Category Archives: Affordable Care Act

Why can’t direct primary care get more traction?

KS97453smThe Affordable Care Act (ACA) allows Direct Primary Care (DPC) providers to compete with traditional health insurance options when combined with a low cost high deductible plan in the health insurance exchange.

The DPC provider may only see 50 patients, allowing thorough conversations and building trust, which helps identify problems earlier and avoid illnesses. The traditional primary care provider could have 2,500 patients and 10-12 minute visits. The DPC also cuts 10-20% off the cost of healthcare simply by not billing insurance companies.

A monthly fee covers your primary healthcare needs, including the extended office visits, follow-ups on treatment plans, and in-house services such as basic lab work, x-rays, splints and vaccinations. Providers are a mix of physicians, nurse practitioners and physician assistants. The DPC will also recommend and coordinate services with specialists and acute care providers when applicable.

Direct Primary Care (DPC) has had many names, including direct care, direct practice medicine, concierge medicine, concierge health care, boutique medicine, retainer-based medicine, innovative medical practice design, membership medicine, and cash-only practice.  With the ACA penalizing readmissions, and unnecessary admissions, you would think DPCs would be very popular in Washington, DC.  The Direct M.D. Care Act (H.R. 3315) had many sponsors last year, but it’s currently stuck in committee. Reimbursements for Medicare patients, and particularly those who are dual eligible in Medicare and Medicaid are, once again, part of the problem.

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7 questions about nurse-patient ratios

KS97487What would you like to see for nurse-patient ratios? California implemented ratios per unit. Florida and Massachusetts legislatures are currently debating similar bills. Waiting for your state to legislate the answer can’t be the best approach.

Variable ratios based on the unit seems reasonable. Florida is considering: 5 patients to 1 RN for rehabilitation and skilled nursing units; and 1:1 for patients in active labor, receiving conscious sedation, in the ER, or in the OR. Does a CNS count the same as an MSN or ADN?

The upcoming RN shortage is undeniable. 50 states legislating RN ratios would be a real problem. Is there a place for LPNs in your hospital?

The Affordable Care Act is pushing more and more healthcare to outpatient settings. Will they legislate RNs at urgent care clinics and surgical centers?

Congress seems unwilling to consider any of the national bills on nurse-patient ratios (insert for favorite jab here). Has your state hospital association come to a consensus? Do you agree with it?

The American Nurses Association (ANA) argues that hospitals should personalize staffing plans for individual hospital units, accounting for individual patient needs and staff experience levels. That doesn’t sound bad, does it?

26 states allow the public to place issues on the ballot. They just wants the child, parent, or grandparent to get well. Do you want the public to decide our ratios? If not, then we better be proactive and find a solution.

How’s your hospital’s quality? Are you sure? Who told you?

Anyone can rate your hospital’s quality of care. Without transparency, each opinion is as valid as your dad’s (didn’t say mom’s cause no one crosses her!).  Defining the metrics, where and how was the data gathered, what period is measured vs. what’s an extrapolation, etc. Learned in college, ‘you can prove anything with enough numbers’ and ‘statistics don’t lie, statisticians do’ (dad was a statistician).

The AAMC (Association of American Medical Colleges) convened a panel of quality experts who developed the Guiding Principles for Public Reporting of Provider Performance (pdf). These 25 principles to evaluate Provider Quality reports call for data and reporting methodologies to be well-defined in terms of purpose, transparency, and validity.

When hospitals are rated, “[they] want to know, ‘How do we talk with our boards, why we should put a lot of emphasis on this rating system or why we shouldn’t, and where is it important?’” explains Joanne Conroy, MD, chief healthcare officer for the AAMC, which spearheaded the project last year. “They need a clear set of principles that’s not their opinion to justify why they should emphasize one [rating] system and not another.”

In fact, none the rating systems published to date, including those from The Joint Commission, the Leapfrog Group, Consumer Reports, Hospital Compare, the Commonwealth Fund, Truven, Healthgrades, and U.S. News and World Report, meet all of the AAMC’s guiding principles. “Nobody meets them all,” Conroy says.

Read More: HealthLeaders Media (3-10-2014)

This is not breaking news. Washington state legislature wants to mandate a statewide Healthcare Procedures Cost Database in response to its ACA implementation. I applaud the efforts for transparency and have trouble trusting those organizations that don’t want to cooperate.

A rural health system can be our model

I love our rural communities. You don’t have to convince them to work together. The people are smart, work hard, and know the value of a dollar. And they can smell a skunk a mile away.

“The only constant is change” is probably the best description of our ‘new normal’ in healthcare. Decreasing inpatient volumes, hospital layoffs, declining reimbursements, mergers and affiliations. Who saw this coming? Clearly, incremental improvements to old processes is no longer “leadership.” I think our rural health system has some distinct advantages that we can learn from.

Rural communities are used to pulling together out of necessity. The local Critical Access Hospital (CAH) already supplies some of the best paying and most stable jobs in town. More importantly, it’s home. My father-in-law had to drive 25 miles to get to his CAH; trying to convince him to go 50 miles the other direction for that ‘big city’ hospital was a waste of time.

So a quality, post-discharge, patient care plan is a plausible goal. Formalizing the integration is work, but not unrealistic. Start with something simple, like HIPPA. Who needs to know what to achieve this quality patient care plan. Suddenly you’ve identified the players and defined the responsibilities. And, since it’s rural, everybody has a right to participate. Federally qualified health centers (FQHCs), rural health clinics (RHCs), community health centers (CHCs), DENTISTS (personal bias), WIC clinics, skilled nursing homes, home health agencies, faith-based organizations, and Telehealth (since most CAHs can’t provide 24×7 pharmacy services).

A review process is important for quality assurance and continuous performance improvement, which will lead to ‘discussions’ about costs and reimbursements. But there’s already one CAH/FQHC collaboration success story (Sakakawea Medical Center and Coal Country Community Health Center in N.D.), so it can be accomplished!

And once those ‘yokels’ make it work, then what’s our excuse?