Posts Tagged ‘insurance’


Nursing, HIV/AIDS, Continuity of Care, Treatment Advances, and the ACA: The Essentials

March 6, 2014

As the Affordable Care Act takes effect, a timely overview in AJN of recent developments in screening, treatment, care, and demographics of the HIV epidemic


The ‘cascade of care’ (from the AJN article)

The newly released March issue of Health Affairs is devoted to looking at the ways the Affordable Care Act (ACA) will affect Americans with HIV/AIDS and those who have recently been in jail. One crucial feature of the ACA is that it prevents insurance companies from refusing coverage to those with a number of preexisting conditions. If you have a preexisting condition and don’t get insurance through work, you know how important this is.

Unfortunately, a large majority of those with HIV and AIDS do not have private health insurance. One article in the March issue of Health Affairs draws attention to the plight of the 60,000 or so uninsured or low-income people with HIV or AIDS who will not receive health insurance coverage because their states are among those that have chosen to opt out of the ACA provision that expands Medicaid eligibility. This means many patients in these states may lack consistent care and reliable access to life-saving drugs.

Antiretroviral therapy (ART) improves patient quality of life and severely reduces expensive and debilitating or fatal long-term health problems in those with HIV/AIDS. As noted in AJN‘s March CE article, “Nursing in the Fourth Decade of the HIV Epidemic,”

The sooner a patient enters care, the better the outcome—especially if the patient stays in care, is adherent to combination antiretroviral therapy (cART), and achieves an undetectable viral load.

The authors, pointing out that only 66% of those with HIV in the U.S. are currently “linked to care” and, of these, only about half remain in care, argue that

“[e]ngaging and retaining people with HIV infection in care is best achieved by an interdisciplinary team that focuses on basic life requirements, addresses economic limits, and treats comorbid conditions such as mental illness and hepatitis C infection.”

But there’s a lot more in this article about screening, advances in drug therapy, treatment, and epidemiology that all nurses will need to know as the ACA brings more HIV-infected patients into every type of health care setting. Here’s the overview, but we hope you’ll read the article itself, which is open access, like all AJN CE features: Read the rest of this entry ?


Forward or Back? Some Personal Notes on Why the Affordable Care Act Matters

June 28, 2012

By Jacob Molyneux, senior editor/blog editor

So today the U.S. Supreme Court did something a little surprising in upholding the individual mandate provision in the Affordable Care Act (here’s the text of the full decision). It was the right thing to do, given judicial precedent, but it still comes as a surprise that Chief Justice Roberts was the swing vote rather than Kennedy, or that they actually did this. Justice Roberts must have looked to his conscience and seen how history would judge him. Or it’s nice to think so.

This is good for many reasons: those under 26 on their parents’ plans can now stay there. A bunch of money earmarked for nurse education will not suddenly disappear. Health care exchanges holding insurance companies to minimum standards will be implemented. Accountable care organizations can continue to experiment in an effort to replace the disastrously expensive fee-for-service model with one tied more closely to outcomes. And a great deal more.

But now we should ask ourselves: Do we go forward or back? This is the real question when it comes to the American health care system. Going back isn’t an option, though many are sure to go on pretending it is (the Republicans will make repealing the Affordable Care Act a centerpiece of their campaign promises, no doubt, a rallying cry against the Democrats). Ignoring reality is something humans are very good at, though it doesn’t always end well, if history is a guide.

And in truth it will take an increasingly powerful act of will to ignore the medical bankruptcies, medical tourism for affordable care to Mexico and further afield, the emergency rooms crowded with the uninsured seeking care for minor and major ailments, the yearly statistics that tell us our health care system is the most expensive per capita and yet has outcomes worse than those of many far poorer countries.

Still, some will surely rise to the occasion as they intone mantras about the free market’s ability to solve all problems for the good of all. Meanwhile the one percent who own an increasingly large percentage of the nation’s wealth will simply avert their eyes, able to afford the best surgeons, concierge care, home visits, brand name drugs.

This matters to me for personal (among other) reasons. At age 27 I left my job working with abused and neglected children and their caregivers and went to graduate school in North Carolina. Living on a tight budget, I opted out of the university’s health care coverage. That is, I chose not to purchase health care . . . it wasn’t mandated, and I didn’t need it.

That fall, as I immersed myself in following my creative dream, I found myself losing touch with reality. My clothes hung off me, I had a thirst that drove me nearly insane (at one point I sat in a bathtub all afternoon sucking on ice cubes just to stop myself from buying and guzzling random selections of liquids at the store—Yoo-hoo, of all things, and orange juice, and Guinness, seltzer, Coke, milk, chocolate milk, etc., etc.). I felt disoriented. One day I saw double as I drove my used pickup truck along the lush parkway. When I went out for a run I found myself barely able to complete a mile, let alone my usual five or six.

As must be clear by now, my immune system had decided to attack my own body, wiping out the insulin-producing cells in my body. It was nothing I did, nothing I could have averted. I was strong, young, healthy, fit. And now, after some blood tests, I learned I had type 1 diabetes and would need to be my own nurse for the rest of my life, checking my blood glucose level many times a day, injecting myself before meals and when the blood glucose level was too high. From then on in I’d need to be attentive to every permutation of exercise, diet, medication as I tried to achieve the “tight” glucose control that would keep me from losing limbs, sight, nerve endings, organs, and eventually my life.

But at the time, in the midst of the initial confusion and struggles, I had a very simple problem on top of all the others: how do I afford this meter to test my blood glucose level, the strips that cost almost a dollar each, the syringes, the two types of insulin, an endocrinologist to monitor the condition? I borrowed some money from an older relative and scraped by. I was lucky enough to have that option. I applied for free medications from a state program. Until I got on my feet a bit more, I spent a lot of time being anxious, broke, and a little scared, skimping on test strips when it was dangerous to do so, regretful that I had decided to go back to graduate school for something unlikely to make me wealthy.

Later still, working as an adjunct university lecturer and a freelance editor, I found what it’s like to be denied access to affordable coverage on the open market. That was upsetting, and it’s one of the things the ACA intends to remedy. Now I’m lucky to get insurance through my job, but the medications are still expensive. I now have two other autoimmune conditions that require medications and specialists. I’m fine, overall, high functioning, but much of my “extra” money is used for medications, tests, physician visits. Without being part of a group plan at work, I’d never be able to afford insurance and all of the medications I need. A full-time job at a large company is a requirement.

So I know why health care reform matters, even if the ACA doesn’t go nearly far enough to control costs, even if it still cedes too much power to the marketplace, to drug companies and insurance companies. Read the rest of this entry ?


Changes in Latitude: Comparing Health Care Systems with Nurses Down Under

October 26, 2011

By Peggy McDaniel, BSN, RN, who writes the occasional post for this blog and currently works as a clinical liaison support manager of infusion in Australia, New Zealand, and Asia Pacific.

latitude lines/ wikimedia commons

I recently found myself sitting on a boat, enjoying a “sausage sizzle,” dressed as a pirate no less. In Australia, a party that includes barbecued meat usually includes sausage; thus the name. The pirate theme was an added bonus. As an American and a nurse, I was pleasantly surprised to find myself seated at the same table as two Australian nurses. What were the chances of that? The conversation that evening gave me some insight into the Australian health care system, which I am just getting familiar with.

Comparing health care systems. Once we all realized we were experienced nurses and shared the belief that quality patient care should always be the primary focus of health care, the conversation turned to cost. In Australia, there is a public health option that all Australians can access. It is paid for by taxes. If you choose to do so, you can also purchase a private plan to supplement this public option. I have yet to determine what part, if any, employers play in paying for health care or private insurance. However, a sick Australian will always get care and not incur a lifetime of debt for that care within their public health care system.

My fellow nurses were amazed to hear that in the U.S., you may not have health insurance for a variety of reasons. One of the nurses purchases private insurance as a “backup” to public care. She used this coverage for an elective procedure, chose her own surgeon and private hospital, and was able to schedule the procedure in a timely manner. This same nurse admitted that if you need a new hip or knee and you only have public coverage, you may have to wait for up to a year. However, if you have cancer and need treatment, it will start promptly after diagnosis, whether or not you have private insurance or not.

Both nurses asserted that the care for acute and emergent issues is of high quality in the public hospitals. They were able to give me examples of how the system works, from a personal and work perspective.

As in the U.S., hospitals here in Australia are struggling with the rising costs of health care. The public hospitals in each state utilize their group buying power to purchase supplies and equipment, which helps keep costs down. The private hospitals often have a bit more polish and shine, but all the hospitals strive to give Australians high quality care and the nurses I’ve met are passionate about that goal.

Imitate the American system? One of the nurses I chatted with exclaimed, “Our politicians keep telling us that we should be more like the American system, but I think that’s a mistake. What do you think?” Admittedly, I have much to learn about Australian health care, but so far I have to agree with her. As an American who has gone without health insurance because I was rejected due to preexisting conditions and was not employed full-time, I thought this system sounded pretty reasonable. The Australian nurses certainly felt that anything less would be unacceptable. Read the rest of this entry ?


What Nursing Independence? And Other Notes from the Nursosphere…

September 21, 2010

Here’s some stuff we’re reading online this week:

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician.

That’s from a smart, if somewhat depressing, blog post at Nurse Story called “Independent Nursing Practice: Reality or Still the ‘Physician’s Hand’?” The writer, Terri Schmitt, goes on to wonder just how nurses can carve out areas of independent practice, even in the most basic matters. Good questions.

And here’s a question of interpretation raised by an incident in Colorado involving a nurse and the policeman who stopped her for speeding:

When Colorado Springs cardiac nurse Miriam Leverington was stopped for speeding, she grumbled to the police officer.

“I hope you are not ever my patient,” she reportedly told him.

What happened next has become a topic of widespread debate in Colorado and on the blogosphere. The police officer, Duaine Peters, complained to the hospital where Ms. Leverington worked that her comment amounted to a threat, suggesting she might give him poor care should he ever become her patient.

The hospital fired the nurse, and now the nurse has countered with a lawsuit. She says she was merely exercising her right to free speech — and expressing her hope that she never see the policeman again.

Much ado about nothing? Are we going out of our way a bit too often lately in our zeal to make people pay for casual, if ill-advised, acts of speech? Or did this nurse cross a line?

For some quick takes on where we are with health care reform implementation, here’s a roundup from Kaiser Health News—which in general has done a great job keeping us abreast of what’s actually happening with this issue, as well as the range of opinions being tossed about. Here’s an excerpt.

Six months after passage of the federal health reform law, major provisions will kick in that supporters say will make it easier for Americans to get and keep health insurance. … Among the major changes: Insurance companies will no longer be able to cancel policies because someone becomes sick, set lifetime caps on coverage or deny insurance to children with pre-existing conditions. … In addition to enabling young people to remain on their parents’ policies up to age 26, several other major provisions kick in on Thursday.

The various nursing blogs are a little quiet today. Since palliative care has been in the news a great deal lately, this might be an appropriate time to note that Pallimed: A Hospice and Palliative Medicine Blog just celebrated post #1,000 with a list, partially excerpted below, of tips for a successful palliative care consult:

  1. Assume nothing, ever. 
  2. Always talk to the team first.
  3. Respond to emotion with emotion. 
  4. 75% of what we do is showing up and shutting up.  
  5. Tame the beast inside who just wants to talk, talk, talk.
  6. Don’t just do something, stand there.
  7. Acute symptoms = acute meds.  (That is – don’t jack around with long-acting/continuous meds for out of control symptoms without first actually making someone comfortable with bolus/immediate-acting meds.)  This is a variation of the idea behind:
  9. ‘Good work’ describes a process, not an outcome.
  10. Palliative care is just good medicine.

Pallimed is an excellent and thoughtful site, even if the focus may be somewhat more toward the MD perspective than the nurse perspective. It is also hosting the medical blog roundup Grand Rounds this week, if you’d like to do some interesting Internet browsing with a shrewd and useful tour guide. (And the latest Change of Shift, the regular nursing blog roundup, can be found at the nursing blog Emergiblog. We appreciate the mention of a recent post from this blog!)—JM, blog editor

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Notes from the Healthweb and Nursosphere

March 5, 2010

This week Not Nurse Ratched has an amusing, meandering, and thoughtful post about the uses of Facebook by patients in the hospital. There’s a short excerpt below, but read the whole thing here.

They update Facebook constantly. CONSTANTLY. They have us take photos of injuries they can’t reach so they can post the photos to Facebook. I am not making this up. “I want a photo of my hideously dislocated ankle/knee/shoulder but I can’t move, so would you mind using my phone to take a picture for me?” And they keep updating and updating. I have actually said, “I’m about to give you a medicine that is going to render you unconscious immediately, so you should set your phone down.”

How could we have a weekly Web roundup that doesn’t at least mention health insurance reform? The spotlight has been slowly turning toward the insurers themselves, a crucial part of the equation (along with cost control and many other factors). This week Secretary of Health and Human Services Kathleen Sebelius met with the top executives of insurance companies to demand an explanation for the steep increases in rates seen in the last year.

salmonella/via CDC

If you’re looking for yet another reason why processed food isn’t good for you (besides the frequent presence of high fructose corn syrup and massive doses of salt, and the inaccurate packaging claims that the foods are “healthy” and “lean”), this week the NY Times reported news of a widespread food recall, stating that “[t]housands of processed food products – from chilis to hot dogs to dips – contain an ingredient that federal food regulators say was contaminated with salmonella . . . ”

Also this week: hopes were crushed for a pill thought promising for the treatment of Alzheimer’s. Garry Schwitzer of isn’t surprised, though–no one’s better at pointing out the way drugs are hyped by mainstream coverage, whether they work and are safe or not. Here’s the short take at his blog.

Lastly, for some widely varying provider-level perspectives on palliative care and end-of-life issues, there’s an excellent roundup of posts and links to blogs and Websites at the Palliative Care Grand Rounds hosted by Larry Beresford.

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Are Domestic Violence and Pregnancy Preexisting Conditions?

November 6, 2009

By Peggy McDaniel, BSN, RN

Kaiser Health News recently ran a story about an attorney who was denied private insurance coverage based on a “preexisting condition”—that is, treatment she’d received following a domestic abuse incident. A majority of states have passed laws prohibiting insurers from denying coverage based on treatment for domestic violence, but  eight states as well as the District of Columbia have no such legislation. It is a challenge to track the occurrence of such denials. Insurers often use alternative ways to find out about a history of domestic abuse. They have been known to search for protective orders at local courthouses, which is public information, and search through medical records for documentation of treatment related to such incidents. 

A bitter irony is that nurses are expected to be aware of and directly question patients about suspected abuse, yet in doing so we could be setting up patients for future loss or denial of coverage. 

Pregnancy, likewise defined as a preexisting condition, can also be used to deny coverage. Health reform bills under consideration would disallow the practice of basing insurance rates on gender, a practice which has in effect discriminated against women, particularly those of child-bearing age. 

The practice of denying private health insurance coverage based on these and other preexisting conditions must stop. As a nurse and a consumer, I believe that everyone should be able to buy health care at a reasonable price. A rate such as $1,000 per month for a family is not affordable. In the end we all pay if people do not have some kind of coverage, since the uninsured do eventually receive care—from ERs, which are mandated to provide this care. 


By moggs oceanlane, via Flickr

The very idea that a person can be denied health insurance coverage for a history of domestic violence should encourage us to look closely at reform efforts under discussion and actively join in the conversation. As nurses we are asked to support our patients and promote physical and mental health.  If the very support we give, such as a referral to a domestic violence support group, causes a patient to lose her insurance, we all fail.

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Mid-October Rainy Thursday Web Roundup

October 15, 2009

By Jacob Molyneux, blog editor/senior editor

The nursosphere is thriving and Change of Shift, the always interesting compendium of what’s new on nursing blogs, is up over at Emergiblog.

The health care reform process creeps slowly but surely toward an end someone somewhere can surely envision. One crucial question many are still asking is whether insurance companies might serve consumers a bit more readily and agreeably if they were forced to face a little competition from a public option. After all, isn’t competition supposed to be a good thing?

Most experts don’t expect the H1N1 vaccine to pose any more danger than the seasonal flu vaccine; even so, many Americans (and nurses commenting here, or taking our poll about the mandatory vaccine) continue to be wary, prompting public health officials to engage in especially aggressive surveillance measures in order to quickly detect any possible negative reactions to the vaccine: “Government Keeps Close Eye on Swine Flu Vaccine.”

AJN clinical editor Christine Moffa posted here a while back about how meditation might help cranky or exhausted or overworked nurses stay focused on what matters during the workday. Today the NY Times has a related piece on “doctor burnout” and meditation.

The role of social media in health care is constantly evolving as we all find our way. Its use by hospital workers is at issue in a recent post at Running a Hospital, about one hospital’s decision to ban social media from all its computers. And here’s something else on this: blogger Not Nurse Ratched wonders if social media policies in the workplace are going too far. How are Facebook, Twitter, etc., being used at your hospital?

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