Monthly Archives: March 2014
The Affordable Care Act, in theory, allows uninsured Americans the opportunity to obtain reasonably priced health insurance. Unfortunately, not only have there been issues with the health insurance exchange, millions of Americans have been left uninsured and cannot afford the health insurance plans offered to them. One proposed solution to this dilemma is the expansion of states’ Medicaid/Child Health Insurance Programs. The Affordable Care Act expanded Medicaid eligibility to cover more people who can’t afford health insurance. Contradictory to the ‘universal’ intentions of the ACA, the U.S. Supreme Court later decided that it was up to individual states to decide whether or not to expand Medicaid.
Despite trying to extend health insurance coverage, and thus minimizing a huge source of economic insecurity in many parts of the county, a little over half of states have opted to expand eligibility for Medicaid as the Affordable Care Act called for – the provision that was supposed to achieve half of the law’s coverage expansion, with the other half coming via subsidies for people earning about 133% of the poverty level to buy private plans on the exchange.
Shortly after the Supreme Court ruled that states can choose whether to adopt the health reform law’s Medicaid expansion to cover low-income parents and other adults, some governors declared that they will forgo the expansion, claiming it would place a heavy financial burden on their states. Claims that states will bear a substantial share of the costs of expanding Medicaid, however, and that the expansion would drain state budgets do not hold up under scrutiny.
Congressional Budget Office (CBO) estimates show that the federal government will bear nearly 93 percent of the costs of the Medicaid expansion over its first nine years (2014-2022). The federal government will pick up 100 percent of the cost of covering people made newly eligible for Medicaid for the first three years (2014-2016) and no less than 90 percent on a permanent basis. The additional cost to the states represents a 2.8 percent increase in what they would have spent on Medicaid from 2014 to 2022 in the absence of health reform, the CBO estimates indicate. This 2.8 percent figure significantly overstates the net impact on state budgets because it does not reflect the savings that state and local governments will realize in other health care spending for the uninsured.
A state’s decision not to go ahead with the Medicaid expansion, despite this extremely favorable financing, would have adverse consequences for many poor individuals and families without health insurance.
- In the typical (or median) state today, a working-poor parent loses eligibility for Medicaid when his or her income reaches only 63 percent of the poverty line (about $12,000 for a family of three in 2012). An unemployed parent must have income below 37 percent of the poverty line (about $7,100 in 2012) in the typical state in order to qualify for the program. Only a handful of states provide coverage to any low-income adults without dependent children, regardless of how poor they are.
- Only individuals with incomes between 100 and 400 percent of the federal poverty line will be eligible for premium and cost-sharing subsidies to buy coverage through health reform’s new health insurance exchanges.
- In states forgoing the Medicaid expansion, therefore, working people with incomes above the Medicaid eligibility limit but below the poverty line would have neither Medicaid nor subsidized exchange coverage. Due to the low wages they earn, many working-poor parents would have incomes too high to qualify for Medicaid but too low to qualify for subsidies to buy coverage in the exchanges. Many would likely remain uninsured and go without needed care leaving them at risk of remaining uninsured if their states do not move forward and expand Medicaid.
Nevada was one of the first states to expand Medicaid coverage. Please check and see if your state has elected to expand this coverage or not and feel free to comment.
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Somewhere along the “Loneliest Road in America,” there sits a small town with a population of a few thousand people. In this town, there is a handful of health care professionals who reliably treat the entire population of Ely and the rest of eastern Nevada. Nevada is the 7th most extensive, the 35th most populous, and the 9th least densely populated of the 50 United States. In fact, 86% of the state’s land is owned by various jurisdictions of the U.S. federal government. While the competence level of clinicians in rural Nevada is not in question, one does wonder how a patient might go about getting a second opinion or further specialist care without having to invest a significant amount of time, money, and other resources traveling to the nearest metropolitan area. This answer can be summed up in one word: Telemedicine.
Telemedicine, or telehealth services include diagnosis, treatment, assessment, monitoring, communication, and education delivered primarily through three kinds of technology: videoconferencing, remote patient monitoring, and store-and-forward offerings, which transmit digital images between providers.
As with many metropolitan hospitals, the health care organization that I work for offers telemedicine service to many rural areas in the region including Ely, NV. R-TeleMed is a partnership between Nevada Health Centers, Nevada Hospital Association, Nevada Rural Hospital Partners, Renown Health, University of Nevada School of Medicine and independently practicing physician specialists based in Reno, Nevada. It allows highly skilled physician specialists in Reno to consult on the evaluation, diagnosis and treatment of patients in outlying areas.
According to our website, R-Telemed is a telemedicine program that uses secure video conferencing technology to enable long-distance medical care between a rural patient and their healthcare provider, in conjunction with a physician specialist in Reno, Nevada. Using state-of-the-art technology specifically adapted for telemedicine, the physician specialist conducts a live, interactive discussion with the patient and rural healthcare provider to obtain a comprehensive medical history and perform a thorough physical exam. The rural healthcare provider and physician specialist work together on the diagnosis and treatment plan.
Telemedicine has many benefits, including:
•Convenient access to specialists that may not be available locally, especially when time is critical for diagnosing and treating serious conditions.
•Allows patients to receive specialized care close to work, home and family while minimizing the cost and inconvenience of traveling long distances for medical treatment.
•Allows two-way communication between the physician specialist and rural patient, allowing a more detailed and comprehensive review of the patient’s medical history and current condition.
If you live in a rural area, I invite you to search for telemedicine services in your area. If you live in rural Nevada, I invite you to visit this link.
Imagine if you had been waiting in your physician’s office for over an hour only to be told exactly what you were feeling, what you will take for it, and how you will feel in a matter of days. While this may not be completely unusual, imagine that you had no opportunity to voice your own concerns during this process. I recently became interested in the concept of the patient-centered medical home, or PCMH, and the principles that govern their operation. The patient-centered medical home is a model organization of primary care that provides patient-centered, comprehensive, accessible, coordinated care, and a systems-based approach to quality and safety. When all of these items are working together, it transforms primary care into “what patients want it to be.” Not only can medical homes lead to higher quality and lower costs, they can improve patients’ and providers’ experience of care.
The medical home encompasses five functions and attributes:
– Comprehensive Care: Providing sufficient care to patients involves a team of health care practitioners.
– Patient-Centered: The PCMH provides primary health care that is relationship-based wit an orientation toward the whole person.
– Coordinated Care: Patient treatment is coordinated among all health care outlets, including specialty care, hospitals, home health care, and community services.
– Accessible Services: Instrumental in the PCHM is the ability to deliver accessible services with shorter waiting times, enhanced in-person hours, and around the clock telephone or electronic access to a member of the care team.
– Quality and Safety: The PCMH demonstrates a commitment to quality and quality improvement.
I believe that the above characteristics of a PCMH shouldn’t be limited to those coordinated models of treatment and greater emphasis should be placed on keeping patients and their families engaged throughout all treatment systems. Patients should not only be involved in their own health care, but serious consideration should be given to their insights regarding practice improvement, policy design and implementation. An increased level of engagement can improve patient knowledge, self-efficacy, outcomes, and may even lead to reductions in utilization or costs of care. Unfortunately, there is no one-size-fits all solution; patient engagement will look very different for different practices, patient populations, and individual patient-provider interactions. I challenge all health care providers to examine closely the benefits as well as the limitations of the PCMH model and apply these important principles in their own practices or health care organizations.
Help! These are the first words that came to mind when a Director and a seasoned Project Manager sat me down and told me that they wanted me to manage the implementation of a new product. Sure, in my last job, I held the title of “Project Manager,” but that was more of a formality than a job description. I was a glorified customer service rep, fielding calls from clients who were asking about anything from the rush status of their sample analysis to the contents of their sampling kits. I had only been in my current position for a couple of months or so before they hit me with this responsibility. I tried to explain to them that I didn’t REALLY have any project management experience and that I would probably be better off if I just took a back seat on this one, but they wouldn’t hear it. They were insistent that it would be better for me in the long run if they just drove me out to the middle of the proverbial lake, threw me in, and expected me to learn to swim. Over the past few months managing this project I have learned a few things that I hope to share with you today.
First, know the key players and form your project team. Unfortunately for this project, it started out with a team of almost twenty individuals all with competing agendas and varying levels of corporate responsibility. During our first few meetings it became apparent to me that not everyone needed to be involved in these meetings or even on the project team. Either they had ideas that were irrelevant to what we were trying to accomplish or they would dump water into our sinking boat as quickly as I could bail it out. Under the guidance of the wise project manager, we shuffled people in and out of the project team, formed a steering committee, and designated an executive sponsor, a project sponsor, and a project champion. Not only has this helped the meetings to run more smoothly, but it has helped me learn who the key players are and delegating responsibility.
Second, follow-up, follow-up, follow-up. I have found that this is critical in getting things done. As I mentioned before, with many different team members from diverse backgrounds and departments it is important to be as diligent as possible checking-in with the members of your team. This has not only helped them to stay on track, but has also given me the knowledge I need to manage the expectations and needs of my team.
Third, get your butt out of the chair. Emails and phone calls are limited in their effectiveness. Sometimes key members of my team would be so behind checking their emails that an important project-related email would get buried under a mountain of “spam.” (For the purposes of this entry, I will refer to emails not having anything to do with my project as spam). If they weren’t getting the message through email, sometimes they would be too preoccupied to answer the phone. Either that or they were screening my calls. If I knew that they were on site, I would take a walk to their office and “hover,” – for lack of better word – until I could gain an audience with them.
Fourth, keep your superiors informed to help ensure their buy-in. Thank you again to my secret weapon (the veteran project manager), for helping me to develop a bi-weekly status report. This one page summary of our activities over the prior two weeks has quickly earned the respect of our project sponsor and our executive sponsor. Because both of these individuals have a lot more responsibilities than I do, this direct and to-the-point document helps them to know exactly where we are at in the process. A brief outline of my document can be found below:
I know that this was a departure from my previous posts, but sometimes it can be refreshing to break free from old habits. Please let me know if you like this style of blog post better than previous ones or if you have any advice about managing a project I would love to hear!
Thank You for Reading!
Imagine seriously injuring yourself, requiring surgical treatment, but not having the insurance or the means to cover the skyrocketing cost of domestic healthcare. Would you submit yourself to treatment at a U.S. hospital, or would you seek out medical care in a foreign country? While it may be significantly cheaper to be treated at an international hospital, one should seriously weigh the pros and cons before wearing the hat of a “Medical tourist.”
“Medical tourism” refers to traveling to another county for medical care. One study estimated that in 2007 up to 750,000 U.S. residents traveled abroad for care. Another consultancy, found that at most 10,000 patients made a healthcare seeking trip only one year later. As we can see, the data is still questionable. Patients Beyond Borders estimates that as many as 12 million people globally now travel for care, the primary motivation being cost savings. In addition to being less expensive, a large number of medical tourists are immigrants to the U.S. returning to their home country for care. Some of the most common procedures that people undergo are cosmetic surgery, orthopedic surgery, heart surgery, and dentistry.
I can understand traveling the world seeking top-notch medical care if you are among the world’s richest citizens or if you feel more comfortable at a hospital in your home country with physicians who share your cultural practices. However, I don’t know if the benefits outweigh the potential risks that come with medical tourism. The following is by no means an all encompassing list of the risks that medical tourists face.
1) Communication – if you are unable to communicate in the native language of your clinician you increase the possibility of misunderstandings arising about your care.
2) Safe Injection Practices – and I would even venture to expand this to infection control procedures in general. Not all countries have strict regulations regarding infection control and so you run the risk of contracting a life-threatening infection such as HIV, hepatitis, or a drug-resistant bacterial infection.
3) Pharmaceuticals – these may be counterfeit or of poor quality in some countries.
4) Blood Supply – the blood supply in some countries comes primarily from paid donors and may not be screened which also puts patients at risk for contracting blood borne pathogens.
5) Flying – flying after surgery increases the risk for blood clots that can increase your risk of TIA or pulmonary embolism.
If you are planning on traveling to another country for medical care, the CDC outlines several key recommendations to help keep you safe.
1) See a travel medicine practitioner at least 4–6 weeks before the trip to discuss general information for healthy travel and specific risks related to the procedure and travel before and after the procedure.
2) Check for the qualifications of the health care providers who will be doing the procedure and the credentials of the facility where the procedure will be done. The Joint Commission International (US-based) certifies health care facilities according to specific standards.
3) Make sure that you have a written agreement with the health care facility or the group arranging the trip, defining what treatments, supplies, and care are covered by the costs of the trip.
4) Determine what legal actions you can take if anything goes wrong with the procedure.
5) If you go to a country where you do not speak the language, determine ahead of time how you will communicate with your doctor and other people who are caring for you.
6) Obtain copies of your medical records that includes the lab and other studies done related to the condition for which you are obtaining the care and any allergies you may have.
7) Prepare copies of all your prescriptions and a list of all the medicines you take, including their brand names, their generic names, manufacturers, and dosages.
8) Arrange for follow-up care with your local health care provider before you leave.
9) Before planning “vacation” activities, such as sunbathing, drinking alcohol, swimming, or taking long tours, find out if those activities are permitted after surgery.
10) Get copies of all your medical records before you return home.
If you have any stories about you or someone you know who has gone overseas for elective surgery or other medical care I would love to hear them!
Other resources include:
One of my post education goals is to work my way up the corporate ladder of a health care system. Whether that takes the form of continuing to work at my current place of employment within the insurance industry or make a lateral move into our associated hospital system, one thing is for sure: anywhere that I end up, I could potentially end up managing healthcare professionals. To be completely honest, this prospect is a little intimidating. Fortunately, there is a wealth of advice on the internet that is there to help out anyone who may be struggling with the same concerns that I have.
Influencing clinician behavior can be very difficult given the default nature of the healthcare economic system, where a there exists a matrix of accountability to many different types of stakeholders. Unlike companies in most any other line of business, there exists no singular “boss” or individual who has hiring/firing authority in the relationship between hospital, insurance companies, patients and physicians.
I have no doubt that there may come a day when I will experience the natural tension that can occur between doctors and managers. According to one article, the fundamental problem is a paradox between calls for a common set of values and the need to recognize that doctors and managers do and should think differently. If managers suddenly became preoccupied with the needs of an individual patient, irrespective of the consequences for others or for their budget, then the health system would collapse. If doctors decided that their principal concern was to ensure the smooth running of the system and the delivery of policy irrespective of the consequences for the patient in front of the, then both the quality of care and public support would collapse. Managers worry about patient experience while doctors worry about patient outcomes. It is suggested that patients are best served by a tension between the two.
Before we address the aforementioned paradox, we must first admit that it exists. Clinicians have traditionally favored professional autonomy, the focus on individual patients, the desire for self-regulation, and the role of evidence based practice. Managers, however, have consistently emphasized populations, the need for public accountability, the preoccupation with systems, and the allocation of resources.
How can we reconcile these differences? The article proposes three solutions as well as potential concerns:
1) Is the solution to deny the legitimacy of any management involvement in clinical issues? This argument ignores the mounting body of evidence that badly managed organizations fail patients, frustrate staff, deliver poor quality care, and cannot adapt to the rapidly changing environment in which they operate.
2) A second solution is to improve the quality of health service managers although there is little evidence to support this view and some to the contrary.
3) A third solution is to make managers think and behave like doctors or vice versa – this may not be possible or desirable. There is undoubtedly much more scope or mutual understanding. Education, training, induction, and possibly regulation can contribute to this but we should not pretend there are no differences between the way that doctors and managers see the world.
Regardless of what we may feel should be the potential solution, there should be open communication between both parties about a shared purpose and mutual respect rather than an environment of conflict, personal abuse, and blame. Both sides should find ways to work towards the shared goal of better patient care. Solutions can be found that involve constructive dialogue, improved understanding, and mutual respect, but they have to be discovered locally and continually maintained.
While searching for potential sources for this blog, I came across a couple of books that I will try to read during summer break. They are, “Influencer: The Science of Leading Change” and “Difficult Conversation.” If anyone has any other advice that they would like to share about working with clinicians please comment!
Thank you for reading.
I recently became employed at a local business that offers health insurance. While that alone is something to be grateful for, my employer also offers a wellness incentive program that can lower my family’s insurance premium. Employer wellness programs used to mean just having a gym in the office or posters on the wall encouraging people to take the stairs instead of the elevator. Now more companies than ever are using real money, and sometimes penalties, as incentives for workers to get in better shape. Fortunately, our wellness program doesn’t impose any penalties; rather, it is based on the principle of positive reinforcement.
According to a recent Wall Street Journal article, nearly 90% of employers offer financial rewards or prizes to employees who work toward getting healthier. This number is significantly higher than the 57% of companies that offered incentives in 2009. Today’s perks are also worth significantly more. On average, employees can earn up to $521 worth of incentives compared to just $260 five years ago.
New legislation put in place by the Affordable Care Act creates new incentives and builds on existing wellness program policies to promote employer wellness programs and encourage opportunities to support healthier workplaces. These rules support workplace wellness programs including “participatory wellness programs,” which are generally available without regard to an individual’s health status, and “health contingent-wellness programs,” which require individuals to meet a specific standard related to their health to obtain a reward. Examples of the aforementioned programs include programs that reimburse for the cost of membership in a fitness center and programs that provide a reward to those who do not use, or decrease their use of, tobacco.
To successfully promote participation and healthy behavior changes, employers should put employees in a position to gain or achieve something tangible. Plenty of people want to lose weight, quit smoking, or reduce stress. However, those goals often seem out of reach. Offering an incentive – such as a fifty dollar gift card for following a wellness program for a set period of time or an extra paid vacation day for achieving a specific priority health goal – presents an attainable goal with a tangible reward.
With an ever-expanding population of obese individuals, I feel that wellness incentive programs can do a lot for the individual and the company they work for. On the other hand, critics of these types of programs argue that some don’t offer enough protection to consumers or flexibility for businesses. In the following section, I will call out a number of pros and cons to wellness incentives.
First, experts say that while action-based incentive models can motivate employees to take the important steps towards changing their unhealthy behaviors, some incentives don’t encourage healthy behavior beyond the completion of the required programs. Second, employees may like the freedom to choose their health activities rather than having to talk to a nurse or participate in an official program to get the reward. A wellness program that lays out a trail to follow will have more success keeping people involved. Too many options; however, can overwhelm employees, and companies can waste money on programs that won’t effectively address workers’ biggest health problems. Third, employers such as mine offer rewards for taking steps to hit optional benchmarks for cholesterol, blood pressure, and weight. Steps can include enrolling in a weight-management program and reducing BMI. In this type of system, employees are financially motivated to improve their health, instead of getting penalized for not being perfect. Unfortunately, rewarding employees for simply showing up to a wellness program doesn’t mean that they will actually get healthier, and there’s a long way to go from a “morbidly obese” BMI of 40 to a healthy under 25.
A well-designed incentive program conveys a positive commitment from the employer to the employee. Employees need to know you care about their health and you’re willing to do whatever it takes to not only get them healthy but keep them that way. I challenge you to take a look to see if your company offers any type of wellness incentive. If not, develop a personal wellness program that rewards you for meeting your individual health goals.
A $1.2 million settlement with the Department of Health and Human Services (HHS) for failing to erase photocopier hard drives containing electronic protected health information (ePHI). A $50,000 settlement with HHS after a laptop containing unencrypted ePHI is stolen. A $100,000 settlement with HHS after posting surgery and appointment schedules on a publicly accessible Internet calendar. Immeasurable reputation damage after a USB flash drive containing ePHI is lost and patients and the local media are notified. These are just a few real-world examples of the consequences practices, health systems, and health plans have faced due to violations of HIPAA.
What is it? The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress and signed into law in 1996. The Act is broken down into 5 separate Titles, each with a distinct role. Title I of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies. It requires and limits restrictions that group health plans can place on preexisting conditions. Title I also requires insurers to issue policies that provide individuals leaving their group plans with creditable coverage exceeding 18 months. Insurers are also required to renew individual policies for as long as they are offered or provide alternatives to discontinued plans for as long as the insurer stays in the market.
Title II of HIPAA defines policies, procedures and guidelines for maintaining the privacy and security of individually identifiable health information. It also outlines numerous offenses relating to health care and sets civil and criminal penalties for violations. In addition to setting forth precedents against fraud, waste, and abuse the most significant Title II provisions may be contained within the Administrative Simplification rules. These five rules are aimed at increasing the efficiency of the health care system by creating standards for the use and dissemination of health care information. For the purposes of this post I will focus solely on the Privacy Rule.
The Privacy Rule regulates the use and disclosure of Protected Health Information (PHI) held by employer sponsored health plans, health insurers, and medical service providers. PHI is any information held by these entities which concerns health status, provision of health care, or payment for health care that can be linked to an individual. PHI includes: name, address information, telephone numbers, FAX numbers, email, social security numbers, medical record numbers including prescription numbera, member IDs), and account numbers.
How does it affect me? Anyone who has ever been treated by a healthcare professional has at one point given out at least a portion of their PHI. Patients should take protection of their health information as seriously as healthcare professionals and the federal government. In the wake of countless incidents of financial identity theft, medical information identity theft is just as serious of an issue.
What can I do to protect my PHI? First of all, never give out your PHI to entities that aren’t covered by HIPAA law. Second, never give out your social security number if you don’t have to. Third, your best protection against medical identity thieves is to make sure you verify the source before sharing your personal or medical information. Finally, if you have health information stored on your home computer or mobile device – or if you discuss your health information over email – simple tools like passwords can help keep your health information secure if your computer is lost or stolen.
Is my health care practitioner doing enough? In my experience, healthcare providers take the protection of your PHI very seriously. If you are concerned about their level of compliance, I invite you to ask your personal healthcare professional about the compliance programs they have in place. If you would like to learn more about HIPAA regulations, please visit the HHS Website.