Investment Rental Properties: When It’s Time to Buy or Sell

How does one determine when to sell a rental property investment? If you are going to buy rental properties – having a plan in place for the appropriate time to sell is important.

I have worked with many individuals over the years and showed them how to buy rental property. There are many things that need to be considered when purchasing for investment purposes. There is also – definitely – a time to sell.

How to Buy an Investment Property

– Is the property in a convenient location? Is it near shopping, in a neighborhood with good schools, and is it easily accessible to Interstates and connecting roads?

– Does the potential investment property have a sound foundation? What sort of issues does the home have? If it needs a new roof or the foundation is sunken in and is creating issues within the structure, it might not be a good investment at this time. If the issues are only cosmetic (needs a new bathroom floor, or painting, or carpeting) it may be worthwhile. Inspection reports will reveal the property’s flaws so the buyer and real estate professional can make a good decision.

– Do you have enough of a down payment to purchase the rental property so financing will not be an issue? In the current real estate market, most lenders will see a down payment of 40-50% as a good risk. If you can invest 100% into the property – this is even better.

– Income gained from the property needs to exceed expenses. Identify a creditworthy tenant, a reliable property manager, and a solid lease to make your property investment profitable. Property management fees are tax deductible.

– For residential property investments, single-family homes, as well as multi-tenant properties such as duplexes and fourplexes, are great ways to build income and wealth. Some investors may want to consider apartment complexes. In this case, a commercial property loan will be necessary to obtain financing.

– Use depreciation on the investment property as a way to receive an annual tax deduction. Check with your accountant, who will apply the depreciation deduction on the building, appliances — even window treatments. The government still allows tax deductions for accelerated depreciation on properties. Savvy real estate investors use this deduction to increase cash flow and net operating profit on a property.

When to Sell a Rental Property

I have a term for properties that need to be sold: alligator properties. These are properties that are eating the investor alive with carrying costs. When an investor looks at the bottom line on an alligator property – there is no profit – just expenses. An alligator property today may have been a good investment ten years ago. But some individuals will continue to hold a property until it depletes all of the profits they may have made in the first 5-7 years.

If a property has sentimental value (it was your first home, or your mother once owned it but now she’s deceased), some investors may tend to want to hold onto it. Having an emotional attachment to an investment property that is supposed to be generating income is not good. Sometimes an individual will hold this type of property even if it is not profitable. It may be time to consider selling this property.

– After a certain number of years, the depreciation tax deduction is used up on a property. Ask your accountant when this depreciation is no longer applicable. When the investment can no longer be depreciated – it’s time to sell that property, and purchase another rental.

– Consider selling the property and applying the 1031 tax code, so no capital gains tax is imposed on the profits. To paraphrase, the code states that an owner can sell one property in exchange for a securitized piece of property or tenant in common piece of property. Roll the profits from one property into a new investment to increase wealth and maintain it.

– On average, in the 12th year of property ownership — it is time to sell an investment. The decision to sell will depend on two factors. 1. Is there enough equity in the property to sell? Or, have you pulled out too much equity in the property? 2. Will the real estate market allow you to sell and obtain a nice profit? Ask a real estate professional for a custom market analysis on the property to see if it’s realistic to obtain a price that nets a nice profit.

– Alligator properties are not profitable for a variety of reasons. I am amazed at the number of investors who are not even aware that their property is losing money. If you have a property that might be losing money, then ask your real estate professional or accountant to perform a cost to income analysis. If it is indeed an alligator property — consider selling.

Investors buy and sell equities all the time. There is a time to purchase and a time to sell a home as well.

Elaine VonCannon is an award winning REALTOR with RE/Max Capital in Williamsburg, Virginia. She specializes in retirement and relocation in the Williamsburg, South Eastern Virginia area and in Virginia Estate properties. To learn more.

Financial Modeling: Investment Property Model

Building financial models is an art. The only way to improve your craft is to build a variety of financial models across a number of industries. Let’s try a model for an investment that is not beyond the reach of most individuals – an investment property.financial-modeling-3.jpg (1600×1271)

Before we jump into building a financial model, we should ask ourselves what drives the business that we are exploring. The answer will have significant implications for how we construct the model.

Who Will Use It?

Who will be using this model and what will they be using it for? A company may have a new product for which they need to calculate an optimal price. Or an investor may want to map out a project to see what kind of investment return he or she can expect.

Depending on these scenarios, the end result of what the model will calculate may be very different. Unless you know exactly what decision the user of your model needs to make, you may find yourself starting over several times until you find an approach that uses the right inputs to find the appropriate outputs.

On to Real Estate

In our scenario, we want to find out what kind of financial return we can expect from an investment property given certain information about the investment. This information would include variables such as the purchase price, rate of appreciation, the price at which we can rent it out, the financing terms available fore the property, etc.

Our return on this investment will be driven by two primary factors: our rental income and the appreciation of the property value. Therefore, we should begin by forecasting rental income and the appreciation of the property in consideration.

Once we have built out that portion of the model, we can use the information we have calculated to figure out how we will finance the purchase of the property and what financial expenses we can expect to incur as a result.

Next, we tackle the property management expenses. We will need to use the property value that we forecasted in order to be able to calculate property taxes, so it is important that we build the model in a certain order.

With these projections in place, we can begin to piece together the income statement and the balance sheet. As we put these in place, we may spot items that we haven’t yet calculated and we may have to go back and add them in the appropriate places.

Finally, we can use these financials to project the cash flow to the investor and calculate our return on investment.

Laying Out the Model

We should also think about how we want to lay it out so we keep our workspace clean. In Excel, one of the best ways to organize financial models is to separate certain sections of the model on different worksheets.

We can give each tab a name that describes the information contained in it. This way, other users of the model can better understand where data is calculated in the model and how it flows.

In our investment property model, let’s use four tabs: property, financing, expenses, and financials. Property, financing and expenses will be the tabs on which we input assumption and make projections for our model. The financials tab will be our results page where we will display the output of our model in a way that’s easily understood.

Forecasting Revenues

Let’s start with the property tab by renaming the tab “Property” and adding this title in cell A1 of the worksheet. By taking care of some of this formatting issuing on the front end, we’ll have an easier time keeping the model clean.

Next, let’s set up our assumptions box. A few rows below the title, type “Assumptions” and make a vertical list of the following inputs:

Purchase Price
Initial Monthly Rent
Occupancy Rate
Annual Appreciation
Annual Rent Increase
Broker Fee
Investment Period

In the cells to the right of each input label, we’ll set up an input field by adding a realistic placeholder for each value. We will format each of these values to be blue in color. This is a common modeling convention to indicate that these are input values. This formatting will make it easier for us and others to understand how the model flows. Here are some corresponding values to start with:

$250,000.00
$1,550.00
95.00%
3.50%
1.00%
6.00%
4 years

The purchase price will be the price we expect to pay for a particular property. The initial monthly rent will be the price for which we expect to rent out the property. The occupancy rate will measure how well we keep the property rented out (95% occupancy will mean that there will only be about 18 days that the property will go un-rented between tenants each year).

Annual appreciation will determine the rate that the value of our property increases (or decreases) each year. Annual rent increase will determine how much we will increase the rent each year. The broker fee measures what percentage of the sale price of the property we will have to pay a broker when we sell the property.

The investment period is how long we will hold the property for before we sell it. Now that we have a good set of property assumptions down, we can begin to make calculations based on these assumptions.

Mallorca Property Market Report October 2010

Introduction

It is 6 months since I wrote my last Mallorca Property Market Report and it is always a little bit worrying going back to reflect on what one has said and, whether with the benefit of hindsight, an alternative conclusion might have emerged! Back in March the big question was whether we could call the “bottom of the market” and what that might actually mean in practice – one thing is a market that has touched bottom and ready to move up the gears quickly, with real growth just around the corner, while the other is a market where values have bottomed out but the expectations are much less about growth and much more about “stagnation”!

My conclusion at the time was that we may indeed be able to call the bottom of the market if we were to define it in terms of reaching the “bottom of the cycle of underlying residential property values in Mallorca” (please note the very important reference to underlying values, something very different to, for example, asking prices!). More specifically:

March 2010 Market Report Conclusions

1. Underlying values to bottom out at current levels
2. The evolution of asking prices to vary dependent upon whether they have been set realistically / adjusted sufficiently to account for the significant falls in property values.
3. Future growth in values to be non existent in the short term and very limited and restricted to underlying inflation in the medium term ie no real growth in the next couple of years. Modest growth over above general inflation levels in the economy to follow thereafter at levels of 1-3%
4. Special properties with “unique” qualities – front line; very good sea views; restrictive planning conditions – rural fincas; high quality developments etc to perform better / out perform the market in the medium / long term.
5. Land values to hold down prices in the medium term as developers take advantage of cheaper land to sell at these new lower levels for the medium term. Long term shortage of supply, save for those in urban areas and for “mid range” apartments, like Palma, Inca and Manacor, should see values rise

Alongside these conclusions I set out a few “tips” or recommendations for both owners and potential investors of Mallorca residential property:

1. If you are a lifestyle purchaser or investor with an income return bias start to look at the emerging buying opportunities BUT..
2. “BUYER BEWARE” it is all about value and ensuring that you buy at an appropriate level and don’t over pay on unrealistically priced properties.
3. Look at new build where good discounts are available (but beware of off plan unless your deposit(s) are backed with a bank guarantee)
4. Look at properties with “defensive” qualities, as set out in (4) above, for greater short term security
5. Look at land to hold as a long term investment / to build a home. Particularly rural plots, front line or with very good sea views etc

Market Update March 2010 – October 2010

So what has been the reality of the last 6 months? Have my conclusions been largely borne out or has hindsight led us to see that we should have reached alternative conclusions?

Lets start by reviewing the statistics and data that have emerged since the March 2010 report and what the so called specialists have been saying. But before that let’s enjoy the headline that greeted me this week that none other than the Spanish Prime Minister had just called the bottom of the property market in Spain! While I am immediately cynical when it comes to anything said by a politician, particularly when it is a Foreign PM talking to US investors in a desperate attempt to convince them to buy bundles of government bonds at the lowest possible yield, he did seem to be confirming what I said, namely that we are at the bottom and although it is true that I said it 6 months ago, if prices have largely remained unchanged over that period, then it could be said that it was the bottom then as well as now!

The problem for me is that Zapatero then proceeded to get over excited, quoting official statistics that appeared to indicate that in many areas of Spain prices were starting to rise ie we had touched bottom and wey hey we are on an upward trajectory again! So let’s look at the emerging data, starting with ZP’s own Housing Ministry.

National Institute of Statistics (INE) According to new figures from the INE, Spanish property prices rose (quarterly) for the first time in 3 years. More specifically these figures claim that average prices at the end of June were 1.6% higher than at the end of March although over 12 months prices are still down but by just 0.9%. For the Balearic Islands / Mallorca the statistics weren’t quite as rosy but still offered “some positive” news for those desperate to call the end of anything called recession / crisis / market crash etc! Here the overall figures put property values unchanged for the last quarter but down 2% for the year. For new build property it appears there is a “rebound” with prices up 1.4% even though for the last 12 months prices remain 2.5% down. Second hand property values were down 1% for the last quarter and 1.6% over 12 months.

Interestingly only Navarra in Northern Spain came out with worse data with a small fall of 0.1% in the last quarter. In other

Should Australians Still Invest Properties in the United States?

For several years now, people have been trying to call me to ask if it is still a good idea to invest in property in the United States? I have been buying properties in the United States for more than 20 years already.Find-the-right-investment-property-with-a-Cohen-Handler-buyers-agent_578_6031873_0_14107055_1000.jpg (1000×831)

Buying a real estate in the United States started in the late 80s when I got myself involved in the loan debacle and savings. This was when the banking system in the southern states was failing and we even had to make transactions of the property buying and selling without any banking system, since there were virtually no banks around.

Now it’s as if there are bank crisis every 20 years in America. Prices significantly dropped, sometimes 95 cents on the dollar, when I was buying properties. We can even buy properties 5 cents on the dollar! There were even home units that we could buy for as low as $600 and a couple of thousand dollars per house

The fact that the Americans are currently going through a major bank crisis, a lot of Australians are apprehensive to take advantage of the US market. Perhaps you don’t have to worry about this issue if you are not going to live in the United States.

In the late 80s, I did spend a lot of time with some Australians who were trying to save what’s left of their capital, the capital that they have invested in the U.S. And after 20 years, I’m doing it again – helping Australians who lost a lot of money, to get out of the United States and will still be able to keep the remaining capital that they have invested.

The American and Australian Culture Differences

Why do you think this happened? Why do some Australians invest in the United States and end up being disappointed? Even if we read about 15% returns – 25% returns. I will examine that fact for you in a little while. But before that, I’d like to go back to analyzing the differences between the way Australians do business from the way the Americans do business. Most of this is outlined in the book, written in the 1970’s called, “American and Australian Cultural Differences”.

In the book that Donald Trump wrote, “The Art of the Deal”, he simply mentioned there is no such thing as a win-win in business. It has always been ‘I win and you lose’. Here’s the first major difference, in Australia, people come first, then the money comes second. While in the United States, it is the other way around, big business and the big bucks come first before the people. This doesn’t mean that Americans are bad and we are good, we simply have a different culture. Also, our governing laws lean that way.

Our Australian culture and mentality are reflected in our legal system, a system that is shared with both legal and equitable law. Once a judge sees a contract that he doesn’t like, he can overturn the contract since under the equitable law, which means fair play law. Unfortunately, this is not how it works in the American playing field. The real deal is always on the piece of paper.

On the lighter side of playing in the US market is, we both can sit down and talk work out a contract. I can even trade a portion of a property in the US for only $7. As long as we both sign a one page General Warranty Deed or Warranty Deed, that property is bought for $7. And it costs that much because that is what cost me to record this at the local courthouse and make the purchase. That is the deal whether we had a creative lease option or an installment contract. Unfortunately, if you get into some bad terms, you have no government body to come in and looks after you. The deal is, the dollar comes first.

So, if ever you are in a country where the real estate has an “I win and you lose” kind of rule, be careful. They do have the different set of rules.

Here are some interesting stories of what actually happened over the years. Perhaps by the end of this article, some people can instill in their heads that the US may not be the best place to invest, unless, you already live there.

US Property Management
A lot of Australians assume that the US Property Management is handled the same way as it is in Australia. Here, when you buy or sell a piece of real estate, it is managed by the real estate agent. In the US, the people who sold the property to you have nothing to do with the management. Here, it is difficult to find someone who shares the same moral code as in Australia. And if ever you find one, it is expensive, and it can drain you financially.

All About Affordable Health Insurance Plans

While consumers search for affordable health insurance, they have priced in their mind as the top priority. A general conception among the consumers is that cheap health plans should not be costly the cheapest health plan available in the market is their target. However, this approach is not good. Sometimes, paying for a cheap health insurance plan but still not getting the required level of coverage results only in wastage of money.

With the implementation of the affordable care act, the reach of affordable health plans is set to increase. Or at least, this is what is believed to be the objective of healthcare reforms. However, lots of consumers are still in confusion about how things would work. In this article, we will discuss some detailed options that consumers can try while looking to buy affordable health plans.

To get a hand on affordable health insurance plans, consumers need to take of certain things. First among them is about knowing the options in the particular state of the residence. There are lots of state and federal government-run programs that could be suitable for consumers. Knowing the options is pretty important. Next would be to understand the terms and conditions of all the programs and check the eligibility criteria for each one of them. Further, consumers should know their rights after the implementation of healthcare reforms, and something within a few days, they may qualify for a particular program or could be allowed to avail a particular health insurance plan. If consumers take care of these steps, there is no reason why consumers can’t land on an affordable health plan that could cater to the medical care needs.

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Let’s discuss some options related to affordable health insurance plans state-wise:

State-run affordable health insurance programs in California

While considering California, there are three affordable health insurance plans that are run by the state government. Consumers can surely get benefitted by these if they are eligible for the benefits.

• Major Risk Medical Insurance Program (MRMIP)

This program is a very handy one offering limited health benefits to California residents. If consumers are unable to purchase health plans due to a preexisting medical condition, they can see if they qualify for this program and get benefits.

• Healthy Families Program

Healthy Families Program offers Californians with low-cost health, dental, and vision coverage. This is mainly geared to children whose parents earn too much to qualify for public assistance. This program is administered by MRMIP.

• Access for Infants and Mothers Program (AIM)

Access for Infants and Mothers Program provides prenatal and preventive care for pregnant women having low income in California. It is administered by a five-person board that has established a comprehensive benefits package that includes both inpatient and outpatient care for program enrollees.

Some facts about affordable health insurance in Florida

Getting Insurance To Pay For Preventive Health Under The ACA

The Affordable Care Act (ACA) mandates that health insurance companies pay for preventive health visits. However, that term is somewhat deceptive, as consumers may feel they can visit the doctor for just a general checkup, talk about anything, and the visit will be paid 100% with no copay. In fact, some, and perhaps most, health insurance companies only cover the A and B recommendations of the U.S. Preventive Services Task Force.

These recommendations cover such topics as providing counseling on smoking cessation, alcohol abuse, obesity, and tests for blood pressure, cholesterol, and diabetes (for at risk patients), and some cancer screening physical exams. BUT if a patient mentions casually that he or she is feeling generally fatigued, the doctor could write down a diagnosis related to that fatigue and effectively transform the “wellness visit” into a “sick visit.” The same is true if the patient mentions occasional sleeplessness, upset stomach, stress, headaches, or any other medical condition. In order to get the “free preventive health” visit paid for 100%, the visit needs to be confined to a very narrow group of topics that most people will find vert constrained.

Similarly, the ACA calls for insurance companies to pay for preventive colonoscopy screenings for colon cancer. However, once again there is a catch. If the doctor finds any kind of problem during the colonoscopy and writes down a diagnosis code other than “routine preventive health screening,” the insurance company may not, and probably will not, pay for the colonoscopy directly. Instead, the costs would be applied to the annual deductible, which means most patients would get stuck paying for the cost of the screening.

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This latter possibility frustrates the intention of the ACA. The law was written to encourage everyone – those at risk as well as those facing no known risk – to get checked. But if people go into the procedure expecting insurance to pay the cost, and then a week later receive a surprise letter indicating they are responsible for the $2,000 – $2,500 cost, it will give people a strong financial disincentive to getting tested.

As an attorney, I wonder how the law could get twisted around to this extent. The purpose of a colonoscopy is determined at the moment an appointment is made, not ex-post facto during or after the colonoscopy. If the patient has no symptoms and is simply getting a colonoscopy to screen for colon cancer because the patient has reached age 45 or 50 or 55, then that purpose or intent cannot be negated by subsequent findings of any condition. What if the doctor finds a minor noncancerous infection and notes that on the claim form? Will that diagnosis void the 100% payment for preventive service? If so, it gives patients a strong incentive to tell their GI doctors that they are only to note on the claim form “yes or no” in response to colon cancer and nothing else. Normally, we would want to encourage doctors to share all information with patients, and the patients would want that as well. But securing payment for preventive services requires the doctor code up the entire procedure as routine preventive screening.

The question is how do consumers inform the government of the need for a special coding or otherwise provide guidance on preventive screening based on intent at the time of service, not on subsequent findings? I could write my local congressman, but he is a newly elected conservative Republican who opposes health care and everything else proposed by Obama. If I wrote him on the need for clarification of preventive health visits, he would interpret that as a letter advising him to vote against health care reform at every opportunity. I doubt my two conservative Republican senators would be any different. They have stand pat reply letters on health care reform that they send to all constituents who write in regarding health care matters.

To my knowledge, there is no way to make effective suggestions to the Obama administration. Perhaps the only solution is to publicize the problem in articles and raise these issues in discussion forums

There is a clear and absolute need for government to get involved in the health care sector. You seem to forget how upset people were with the non-government, pure private sector-based health care system that left 49 million Americans uninsured. When those facts are mentioned to people abroad, they think of America as having a Third World type health care system. Few Japanese, Canadians, or Europeans would trade their existing health care coverage for what they perceive as the gross inequities in the US Health Care System.

The Affordable Care Act, I agree, completely fails to address the fundamental cost driver of health care. For example, it perpetuates and even exacerbates the tendency of consumers to purchase health services without any regard to price. Efficiency in private markets requires cost-conscious consumers; we don’t have that in health care.

Ten Tips for Comparing Health Care Policies

Australians already know that health coverage can provide security for individuals and families when a medical need arises. Many, however, do not know how to find the best value when comparing health insurance policies.

Below are 10 tips everyone should read before shopping for private health coverage.

1. Choose coverage that concentrates on your specific health needs or potential health needs.

The first thing you should do before comparing your health plan options is determine which policy features best fit your needs. A 30-year-old accountant, for instance, is going to need very different coverage than a 55year-old pro golfer, or a 75-year-old retired veterinarian. By understanding the health needs that most often correspond to people in your age and activity level group – your life stage – you can save money by purchasing only the coverage you need and avoid unnecessary services that aren’t relevant. For instance, a young family with two small children isn’t going to need coverage for joint replacement or cataract surgery. A 60-year-old school teacher isn’t going to need pregnancy and birth control-related services.

Whether it’s high-level comprehensive care you’re after, or the least expensive option to exempt you from the Medical Levy Surcharge while providing basic care coverage, always make sure you’re comparing health insurance policies with only those services that make sense for you and your family.

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2. Consider options such as Excess or Co-payment to reduce your premium costs.

When you agree to pay for a specified out-of-pocket amount in the event you are hospitalized, you sign an Excess or Co-payment option that will reduce your health insurance premium.

If you choose the Excess option, you agree to pay a predetermined, specific amount when you go to hospital, no matter how long your stay lasts. With a Co-payment option, you agree to pay a daily sum up to a pre-agreed amount. For example, if Joanne has an Excess of $250 on her medical coverage policy and is admitted to hospital, regardless of how long her stay turns out to be, she will pay $250 of the final bill. If Andrew has signed a $75×4 Co-payment with his provider, he will pay $75 per day for just the first the first four days of his hospitalization.

For younger individuals who are healthy and fit with no reason to expect to land in the hospital anytime soon, either of these options is great ways to reduce the monthly cost of your medical insurance premiums.
Keep in mind that different private insurers have their own rules when it comes to Excess and Co-payments, including how many payments you will need to make annually on either option. It is important to read the policy thoroughly and ask questions in advance in order to have a clear understanding of what you are paying for, and what you can expect coverage-wise in the event that you are hospitalized. Also, make sure you choose an Excess option greater than $500 if you’re purchasing an individual policy, or $1,000 for family coverage, in order to be exempted from the Medicare Levy Surcharge.

3. Pay your health insurance premium in advance before the cost increases.

Each year insurance providers increase their premiums by approximately five percent sometime around the first of April, a practice approved by the Minister of Health. By instituting these annual increases, your health insurance provider retains the ability to fulfill their obligations to policyholders despite increasing medical costs.

Most private medical policy providers allow policy holders to pay for one year’s premium in advance, which locks them into the previous year’s rate for an additional 12 months – a great way to save money. In order to take advantage of the savings offered, most insurers require payment in full be made within the first quarter of the year, between January and March.

4. Lock in to low cost health insurance at an early age.

The most obvious advantage any Australian can take when it comes to saving money on your insurance premiums is to buy in early to the least expensive rate available. And by early, we mean before age 31. Everyone who is eligible for Medicare will receive at least a 30 percent rebate from the government on the price of their health care premium, no matter what age you are. However, by purchasing hospital coverage before the July first following your 31st birthday, you can be ensured the lowest premium rate available.

After age 31, your health insurance rate is subjected to a two percent penalty rate increase for every year after age 30 that you did not have health insurance. Therefore, if you wait to purchase private health coverage until your age 35, you will pay 10 percent more annually than you would have if you had purchased it at age 30.

There are exemptions for some people who were overseas when they turned 30, or for new immigrants, and certain others under special exception status. However, if you purchased private insurance after age 30 and are paying an age loading penalty on your health coverage, you will be relieved of the excess penalty after 10 years of continuous coverage.

The earlier in life that you lock into a private health plan, the more money you will save both immediately and over your lifetime.

Health Care Reform – Why Are People So Worked Up?

Why are Americans so worked up about health care reform? Statements such as “don’t touch my Medicare” or “everyone should have access to state of the art health care irrespective of cost” are in my opinion uninformed and visceral responses that indicate a poor understanding of our health care system’s history, it’s current and future resources and the funding challenges that America faces going forward. While we all wonder how the health care system has reached what some refer to as a crisis stage. Let’s try to take some of the emotion out of the debate by briefly examining how health care in this country emerged and how that has formed our thinking and culture about health care. With that as a foundation let’s look at the pros and cons of the Obama administration health care reform proposals and let’s look at the concepts put forth by the Republicans?

Access to state of the art health care services is something we can all agree would be a good thing for this country. Experiencing a serious illness is one of the life’s major challenges and to face it without the means to pay for it is positively frightening. But as we shall see, once we know the facts, we will find that achieving this goal will not be easy without our individual contribution.

These are the themes I will touch on to try to make some sense out of what is happening to American health care and the steps we can personally take to make things better.

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A recent history of American health care – what has driven the costs so high?
Key elements of the Obama health care plan
The Republican view of health care – free market competition
Universal access to state of the art health care – a worthy goal but not easy to achieve
what can we do?
First, let’s get a little historical perspective on American healthcare. This is not intended to be an exhausted look into that history but it will give us an appreciation of how the health care system and our expectations for it developed. What drove costs higher and higher?

To begin, let’s turn to the American civil war. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause ghastly results. Not generally known is that most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace and this caused severe delays in treating the wounded. Secondly, many wounds were subjected to wound care, related surgeries and/or amputations of the affected limbs and this often resulted in the onset of massive infection. So you might survive a battle wound only to die at the hands of medical care providers who although well-intentioned, their interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!

Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war, there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part, the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and increasingly attempt risky surgeries (now largely performed in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.

This very basic review of American medical history helps us to understand that until quite recently (around the 1950’s) we had virtually no technologies with which to treat serious or even minor ailments. Here is a critical point we need to understand; “nothing to treat you with means that visit the doctor if at all were relegated to emergencies so in such a scenario costs are curtailed. The simple fact is that there was little for doctors to offer and therefore virtually nothing to drive health care spending. A second factor holding down costs was that medical treatments that were provided were paid for out-of-pocket, meaning by way of an individual’s personal resources. There was no such thing as health insurance and certainly not health insurance paid by an employer. Except for the very destitute who were lucky to find their way into a charity hospital, health care costs were the responsibility of the individual.

Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges

The United States is facing the largest shortage of healthcare practitioners in our country’s history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.

This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati-based HIE and one of the largest community-based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases, communication can be achieved but the process is cumbersome and often ineffective.”

United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid-America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.beneficios-deporte-en-la-salud.jpg (1600×1062)

History of Health Information Exchanges

Major urban centers in Canada and Australia were the first to successfully implement HIE’s. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it’s third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.

In the United States, one of the earliest HIE’s started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.

In Tennessee Regional Health Information Organizations (RHIO’s) initiated in Memphis and the Tri-Cities region. Carespark, a 501(3)c, in the Tri-Cities region was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta, the Midsouth eHealth Alliance is an RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.

Diet or Exercise: What’s Best for the Middle-Aged Heart

THURSDAY, Sept. 15, 2016 (HealthDay News) — In case you’re a center-elderly sofa potato in severe want of boosting your coronary heart health, is it better to exercising or food regimen?

New research says weight-reduction plan, workout or a mixture of the two can all get the task done about equally nicely so long as you lose some weight.

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But the examine authors brought that exercising in tandem with weight-reduction plan might be the excellent manner to head.

The researchers designed the three examine interventions so people participating could drop approximately 7 percent of their body weight — through any method — over a roughly three-month length.

The have a look at confirmed it did not appear to remember which intervention humans chose to lose weight. Members in all 3 corporations noticed their lifetime cardiovascular hazard drop from 46 percentage to 36 percent.

“workout and a low-calorie healthful weight loss plan are both known to improve chance elements for cardiovascular ailment, even within the absence of weight reduction,” said observe lead author Edward Weiss. He’s an associate professor at Saint Louis University’s branch of nutrients and dietetics, in Missouri.

“In light of this, we predicted the aggregate of eating regimen and workout to have ‘additive effects’ on danger elements, and consequently anticipated more upgrades inside the mixed-intervention organization, in comparison to eating regimen or exercising alone,” he stated.

Rather, the study observed that “the magnitude of gain does not rely upon whether food plan, exercise, or a combination of weight loss program and workout is used to sell weight loss,” Weiss stated.

What without a doubt regarded to count number became that people slimmed down.

For the look at, investigators divided 52 obese men and women into one in every of three organizations: a food plan institution; an exercising institution; and a combined food plan and workout organization.

Dieters were instructed to cut 20 percentage in their caloric consumption, at the same time as exercisers have been advised to boom pastime degrees through 20 percentage. The mixture organization turned into advised to do both with the aid of 10 percent.

Weiss described a 20 percentage caloric cutback as “modest for the majority,” equaling a drop of about three hundred to 500 calories consistent with day — kind of the equal of two sugary sodas.

But “increasing calorie expenditure with the aid of 20 percentage in step with day is greater difficult,” he said. “In particular for the non-exercising ladies and men who have been recruited for this take a look at. This interprets to taking walks three to 5 miles, six to seven days in step with week, for someone who turned into no longer exercising once they began the study.”

In the end, all three corporations registered the identical degree of improvement in terms of blood pressure, cholesterol levels and coronary heart fee, and the same amount of heart disorder risk discount, the observe findings confirmed.

But Weiss although suggested that a blended technique can be best.

The mixture group misplaced weight more fast and these people have been additionally more likely to paste to their desires, he cited. approximately 30 percent of study Participants from the diet or exercising corporations dropped out, However only five percent of the aggregate institution cease.

weight loss program and exercise collectively may additionally have “additive benefits for other elements of fitness,” Weiss said. For example, a bigger cut in type 2 diabetes threat changed into visible among those who embraced each tactics.

And for reasons not absolutely clean, including exercise to weight-reduction plan appears to specially confer a cardiovascular advantage, he added.

“If two humans have the same blood strain, cholesterol, circle of relatives records, age, etcetera, But one person sporting activities and the other does now not, the non-exerciser is -to-three instances more likely to expand coronary heart disorder,” Weiss said.

Registered dietitian Lona Sandon agreed that “both healthy eating and exercising are crucial given what we recognize from preceding studies demonstrating the gain of every.”

Sandon defined that “a healthful diet offers key nutrients for most reliable functioning of the frame and ailment prevention. workout can’t offer nutrients, But may additionally help us make use of nutrients more correctly.”

And she or he stated that the important thing to fulfillment is selecting delight over pain.

“If walking or strolling on a treadmill seems like punishment, locate something else to do. Possibly weight training, Zumba, or strolling inside the park is a higher option,” suggested Sandon. She is an assistant professor of clinical nutrition at the College of Texas Southwestern Scientific Middle at Dallas.

“equal factor applies to eating,” she delivered. “If ingesting kale smoothies looks as if punishment, don’t trouble. Have some carrot sticks dipped in light ranch dressing Rather, or hold dessert to just one time consistent with week.”