Daily Archives: May 11, 2015

05.11.15
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In Louisiana, Obamacare Subsidies Mean Financial Independence For Some

The politics of the Affordable Care Act in the state of Louisiana are not subtle: It is not popular. The state was part of the lawsuit to strike down the law in 2012; it didn’t expand Medicaid and has no plans to, even as other Republican-led states have done so. And Louisiana didn’t set up its own marketplace to sell Obamacare insurance.

Nevertheless, about 186,000 people in Louisiana signed up for health insurance under the law and almost all of them got help from the federal government to pay their premiums.

The U.S. Supreme Court could soon rule illegal the insurance subsidies in Louisiana and more than 30 other states that use the federal website healthcare.gov. If the subsidies are eliminated, the number of uninsured people in the affected states would rise by 8.2 million in 2016, according to recent Senate testimony by Linda Blumberg, a senior fellow at the Urban Institute.

Jeff Cohen from member station WNPR spent three days driving around his home state of Louisiana speaking with people who got insurance under the law. Here are the stories of three people who say their financial independence is riding on the latest health law case before the Supreme Court.

Sheron Bazille

Sitting at her kitchen table in the Baton Rouge home she owns by herself, Sheron Bazille says she had a good job that offered benefits — like health insurance. But she got sick and had to stop working: “It was either me or my job. And my life and my health was more important.”

Bazille, 62, retired early, and she says leaving that job of 10 years meant losing her insurance – and some of her dignity, too.  Now, under Obamacare, she’s got subsidized insurance. She knows exactly how much her share is: “My monthly is 219. And one cent.”

The coverage has given her a sense of security, because she can take care of her health and her health care bills.

“Peace. I have peace now that I know I have hospitalization [coverage],” says Bazille. “If anything happens, I can go to the hospital.”

She worries the Supreme Court justices could take away that peace and asked what she would tell the justices if she could, she says: “Think about your kids, your family. If they could not afford to pay for health insurance. Wouldn’t you want someone to help them?”

Jimmy See

At a coffee shop in Zachary, half an hour north of Bazille’s home in Baton Rouge, Jimmy See says he never felt like he needed health insurance – until he did. He’s 54, a self-employed housing and maintenance worker, and he’d always felt like health insurance was too expensive. But then he started having trouble breathing and he went to the hospital: “They said, ‘Well do you have any insurance? And I said, ‘No.’”

Rather than pay a lump sum up front, he went home and got worse.  Eventually, he collapsed and had to be hospitalized for close to two weeks for pneumonia. His remembers his bill being between $8,000 and $9,000. See negotiated with the hospital and received financial assistance to settle the bill.

“If I hadn’t gotten that, I’d be looking for bill collectors after me,” See says. “And bill collectors don’t play. They come after you.”

See’s Obamacare subsidy covers all of his premium, and he says having insurance is a relief.

“If I had a big operation or whatever, you can’t afford no $70,000, $80,000, $90,000,” he says. “So, through the Affordable Care Act, the government’s going to help you out with all that.”

If the Supreme Court rules against subsidies, See says, for him it would be, “Back to square one. No insurance.”

James Marks

James Marks lives four hours north of Baton Rouge in Shreveport. He doesn’t want to go back to square one, either.

Marks is 36 and works as a freelance computer technician and an afterschool art teacher. Neither job provides insurance and being uninsured has been a blow to his self-esteem.

“It made me feel lousy,” Marks says. “It made me feel like I was sponging off my parents. It made me feel like I wasn’t able to take care of myself.”

Marks lives with a mental health issue – and, for the better part of 10 years, his parents paid for both his psychiatrist and his expensive medications. Now, he pays about $180 a month for a subsidized insurance policy, and he says it makes him feel like an adult.

Asked what he would tell the justices, Marks says: “I know the Supreme Court tries to decide stuff based on the law and not based on the impact that it has on America.  But it’ll wind up making a lot of people who were insured, who had insurance, who were able to go to the doctor and pay for their pills, not be able to anymore. And that’s just pretty lousy.”

This story is part of a reporting partnership that includes WNPR, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

05.11.15
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Population Health Education

Join PSNA District 27 at Evangelical Community Hospital, Lewisburg on June 4, 2015 (5 pm) for a “Population Health and the Nursing Profession.” This presentation will be led by Dr. Aislynn Moyer, DNP, RN. Dr. Moyer is coordinator of the population health certificate program at Pennsylvania College of Health Sciences. The certificate program is an interprofessional educational program that helps all members of the health care team understand how to engage patients toward better health through empowerment. The team-based approach is unique to health care education and has had great success with results being published in national journals as well as showcased at interprofessional conferences. This session awards 1.0 CNE. Learn more here.

05.11.15
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‘Free’ Contraception Means ‘Free,’ Obama Administration Tells Insurers

Free means free.

The Obama administration said Monday that health plans must offer for free at least one of every type of prescription birth control — clarifying regulations that left some insurers misinterpreting the Affordable Care Act’s contraceptive mandate.

“Today’s guidance seeks to eliminate any ambiguity,” the Health and Human Services Department said. “Insurers must cover without cost-sharing at least one form of contraception in each of the methods that the Food and Drug Administration has identified … including the ring, the patch and intrauterine devices.

The ruling comes after reports by the Kaiser Family Foundation and the National Women’s Law Center, an advocacy group, found many insurers were not providing no-cost birth control for all prescription methods. (KHN is an editorially independent project of the Kaiser Family Foundation.)

Gretchen Borchelt, a vice president with the women’s law center, applauded the guidance.

“Insurance companies have been breaking the law and, today, the Obama Administration underscored that it will not tolerate these violations,” she said. “It is now absolutely clear that ‘all’ means ‘all’— ‘all’ unique birth control methods for women must be covered.”

The law requires that preventive services, such as contraception and well-woman visits, be covered without out-of-pocket expenses, such as a co-pay or deductible.

While HHS said insurers must offer for free at least one version of all 18 FDA approved contraceptives, the plans may still charge fees to encourage individuals to use a particular brand or generic. For example, a generic form might be free, while a brand name version of the drug can include cost sharing, HHS said.

The administration Monday said insurers could have misinterpreted prior rules to mean they only had to offer certain types of contraception without cost-sharing. Plans have until July to implement the policy, which will generally not take effect until a new plan year begins. That means for most people the new rule will start in January.

Cecile Richards, president of Planned Parenthood Action Fund, the political arm of Planned Parenthood of America, thanked the administration.

“This is a victory for women and the more than 30,000 Planned Parenthood supporters who spoke out to ensure all women, no matter what insurance they have, can access the full range of birth control methods without a copay or other barriers,” she said. “We know that increased access to birth control has helped bring teen pregnancy rates to a 40-year low and we must continue to drive forward policies that build on this progress.”

The Kaiser study  — which looked at a sample of 20 insurers in five states — found one that simply didn’t cover the birth control ring (NuvaRing) at all and four that “couldn’t ascertain” whether they covered such birth control implants. More commonly, insurers would restrict access to certain contraceptives when they believed a cheaper, equally effective way for patients to get the same treatment was available.

The report by the health law center, which analyzed coverage from 100 insurance companies during 2014 and 2015, found that 15 plans in seven states failed to cover all FDA-approved methods of birth control. Among the companies named as not complying with the law’s requirements in some states are Aetna, Cigna, Physicians Plus and Anthem Blue Cross Blue Shield.

The insurance industry disputes the reports’ conclusions that the problem is widespread. “This report presents a distorted picture of reality,” Karen Ignagni, president and CEO of America’s Health Insurance Plans, the industry’s primary trade group, said when the report came out.

AHIP did not have an immediate comment Monday on the federal guidance.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

05.11.15
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Proposed Law Would Revoke Licensure for Medication Errors

Mat Keller headshot

By Mathew Keller, RN JD, MNA Nurse Practice & Policy Specialist

“Samuel’s Law,” under consideration in the South Carolina Senate, would require the South Carolina Board of Nursing to revoke a nurse’s license “upon the board’s finding that a licensed nurse misreads the physician’s order and overmedicates or undermedicates a patient.”

While the circumstances surrounding the introduction of Samuel’s Law, involving the fatal overmedication of a 7-year old, are tragic, the bill is an inappropriate response and does nothing to correct the systems-level failures that are often the basis of medication errors.

As a systemic review of 54 studies on medication errors puts it, since “nurses find themselves as the ‘last link in the drug therapy chain’ where an error can reach the patient, they have traditionally been blamed for errors. However, the reality is that the conditions within which the person responsible for the error works, as well as the strategic decisions of the organization with whom they are employed, are often the key determinants of error.”[1] 

Therefore, any law that purports to reduce the incidence of medication errors ought to focus on systems-level failures that can lead to medication errors, including inadequate communication pathways (e.g. illegible prescriptions, poor documentation, lack of transcription), problems with pharmaceutical supply and storage, unmanageable workload, availability and acuity of patients, staff fatigue and stress, and interruptions or distractions during drug administration.

Correcting or addressing the above issues, rather than punishing unintentional errors with the loss of one’s livelihood, will go a long way toward addressing the root cause of medication errors Samuel’s Law seeks to address.  It also fits with the model of “just culture,” widely accepted and adhered to in both the medical and aviation industries, which seeks to create an environment that encourages reporting mistakes so that precursors to errors can be understood and systems issues can be fixed.

As Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, said in testimony before Congress, “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.” (Leape, 2000).

Samuel’s Law, while well-intentioned, uses the wrong approach to prevent medication errors.  How would you change the language to better prevent errors?  Share your thoughts in our comment section below.

[1] Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067.

05.11.15
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How One Hospital Brought Its C-Sections Down In A Hurry

NEWPORT BEACH, Calif.— Hoag Memorial Hospital Presbyterian, one of the largest and most respected facilities in Orange County, needed to move quickly.

A big insurer had warned that its maternity costs were too high and it might be cut from the plan’s network. The reason? Too many cesarean sections.

“We were under intense scrutiny,” said Dr. Allyson Brooks, executive medical director of Hoag’s women’s health institute.

The C-section rate at the time, in early 2012, was about 38 percent. That was higher than the state average of 33 percent and above most others in the area, according to the California Maternal Quality Care Collaborative, which seeks to use data to improve birth outcomes.

Within three years, Hoag had lowered its cesarean section rates for all women to just over a third of all births. For low-risk births (first-time moms with single, normal pregnancies), the rate dropped to about a quarter of births. Hoag also increased the percentage of women who had vaginal births after delivering previous children by C-section.

In medicine, this qualifies as a quick turnaround. And the story of how Hoag changed sheds light on what it takes to rapidly improve a hospital’s performance of crucial services, to the benefit of patients, insurers and taxpayers.

Decreasing C-sections results in “better health to mothers and better health to babies and lower costs,” said Stephanie Teleki, senior program officer at the California HealthCare Foundation, which helped fund the data collection and analysis by the California Maternal Quality Care Collaborative. “That’s like a nirvana moment in health care.”

Experts have long been troubled by the wide variation of C-sections among hospitals nationally. (In California, the rates range from 18 percent to 56 percent.)  Certainly there are instances in which C-sections are typically recommended – such as a baby in breech position. But the disparities suggest that decisions are being driven by factors other than medical necessity – such as doctors’ time constraints and malpractice concerns.

Over the past few years, there has been a coordinated push to cut C-section rates in other states and in births covered by Medicaid, the health coverage program for low-income Americans.

Across California, data publicly released by the California HealthCare Foundation, the Pacific Business Group on Health and others in the past few years have underscored the differences in how hospitals handle maternity care. http://www.chcf.org/publications/2014/11/tale-two-births  http://www.pbgh.org/storage/documents/PBGH_C-Section_NTSV_Variation_Report.pdf

Despite the increased transparency, however, many hospitals don’t act until dollars are at stake, said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. That’s what happened with Hoag, which Main said is now becoming a model for others.

“In quality improvement, we call it ‘the burning bridge,’” he said. “You can’t just stay still. You’ve got to move.”

Focus on Physicians

At Hoag, where more than 6,000 babies are born each year, Brooks and other administrators knew that they had to focus on changing the mindset and behavior of physicians. “Hospitals don’t do C-sections, doctors do,” she said.

So they took some aggressive steps. First, they shared the data with all the physicians in the department without names — then decided to reveal the names. Suddenly, everyone knew who had exceeded or come in under the average.

“There was a lot of upheaval,” Dr. Jeffrey Illeck, a community OB-GYN and the hospital’s obstetrics department chair. “None of us want to look bad in front of our peers. … And some looked horrible.”

Some physicians reacted with surprise and frustration. Initially, many attributed the high rates to the patients, saying they were older, had more complicated pregnancies or demanded scheduled C-sections.

Dr. Amy VanBlaricom, an OB-GYN who delivers about 25 to 30 babies a month, said she wasn’t opposed to sharing the data. But she said doctors were worried that the rates would be used to penalize them rather than to drive improvement.

“It’s very heated,” she said. “We should use this data as an opportunity rather than a polarizing topic.”

VanBlaricom already tracked her own rates, which she said fell in the middle of the pack, and has only seen a small drop since. But she said being aware that Hoag is monitoring the C-sections has changed how she thinks about her practice and has encouraged her to let women remain in labor longer.





That’s what Hoag administrators were aiming for – a realization among doctors that C-sections should not be undertaken lightly. They carry surgical risks, including serious infection and blood clots, and require longer hospital stays.

“Doctors and patients look at cesareans as an easy way to time the birth,” said Dr. Marlin Mills, chief of perinatology at the hospital. “But a C-section is not benign. It’s a big surgery.”

The costs are also well-documented. Surgical births cost nearly $19,000, compared to about $11,500 for vaginal births, according to the Pacific Business Group on Health, an organization of employers that is also working to bring down C-section rates around the state.

The business group worked with the hospital on the financial side. It enlisted the help of some of the biggest local employers, including Disney, and another insurer, Blue Shield, to adjust payments so the hospital didn’t earn more from elective C-sections than vaginal births.

In addition, the hospital set new scheduling rules. In the past, doctors could simply call in with the woman’s due date and schedule the birth. Now, they would have to fill out a detailed form, with some requests needing special approval.

The hospital also stepped up its patient education, encouraging women to wait for labor to come naturally.  If patients did want an elective C-section, they would have to sign an easy-to-understand consent form in the doctor’s office that detailed the risks.

The nurses received end-of-year bonuses if they helped the hospital reach certain goals on reducing surgical births.

The hospital opened an obstetrics emergency department and gave more responsibility to “laborists,” doctors who were there around the clock to respond to emergencies, monitor women in labor and deliver babies.

Dr. Alex Deyan, who delivered more than 500 babies at the hospital last year, used to turn away patients who wanted vaginal births after cesarean sections. With a busy private practice, Deyan said he couldn’t always be immediately available if labor didn’t go as expected and a woman needed a C-section. That changed with the laborist program.

“Having in-house doctors 24/7 is a huge benefit,” Deyan said. “I can be a little more patient.”

Good for Patients Too

Holly Grim appreciated Hoag’s approach. She knew she didn’t want a C-section with her second baby. Her first labor at another hospital in December 2013 was long and painful and ended with a cesarean section that kept her in the hospital for days. Her son was healthy, but she said, “this wasn’t exactly how I had it planned – not even close.”

This time, she needed to get back on her feet quickly so she could chase after her 16-month-old. She decided to switch doctors and hospitals. And in early April, she got her wish — giving birth naturally to an 8-pound girl, Agnes, at Hoag.

The day after Agnes was born, the family was packing up to go home. She didn’t have any restrictions on lifting or driving, and she wasn’t in severe pain. This, she said, is how childbirth is supposed to be.

“I’m feeling really good,” she said as she nursed Agnes, wrapped in a blanket decorated with pastel footprints. “I’m relieved I’ll be able to run around after my son.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.