Posts Tagged ‘Affordable Care Act’

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Tightly Scripted: One NP’s Experience with Retail Clinics

November 1, 2013

By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor

Retail health clinics (walk-in clinics that are in a retail setting such as a drugstore or discount department store)KarenRoush have become an effective mode of providing increased access to care for many people and a growing source of employment for nurse practitioners (NPs). Their place in the health care arena may take on even more significance as the Affordable Care Act (ACA) increases access to care for previously uninsured people.

I worked as an NP in a retail clinic for about six months while working on my PhD. I left because of concerns I had about the model of practice. It didn’t have to do with the fact that I had to mop the floor at closing time or collect the fees and cash out the “drawer” every night. Nor because I spent eight hours alone in a small windowless room tucked away in the back of a drugstore. Those aspects were not great, but they weren’t deal breakers.

What was a deal breaker was the rigid programming of my practice. The computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer.

The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence. And as much as they insisted the programming was guided by evidence, it was clearly also guided by what would result in the highest level billing code.

From the moment I entered the chief complaint in the computer, it directed me on what to include in the history and what to do for the exam. The problem was that unless I filled out all the information, I couldn’t go on to the next screen. Say I have a feverish four-year-old with tonsillitis, screaming in her mother’s arms, and the computer insists I take her blood pressure. Why? Because there is strong evidence that strep throat is associated with pediatric cardiovascular disease? Nope. It’s because the more systems you include in your exam, the higher the billing code. As a result, I find myself struggling to take an unnecessary blood pressure, causing unnecessary distress for a sick toddler. But unless I put a value in the box asking for the blood pressure, I can’t proceed with the exam. Read the rest of this entry ?

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They’re Not Taking Away Our Puppies (And God Help Them If They Do)

September 30, 2013

By Jacob Molyneux, AJN senior editor/blog editor

I am amazed at the amount of time being wasted on the relatively mundane matter of health care exchanges. It seems we are now facing a government shutdown; there are creepy and misleading advertisements funded by conservative billionaires like the Koch brothers in order to scare people from signing up for insurance; some red states have actually enacted laws forbidding the health care navigators from helping people understand the new system and sign up for it, and many of these states have refused to create their own exchanges to help their citizens comply with the new law.

The ACA is a law. You can’t just ignore it if it doesn’t meet your personal preferences or political ideas. Given the heated rhetoric the Republicans are trotting out about it, you’d think the government was trying to take away our puppies, instead of implementing ideas originally floated by Republicans themselves to make life a bit easier for millions of Americans whose life decisions are unduly ruled by crazy health care billing practices, byzantine insurance regulations, discrimination against those who have chronic conditions, insanely varying pricing for simple tests, and the like. Read the rest of this entry ?

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One Is the Loneliest Number

September 13, 2013

By Shawn Kennedy, AJN editor-in-chief

The great Bartholdi statue, liberty enlightening the world: the gift of France to the American people.  Speculative depiction published the year before the statue was erected. In this depiction the statue faces south; it actually faces east/Wikimedia Commons

The Bartholdi statue, liberty enlightening the world: the gift of France to the American people. Speculative depiction published the year before the statue was erected. In this depiction the statue faces south; it actually faces east/Wikimedia Commons

I’ve been struck recently by how the United States sometimes seems to stand apart from other nations. This is sometimes called “American exceptionalism.”

The most obvious example of this is the recent push—temporarily put on hold due to the emergence of negotiations about the possible handover of Syrian chemical weapons to Russia—to garner support among other nations for a military strike against the Syrian government in response to its use of chemical weapons against its own people.

By now, most of us have seen the graphic videos on media outlets and they are indeed disturbing. There are signs of neurotoxicity in some of the victims: rigid posturing, seizures, and foaming at the mouth. According to news reports, U.S. Secretary of State John Kerry says the evidence is “undeniable” and it deserves a harsh response. While several other countries and alliances have issued statements condemning the use of chemical weapons, thus far, other than France, none have come forward to agree to military action; there seems to be little likelihood of action by the United Nations (UN).

It may well be a case of apples and oranges, but another example of how the United States stands alone in comparison to other developed countries is in our approach to health care. The passage of the Affordable Care Act (ACA), and then the Supreme Court’s upholding of its individual mandate provision, made me think this country would at last join most of the other developed nations of the world in providing for the health of its people.

But how naive I was! The resistance by opponents of the law has now moved to the states, many of which have refused to expand Medicaid or institute the insurance exchanges that are essential to providing health coverage for those currently without it and who must obtain it to meet the individual mandate. According to Kaiser Health News, a number of states are offering insurance exchanges or marketplaces where consumers not covered by employer-provided insurance can “shop” for low-cost plans and plans that fit individual health care needs and budgets (according to one report, a Minnesota resident can purchase a plan for under $100 a month). In those states which declined to set up exchanges, a federal plan will be available. Enrollment in the exchanges is set to begin October 1. Read the rest of this entry ?

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48 Years of Medicare (and Counting)

July 26, 2013

By Shawn Kennedy, AJN editor-in-chief, and Jacob Molyneux, senior editor

Next week marks Medicare’s 48th anniversary. President Lyndon Johnson signed the legislation creating Medicare on July 30, 1965, guaranteeing health coverage for the elderly. With the gradual implementation of the Affordable Care Act (ACA; 2010), Medicare, along with other government and private forms of health insurance, is undergoing changes, with efforts being made to rein in rising costs, combat fraud, tie quality of care to reimbursement, and so on.

PPresident Lyndon B. Johnson signing the Medicare Bill at the Harry S. Truman Library in Independence, Missouri. Former President Harry S. Truman is seated at the table with President Johnson. Photo: National Archives and Records Administration.

President Lyndon B. Johnson signing the Medicare Bill. Former President Harry S. Truman is seated at the table with President Johnson. Photo: National Archives and Records Administration.

With the ACA’s date for mandated purchase of health insurance fast approaching, some states are setting up state-run health insurance exchanges to provide consumers with a standardized menu of health insurance plans in order to make it easier to purchase a plan that fits both budget and health care needs. Other states have refused to participate (see “Policy and Politics: Update on the Affordable Care Act” in the April 2013 issue of AJN); by default, citizens of those states will instead participate in federally run exchanges.

The debate over government-sponsored health insurance is not new. According to a timeline at SocialSecurity.gov, Congressional hearings on the topic occurred as early as 1916, with the American Medical Association (AMA) first voicing support for a proposed state health insurance program and then, in 1920, reversing its position. A government health insurance program was a key initiative of President Harry Truman, but, as with the Clinton health initiative several decades later, it didn’t go anywhere because of strong opposition from the AMA and others.

AJN covered the topic in an article (AJN articles cited in this post will be free until August 26) in the May 1958 issue after a health insurance bill was introduced in 1957 by representative Aime J. Forand of Rhode Island  (HR 9467). Yet again, one of the staunchest opponents was the AMA. In the September 1958 issue, “at the request of the American Medical Association,” AJN published an article by its general manager, explaining the AMA’s opposition.

Many commentators have pointed out that the ACA, frequently attacked and undermined by its opponents during these years of its gradual implementation, may one day be seen much as we now see Medicare, which was also widely attacked when it began—that is, the ACA may be simply taken for granted as a necessary, if complex and flawed, program that many people depend upon. Read the rest of this entry ?

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The ACA and Me: A Dispatch From the Trenches

June 5, 2013
Argonauta: The Beach at My Back/ oil stick on paper, 2010 by Julianna Paradisi

Argonauta: The Beach at My Back/ oil stick on paper, 2010 by Julianna Paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

 “Reality is the leading cause of stress among those in touch with it.”—Jane Wagner

By 2014, up to 30 million Americans will have gained access to health care insurance under the Affordable Care Act (ACA). As a nurse human being, I support increased access to health care. However, it is naive to believe it can be accomplished without sacrifice.

My job is a casualty of the ACA.

But let’s backtrack:

It’s more accurate (but less dramatic) to say that our country’s need of better health care delivery significantly affects my job. Most hospital nurses are familiar with Medicare tying reimbursement to patient outcomes. Further, built into the ACA is a requirement that hospitals expecting Medicare reimbursement form accountable care organizations (ACOs):

Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve with Original Medicare (that is, those who are not in a Medicare Advantage private plan). The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

In other words, hospitals are expected to stop competing for Medicare dollars and work together to reduce duplication of services, decreasing costs within their communities. This is not an entirely new idea in health care. Trauma and neonatal tertiary care centers existed before I graduated from nursing school. They provide advanced health care technology to communities unable to afford them.

ACOs go beyond this concept, however, mandating “partnerships or joint ventures arrangements between hospitals and ACO professionals.”

For example, one hospital will purchase the most advanced machine for radiology, while its competitor will invest in the latest laser surgery technology. Patients needing either will be referred to the center in their community providing that service, thereby increasing its number of billable Medicare patients, decreasing cost and duplication of services. This is my understanding of some of the changes taking place in accordance with the ACA. May I remind you, I am a staff oncology nurse, not an economist.

Here’s how ACOs affect me: My job as an oncology infusion nurse is being combined with those of another hospital offering similar patient services. The short version: After 20 years of employment, along with my coworkers I will have a new employer.

I know it’s just business. I go to work, and every two weeks receive a paycheck for my hours. Every two weeks, my employer and I are even. Still, it feels a little like how I imagine if, after 20 years of marriage, your spouse informs you he is leaving for no particular reason: “It’s not you, it’s me.”

Initially, I couldn’t help but feel abandoned.

A person’s reaction to such situations is clouded by sentiment. There are concerns about possible changes to regular work routines. There is worry over potentially commuting to other work sites. The funniest one occurred while I perused the hospital gift shop, lamenting to myself about the loss of my employee discount. Then I remembered: “We don’t have an employee discount, you sentimental fool!” Feelings of rejection play tricks on memory. Read the rest of this entry ?

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AJN’s April Issue: Sustainable Health Care Environments, Preventing Kidney Injury, Lateral Violence, Mental Health, More

April 5, 2013

AJN0413.Cover.2nd.inddAJN’s April issue is now available on our Web site. Here’s a selection of what not to miss.

Mechanical prophylactic devices such as intermittent pneumatic compression (IPC) devices, are applied, maintained, and monitored exclusively by nursing personnel. In this month’s original research article, “The Application of Intermittent Pneumatic Compression Devices for Thrombophylaxis,” the authors observed frequent misapplications of ordered IPC devices, and highlighted the need to study the consequences of such errors. This article is open access and can earn you 2.3 continuing education (CE) credits.

Over the past decade, the incidence of acute kidney injury requiring dialysis has risen sharply in the U.S., with associated death more than doubling. “Preventing and Responding to Acute Kidney Injury” makes the case that by identifying the signs and symptoms of acute kidney injury in its early stages, nurses may be able to help reduce the severity of injury and improve outcomes. This article is open access and can earn you 2.6 CE credits. You can also listen to a podcast interview with the author.

Lateral violence is a term used to describe what happens when a person acts in a verbally, emotionally, or physically abusive way toward someone else of a similar status or level of authority. As has been noted more than once before, RNs sometimes commit lateral violence against other staff members. “‘Crucial Conversations’ in the Workplace,” the second article in our leadership series, offers nurse managers a framework for discussing and resolving incidents of lateral violence.

Even in mental illness, there can be mental health—a notion tackled this month in Our Mental Health Matters article, “Where’s the ‘Health’ in Mental Health?” This article provides an overview of what it means to be mentally healthy and describes the major components of the Diagnostic and Statistical Manual of Mental Disorders, the primary source of diagnosing mental disorders in the Unites States. A podcast interview with the author is also available.

And, as you may have noticed from our cover this month, we are focusing on sustainable health care environments. For more on this topic, read “Greening the ‘Proclamation for Change’: Healing Through Sustainable Health Care Environments,” which includes a list of valuable resources for those interested in helping to transform their facilities. Look out for a blog post on Monday that will include a podcast interview with the authors of this article.

There is plenty more in this issue, including an update on the Affordable Care Act and the implications for nurses, so stop by and have a look. Tell us what you think on Facebook, or here on our blog.

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What Do You Value?

October 8, 2012

By Shawn Kennedy, MA, RN, AJN editor-in-chief

“ ‘The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.’—Hubert Humphrey

These are the words that physician Donald Berwick saw as he went to work in the building that bears Humphrey’s name and houses the U.S. Department of Health and Human Services in Washington, DC. They reminded Berwick, the former administrator of the Centers for Medicare & Medicaid Services (CMS), of his most important mission: “to help the people who need our help the most.” And they are at the heart of an important topic of debate during this election season: what is the proper role of government in our lives?”

AJN Oct. cover, detail

So begins a blog post on the JAMA Forum by Diana Mason, PhD, RN, Rudin Professor of Nursing and codirector of the Center for Health, Media, and Policy at Hunter College, City University of New York, as well as president-elect of the American Academy of Nursing (and, for the sake of transparency, former editor-in-chief of AJN).

Her question is a critical one and one that has been a fundamental issue, tug-of-war even, for Americans. Our citizens take a great deal of pride in being independent, self-made, and self-reliant—yet it’s obvious that most of us also believe in a sense of obligation to community, in helping our neighbors. Witness the many community organizations like Meals-on-Wheels and food pantries manned by volunteers; the millions of dollars in donations to the American Red Cross and the United Fund; the hours of volunteer labor donated to building houses for Habitat for Humanity.

And we feel it’s important to imbue future generations with this sentiment as well—many schools have implemented student service projects as part of the graduation requirement.

Yet, it appears that many feel that our government should not have a role in providing basic health care and social services to those who are in need. Shouldn’t the government embody the values of its people?

The discussion reminds me of how disheartened I felt when I watched Sicko, Michael Moore’s film about America’s health care system. One scene showed the infamous film clip of a Carol Ann Reyes, a hospital patient being “dumped” on Los Angeles’ skid row, in what apparently was a common practice by several hospitals to be rid of patients who were homeless and had nowhere to go. As I watched the film of the disoriented woman getting out of a taxi and wandering the street in a hospital gown and no shoes, the voice-over asked, “Is this how we treat our sick and vulnerable? Is this what we have become as a nation?”

If the government isn’t going to provide for and protect people like Carol Reyes, who will? Does a sense of community refer only to people like ourselves or those in our own neighborhoods? And if many Americans feel that way, what does that say about our values and our identity as a nation?

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(Related article: “The 2012 Republican and Democratic Health Care Platforms,” AJN, October issue.)

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About Those Death Panels

July 18, 2012

By Shawn Kennedy, AJN editor-in-chief

Diana Mason, former editor-in-chief of AJN, wrote a post on July 9 on the JAMA Forum blog that’s well worth reading. In it, she talks about the resurgence of “death panels” rhetoric to stir opposition to the Affordable Care Act (ACA), specifically in relation to the Independent Payment Advisory Boards, which are to issue binding recommendations for controlling costs if Medicare grows too rapidly.

In a nutshell, these boards will determine where to reduce costs. If Congress opposes the plan, it will have to come up with same-size cost cuts if it doesn’t want to institute what the board recommends. The message that opponents of the ACA want the public to hear is that their fates will be determined not by them but by an arbitrary committee.

But IPABs are about reducing costs of programs, not passing judgment on individuals.  (As Mason notes, the death panel rhetoric was “declared the “2009 Lie of the Year” by PolitiFact, a project of the Tampa Bay Times and partner news organizations.”)

People should have conversations about how they wish to be treated in their last moments, but these should occur with loved ones and direct care providers and be supported by the legal system. People shouldn’t have to worry that they will be rushed along to death if they’re not ready—in fact, this seems to be the opposite of what usually happens.

According to a report from NPR, on Monday, July 9, the Republicans, for the 31st time, introduced a bill to repeal the ACA (this bill is called “The Repeal of Obamacare Act”). It’s political posturing—it will pass the House but will fail in the Senate, as all the prior bills have. One Connecticut representative, Rep. Rosa DeLauro, commented like this: “Mr. Speaker, instead of working to create jobs, reduce the deficit, and do the business of the American people, this majority has been consumed for months now with trying to repeal health care reform.” 

But the Republicans will continue to do this to send a political message. And the rhetoric will likely continue and only get worse as we approach the November election. Mason’s post points back to a message in my post from last week: nurses, take the time to learn the facts, for your own and for your patients’ sake. Politicians have not been known to be especially truthful, but outright lies to instill fear in the very people they are supposed to care so much about—shame on them.

 
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Transitional Care: How the Affordable Care Act Would Have Helped My Father

July 12, 2012

By Susan B. Hassmiller, PhD, RN, FAAN, senior adviser for nursing at the Robert Wood Johnson Foundation. This post is also being published at the Robert Wood Johnson Foundation Human Capital blog.

When I heard that the Supreme Court had upheld the Affordable Care Act, I immediately thought of my father. He suffered mightily at the end of his life. Plagued with multiple chronic illnesses, he spent his last year in and out of hospitals. He received good hospital care, but his health deteriorated every time he left the hospital.

He simply couldn’t keep track of a growing list of prescriptions, tests, and doctor visits. He accidentally skipped antibiotics, which led to infections, which landed him back in the hospital. He accidentally skipped blood tests, which landed him back in the hospital. It seemed that every time he came home, he’d land back in the hospital. I lived thousands of miles away and couldn’t be the advocate that he needed.

What he needed was transitional care—he needed a nurse to meet with him during a hospitalization to devise a plan for managing chronic illnesses and then follow him into his home setting. He needed a nurse to identify reasons for his instability, design a care plan that addressed them, and coordinate various care providers and services. He needed a nurse to check up on him at home. Transitional care would have eased his suffering and allowed him a better life.

One of the best parts about the Affordable Care Act is that it will make transitional care possible for more patients. The transitional care program is one of many provisions in the law that will provide an unprecedented opportunity for nurses to take on greater roles as members of health care teams—they’ll be better able to provide preventive health care services, care coordination, and chronic disease management to patients.  

The Affordable Care Act came too late for my father, but I’m grateful that other patients and their families will be able to avoid the costly and heart-wrenching cycle of repeat hospital visits and unnecessary suffering at the end of life. At least that is my hope.

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The Affordable Care Act Survives, At Least for Now

July 9, 2012

Shawn Kennedy, AJN editor-in-chief

Senate roll call, Affordable Care Act/by Kurykh, via Wikimedia Commons

It’s been a couple of weeks now since the Supreme Court upheld the constitutionality of the Affordable Care Act (ACA), and there have been too many articles and analyses to count. The bottom line is that its fate won’t be settled until after the November elections. If the Republicans win the election, the ACA will become the first battleground, as its repeal has been promised by candidate Mitt Romney.

What is concerning is that a great many people pay attention to the rhetoric rather than finding out the facts (remember “death panels”?). This point was well made by political cartoonist Stuart Carlson in this cartoon. It’s hard not to be in favor of many of the provisions—like extending coverage under a parent’s plan for children up to 26 years of age, or barring insurance companies from denying coverage for preexisting conditions.

As nurses, we need to know the facts and go beyond the political rhetoric. We need to be informed for ourselves (anything that has an impact on health care delivery and funding will affect nursing) and for our patients, who will have questions. Get the facts—read the law at the link above, a summary of the law, or the articles we published summarizing how it will affect nursing (our original article, and a 2011 update, both open access until August 9th).

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