compared to 51 percent in the Northeast) and 20 percent reported offering benefits to opposite-sex domestic partners (compared to 46 percent in the Northeast).[48]High Costs Drive Americans into BankruptcyUniversal coverage, in countries like the United Kingdom, Switzerland, Japan, and Germany makes the number of bankruptcies related to medical expenses negligible.[49] Conversely, a 2014 survey of bankruptcies filed between 2005 and 2013 found that medical bills are the single largest cause of consumer bankruptcy, with between 18 percent and 25 percent of cases directly prompted by medical debt.[50] Another survey found that in 2013, 56 million Americans under the age of 65 had trouble paying medical bills.[51] Another 10 million will face medical bills they are unable to pay despite having year-round insurance.[52]It has been suggested, based on the experience of Massachusetts, where medical-related bankruptcies declined sharply after the state enacted its health reform law in 2006, that the ACA may help reduce such bankruptcies in the future.[53]The Affordable Care Act: Successes and Remaining ChallengesIn March, 2010, President Obama signed the ACA into law that made hundreds of significant changes to the U.S. healthcare system between 2011 and 2014. Provisions included in the ACA are intended to expand access to healthcare coverage, increase consumer protections, emphasizes prevention and wellness, and promote evidence- based treatment and administrative efficiency in an attempt to curb rising healthcare costs.Beginning in January 2014, almost all Americans are required to have some form of health insurance from either their employer, an individual plan, or through a public program such as Medicaid or Medicare. Since the so-called “individual mandate” took effect, the total number of nonelderly uninsured adults dropped from 41 million in 2013 to 32.3 million in 2014.[54] The largest coverage gains were concentrated among low-income people, people of color, and young adults, all of whom had high uninsured rates prior to 2014.[55]A major provision of the ACA was the creation of health insurance marketplace exchanges where individuals not already covered by an employer-provided plan or a program such as Medicaid or Medicare can shop for health insurance. Individuals with incomes between 100 percent and 400 percent of the federal poverty line would be eligible for advanceable premium tax credits to subsidize the cost of insurance. States have the option to create and administer their own exchanges or allow the federal government to do so. Currently, only 14 states operate their own exchanges.[56]Designed to promote competition among providers and deliver choice transparency to consumers, the state-based exchanges appear to be doing just that. A recent analysis by the Commonwealth Fund found that the number of insurers offering health insurance coverage through the marketplaces increased from 2014 to 2015.[57] Additionally, there was generally no reported increase in average premiums for marketplace plans over that period. The analysis found only a modest increase in average premiums for the lowest cost plans from 2015 to 2016.[58]The ACA also included a major expansion of the Medicaid program, although the Supreme Court ruled in 2012 that this expansion is a state option. As of November 2015, 30 states have chosen to expand Medicaid. As of 2014, adults with incomes at or below 138 percent of the federal poverty line are now eligible for Medicaid in the states that have adopted the expansion.[59]Despite improvements to the U.S healthcare system under the ACA, a number of challenges remain. In 2014, 10.4 percent of Americans were still uninsured[60], and those with insurance still face high deductibles and premium costs. Furthermore, in the 20 states that had not expanded Medicaid, an estimated three million poor adults fall into the “coverage gap” where their incomes are above current Medicaid eligibility limits but below the lower limit of premium credits on the healthcare exchanges. The bulk of people in the coverage gap are concentrated in the South, with Texas (766,000 people), Florida (567,000), Georgia (305,000) and North Carolina (244,000) having among the highest number of uninsured.[61]The ACA included a number of other provisions to improve healthcare access and affordability. The law banned lifetime monetary caps on insurance coverage for all new plans and prohibited plans from excluding children and most adults with preexisting conditions.[62] Insurance plans are also prohibited from cancelling coverage except in the case of fraud, and are required to rebate customers if they spend less than 85 percent (80 percent for individual and small group plans) of premiums on medical services. Additionally, the ACA established the Prevention and Public Health Fund to allocate $7 billion towards preventative care such as disease screenings, immunizations, and pre-natal care for pregnant women and between 2010 and 2015. Furthermore, $11 billion in funding for community health centers and $1.5 billion in additional funding for the National Health Service Corps was included in the law.[63]A number of cost control provisions were included in the ACA in an attempt to curb rising medical costs. Among them is the Independent Payment Advisory Board, which will provide recommendations to Congress and the President for controlling Medicare costs if the costs exceed a target growth rate. The administrative process for billing, transferring funds, and determining eligibility is being simplified by allowing doctors to bundle billing for an episode of care rather than the current ad hoc method. Additionally, changes were made to the Medicare Advantage program that would provide bonuses to high rated plans, incentivizing these privately-operated plans to improve quality and efficiency. Furthermore, hospitals with high readmission rates will see a reduction in Medicare payments while a new Innovation Center within the Centers for Medicare and Medicaid Services was created to test new program expenditure reduction methods.[64]Common Methods to Lower Health Care CostsBy taking an international perspective and looking to other advanced industrialized countries with nearly full coverage, much can be learned. While methods range widely, other OECD countries generally have more effective and equitable health care systems that control health care costs and protect vulnerable segments of the population from falling through the cracks. Among the OECD countries and other advanced industrialized countries, there are three main types of health insurance programs:A national health service, where medical services are delivered via government-salaried physicians, in hospitals and clinics that are publicly owned and operated—financed by the government through tax payments. There are some private doctors but they have specific regulations on their medical practice and collect their fees from the government. The U.K., Spain, and New Zealand employ such a system. [65]A national health insurance system, or single-payer system, in which a single government entity acts as the administrator to collect all health care fees, and pay out all health care costs. Medical services are publicly financed but not publicly provided. Canada, Denmark, Taiwan, and Sweden have single-payer systems.A multi-payer health insurance system, or all-payer system, which provides universal health insurance via “sickness funds,” used to pay physicians and hospitals at uniform rates, thus eliminating the administrative costs for billing. This method is used in Germany, Japan, and France.[66]A universal mandate for health care coverage defines these systems. Such a mandate eliminates the issue of paying the higher costs of the uninsured, especially for emergency services due to lack of preventative care.[67] Other methods for reducing costs may include:Funding health care costs in relation to income rather than risk or people’s medical history.[68]Negotiating the price of prescription drugs and bulk purchasing of prescription medications and durable medical equipment is a method used in other countries for lowering costs. This has been effectively used by the U.S. Department of Veterans Affairs, Medicaid, and Health Management Organizations in the U.S. Yet, it has been prohibited by law from traditional Medicare. Savings of up to five percent of total health care expenditures could result from the full adoption of these practices.[69]An International Case Study: How Germany Pays for Health CareGermany has one of the most successful health care systems in the world in terms of quality and cost. Some 240 insurance providers collectively make up its public option. Together, these non-profit “sickness funds” cover 90 percent of Germans, with the majority of the remaining 10 percent, generally higher income Germans, opting to pay for private health insurance. The average per-capita health care costs for this system are less than half of the cost in the U.S. The details of the system are instructive, as Germany does not rely on a centralized, Medicare-like health insurance plan, but rather relies on private, non-profit, or for-profit insurers that are tightly regulated to work toward socially desired ends—an option that might have more traction in the U.S. political environment.[70]The average insurance contributions to German sickness funds are based on an employee’s gross income, around 15.5 percent with an income cap at $62,781, and employers and employees each pay about half of the premium. Generally, an individual employee’s contribution is 8.2 percent and the employer pays the remaining 7.3 percent.[71] [72]Premiums are not based on risk and are not affected by a person’s marital status, family size, or health. Germans have no deductibles and low co-pays.[73]Doctors are private entrepreneurs and get a fee from insurers for every visit and procedure they perform. However, they are tightly regulated. Groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets. Doctors must remain in these budgets, as they do not receive additional funding if they go over. This helps keep health care costs in check and discourages unnecessarily expensive procedures. The average German doctor also makes about one-third less per year than in the U.S., around $123,000.[74]Government general revenues cover premiums for children, on the premise that the next generation should be the entire nation’s fiscal responsibility, instead of just the responsibility of the parents.[75]Germany reformed its coverage for prescription drugs in 2010 after costs for prescription drugs continued to rise. Prior to reforms, drug companies set the price for new drugs and were not required to show that the new drug was an improvement over previously available prescription drugs. Pursuant to the reforms effective in 2011, manufacturers could set the price for the first 12 months a new drug is on the market. “As soon as the drug enters the market, a new process of benefit assessment begins.” Manufacturers must establish, through comparative effective research that the new drug has an “added benefit to the patient, compared to the previously existing standard treatment.” Drugs without added benefit will be reimbursed according to a government pricing list. New drugs without added benefits are available to patients, but the patient has to pay the price difference. For drugs with added benefit, a price will be negotiated between health insurers and the manufacturer.[76]Quality of U.S. Health Care in an International ContextU.S. health care specialists are among the best in the world. However, treatment in the U.S. is inequitable, overspecialized, and neglects primary and preventative care.[77] The end result of the U.S. approach to health care is poorer health in comparison to other advanced industrialized nations. According to the Commonwealth Fund Commission, in a 2014 comparison with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., the U.S. ranked last overall. In terms of quality of care, the U.S. ranked fifth, but came in last place in efficiency, equity, and healthiness of citizens’ lives.[78]Comparing other health care indicators in an international context underscores the dysfunction of the U.S. health care system.Despite the relatively high level of health expenditure, in the U.S. there are fewer physicians per capita than in most other OECD countries. In 2013, the U.S. had 2.6 practicing physicians per 1,000 people—below the OECD average of 3.3.[79]In the U.S., there are only about 1.2 primary care physicians per 1,000 people. Projections indicate that the U.S. will need 52,000 more primary care physicians by 2025 to meet demand.[80] While population growth and aging make up a substantial proportion of this increased need, expanded access to insurance under the Affordable Care Act means more people will seek out treatment. Therefore, there are provisions in the legislation to increase the number of primary care physicians in the U.S.There is a significant spatial mismatch within the United States for physicians as well. While the U.S. averaged 225.6 doctors active in patient care per 100,000 people in 2014, there is a wide variance across states; Massachusetts ranks highest with 349.5 active doctors per 100,000 people, while Mississippi has only 170.3.[81]In 2013, the U.S. infant mortality rate was 5.96 per 1,000 live births[82], while the OECD median was 3.8.[83]The obesity rate among adults in the U.S. was 35.3 percent in 2013, down slightly from 36.5 in 2011. This is the highest rate among OECD countries. The average for the OECD countries was 19.0 percent in 2013.[84]Thanks

This is a question that Christians should have investigated before they voted for him.The story is Paula White lead Trump to the Lord (there are some stories that say it was James Robertson but I cannot verify those)It was an early afternoon in late July, and Paula White, 51, was holding court before an audience of about 25 Southern Baptist ministers in an ornate diplomatic reception room in the Eisenhower Executive Office Building. The televangelist was recounting one of her favorite stories — about when Donald Trump reached out to her in 2011 for guidance on a possible White House run. “Would you bring some people around me to pray?” she said he asked her. “I really want to hear from God.” White recalled that she and another pastor gathered about 30 ministers from different evangelical Christian traditions at Trump Tower in Manhattan. After the prayer session, when Trump asked her what she thought, she responded: “I don’t feel it’s the right timing.”He listened, she continued, and the two talked and prayed about the matter over the next four years. When White again gathered religious leaders at Trump Tower in September 2015, she backed the decision he’d already made to run. Videos on YouTube of that event show her standing on his right, head down, laying hands on him as she prayed.The question is also, is Paula to be trusted DUMPSTER FIRE: Paula White's Divine Protection Racket, The Story Behind Trump’s Controversial Prayer Partner, Reformed Rapper Calls Out 12 Popular Pastors as 'False Teachers'. This story has elevated her position in Washington.Now while it is CLEAR Trump does not act like a Christian when we listen to him speak or tweet, that alone does not prove he isn't. I know some pastors even who act like Trump, but just because they are a pastor does not mean they are saved.Trump’s Religious Liberty Order Doesn’t Answer Most Evangelicals’ PrayersBut what has he done that is “Pro-Christian”?Judicial appointments: In addition to appointing Neil Gorsuch to the Supreme Court, Trump placed a first-year record of 12 justices on the U.S. Court of Appeals, in addition to six district court judges. “His record on judicial nominees has been one of the most impressive, if not the most impressive, that we’ve had out of any president,” said Reed, who has worked closely with, or known, many presidents.Anti-abortion actions: Trump’s steps included not just reinstating, but expanding, a policy first adopted by GOP presidents in 1984 to prohibit U.S. aid from supporting international groups that promote abortion. Vice President Pence was the highest-ranked administration figure to speak at the annual March for Life anti-abortion rally last year. Trump is addressing this year's march by satellite Friday. “It’s part of the DNA of this administration,” Daly said.Elevating religious protections: After Trump signed an executive order to “protect religious liberty,” the Justice Department issued new guidance aimed at giving religious groups and individuals broad protections to express their beliefs when they come into conflict with government regulations, including when making hiring decisions. The Health and Human Services Department Thursday announced a new division aimed at protecting doctors and other medical professionals who don’t want to perform abortions, treat transgender patients or take part in other types of care that go against their beliefs. While opponents say the administration is allowing religion to be used as an excuse for discriminating, evangelical adviser Moore says Trump has demonstrated that “you don’t have to check your belief system at the door to have a cooperative and beneficial relationship with the federal government.”Weighing in on Supreme Court case: The Justice Department sided with the Colorado baker who refused to design a wedding cake for a same-sex couple, a case pending before the Supreme Court. The administration didn’t have to get involved, noted Curt Smith, whose Indiana Family Institute filed a brief in support of the baker. “The Obama administration would have been on the other side,” Smith said. “George Bush, maybe on my side, maybe quiet.”Recognizing Jerusalem as capital of Israel: Evangelicals' support for Israel stems in part from passages in the Bible they say show God promised Israel to the Jewish people, and that God blesses those who bless the Jews. Some also believe that Jewish possession of Jerusalem is necessary for the prophesized second coming of Jesus. “I don’t think you can underestimate the way in which American evangelicals identify with Israel as part of their notions of Biblical prophecy,” said Julie Ingersoll, a religious studies professor at the University of North Florida.Allowing federal money to pay to rebuild churches: The Federal Emergency Management Agency recently said houses of worship can receive federal dollars to rebuild after natural disasters. “The Constitution is pretty clear that the government doesn’t build houses of worship,” said Garrett of Americans United for the Separation of Church and State. But after Hurricane Harvey hit Texas in September, Trump tweeted that churches should get FEMA funds “just like others.”Directing aid to persecuted Christians through faith-based groups: Trump instructed the State Department to bypass the United Nations and use faith-based groups to help Iraqi Christians and other persecuted religious minorities. Pence announced the policy change in a speech to a group that advocates for greater protection of Christians in the Middle East, one of several times he has spoken about the need to help persecuted Christians.Doubling the tax credit for children: The tax changes Trump signed into law doubled the child tax credit from $1,000 to $2,000 per child. While other changes mitigate the effects, especially for larger families, Reed calls it a “huge victory.” “We have shifted the center of gravity in Republican fiscal orthodoxy from being something that is purely supply-side and pro-growth — even though I support all that —– to a tax code that is pro-child, pro-life and pro-family,” he said.So these things would say that he is, or it says he is at least a Republican. But IS he one?First, he isn't sure he has ever asked God for forgiveness, as he doesn't "bring God into that picture." He soon backtracked. Asking God for forgiveness is a central aspect of Christianity across the many traditions. This is not relevant to his political views, but it is curious that many Christians support Trump and believe his claims about his Christian faith.Second, Trump has stated that the United States should take out the families of terrorists: "...you have to take out their families, when you get these terrorists, you have to take out their families. They care about their lives, don't kid yourself. When they say they don't care about their lives, you have to take out their families." This policy would clearly contradict just war theory, which is a prominent Christian view related to declaring and conducting war. One of the tenets of just war theory is that it is immoral to intentionally kill innocent civilians. Given the nature of war, non-combatants will be injured and killed, but according to just war theory this should be avoided if at all possible. It should never be done intentionally. Trump's proposal is not only immoral, it is also illegal and would be ineffective. If we attack innocent women and children, we only provide evidence for the terrorists who claim that they are fighting an immoral enemy.Third, Trump has proposed that all Muslims should be banned from entering the United States. He's also open to forming a database tracking all Muslims who live here. In addition, he will not rule out requiring some sort of special ID for Muslims. While this taps into the fears and irrational beliefs many hold about Islam, terrorism, and our safety, it is simply wrong to discriminate against people on the basis of their religious faith (or lack thereof). We certainly need to have better screening procedures so that we can identify individuals who may be a threat, given their views and affiliations. But to ban all Muslim immigration because of terrorism that emerges from misguided interpretations of Islam is like banning all Christian immigration because of attacks on abortion clinics or violent racist ideology emerging from incorrect interpretations of Christianity.Fourth, Trump has a problem with women. His comments about Carly Fiorina's appearance and Megyn Kelly's blood are well-known. His sexism is not new. I was recently reading the classic book On Writing Well, when I came across the following anecdote from a writer who interviewed Trump at a spa he developed in Florida:"Evidently, Trumps philosophy of wellness is rooted in a belief that prolonged exposure to exceptionally attractive young spa attendants will instill in the male clientele a will to live...Trump introduced me to 'our resident physician, Dr. Ginger Lee Southall'--a recent chiropractic college graduate...I asked Trump where she had done her training. 'I'm not sure,' he said, 'Baywatch Medical School? Does that sound right? I'll tell you the truth. Once I saw Dr. Ginger's photograph, I didn't really need to look at her resume or anyone else's. Are you asking me, 'Did we hire her because she trained at Mount Sinai for fifteen years? The answer is no. And I'll tell you why: because by the time she's spent fifteen years at Mount Sinai, we don't want to look at her'" (p. 221).The notion that women are equal to men because they are also created in the image of God is an important theological truth, even though many Christians and Christian institutions have not lived up to this. The dignity of women is not grounded in their appearance, but rather their humanity. That Trump has the support of so many women is baffling, to say the least.Donald Trump Criticized for Mocking Disabled Reporter.The GOP candidate performed an unflattering impression of Serge Kovaleski, who suffers from a congenital joint condition, at a South Carolina rally.Finally, Trump appears to be a narcissist. This might work for reality television or real estate deals, but it is not a desirable trait for the President of the United States. The most important moral principle, according to Jesus in the gospels, is to love God with all of your heart, soul, mind, and strength, and to love your neighbor as yourself. The Christian understanding of love is that it involves sacrifice, self-denial, and preferring the good of others over one's own. It does not appear that Donald Trump understands this.Well these do not mean that he is not,but it sure proves Christians should have have voted for him as leader. With all this in mind Blake , I can not give a firm answer one way or another because he gives conflicting actions (but what he has done in some cases would seem so). I do thank you for trusting me with your A2A as it has been a privilege to serve!