Moving to close what many see as a major loophole in Affordable Care Act rules, the Obama administration will ban large-employer medical plans from qualifying under the law if they don’t offer hospitalization coverage.

The administration intends to disallow plans that “fail to provide substantial coverage for in-patient hospitalization services or for physician services,” the Treasury Department said in a notice Tuesday morning. It will issue final regulations banning such insurance next year, it said.

Hundreds of lower-wage employers such as retailers and temporary-staffing companies have been preparing to offer such plans for 2015, the first year large companies are liable for fines if they don’t provide minimum coverage. Some have enrolled workers for insurance beginning Oct. 1.

For employers that have committed as of Nov.4 to such coverage, the administration will temporarily allow it under the health law, the notice said.

As reported by Kaiser Health News in September, an online calculator published by the Department of Health and Human Services allows large-employer coverage to pass the law’s “minimum-value” standard even if it doesn’t include inpatient benefits. Many see the calculator as flawed.

For employees enrolled in such plans, the disadvantage is double, say consumer advocates. Not only do they lack hospital coverage; but if employees are offered insurance passing the minimum-value standard at work, they are barred from receiving federal subsidies to buy better coverage through online marketplaces.

The administration said in Tuesday’s bulletin that it intends to fix that problem, too. Final regulations will say that “in no event” will workers offered such coverage be disqualified from subsidies, the notice said.

The administration had signaled last month it would move to disallow plans without hospital benefits from passing the minimum-value test. Large employers that fail to offer minimum-value coverage next year could be fined up to $3,120 per worker.

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

Two years ago, Inova Health System recruited a top executive who was not a physician, had never worked in hospital administration and barely knew the difference between Medicare and Medicaid.

What Paul Westbrook specialized in was customer service. His background is in the hotel business – Marriott and The Ritz-Carlton, to be precise.

He is one of dozens of hospital executives around the country with a new charge. Called chief patient experience officers, their focus is on the service side of hospital care: improving communication with patients and making sure staff are attentive to their needs, whether that’s more face time with nurses or quieter hallways so they can sleep.

It’s a dimension of hospital care that has long been neglected, patient advocates say, and it was put high on hospitals’ agendas only when Medicare started tracking patient satisfaction and, in late 2012, shaving payments to hospitals that fell short.

“There is a new recognition that the patient is important,” said Leah Binder, president and chief executive of the Leapfrog Group, an employer-based coalition that advocates for greater health-care quality and safety.

Hospital routines have traditionally been designed to suit employees, not customers, she said. “The patient used to be maybe 10th on the list of a hospital’s priorities.”

The financial penalties introduced by the Affordable Care Act are part of a broader effort to transform health-care delivery and improve quality while reining in costs, increasing transparency and holding hospitals and providers accountable for their work.

The penalties — which for now make up only a fraction of Medicare reimbursements — are based on a hospital’s ranking relative
to other hospitals. One component is how they do on surveys of recently discharged patients. The hospitals are judged on answers to such questions as how well their doctors and nurses communicated with them, how clean and quiet the hospital was, whether they received help when they needed it and how well providers explained the drugs they were given.

Many hospitals commission additional surveys to use for their own purposes, such as marketing and branding.

Chief patient experience officers treat these survey results like sacred texts.

“The one thing I’m not trying to do is to put a mint on the pillow,” said Westbrook, who reports directly to Inova’s president and chief operating officer. “This is a different customer, with very different needs.”

But as patients’ out-of-pocket costs have risen, he said, they have become savvier, more demanding consumers.

“They are going to look on the Internet and on Medicare’s site comparing hospitals, and they are going to read comments,” he said, and increasingly, they will select hospitals based on the reviews. “It’s no different from TripAdvisor.”

Lofty Goals, Practical Implementation

Unlike Westbrook, most chief patient experience officers rise through the ranks of a health system. Like him, though, they speak in lofty terms about teamwork, leadership and developing a philosophy and culture of compassion, service and respect at their institutions.

Westbrook, for instance, talks constantly about the “Inova promise” to “meet the unique needs of each person we are privileged to serve – every time, every touch.”
That phrase had “always hung on a wall,” Westbook said. “Now, we don’t begin a meeting without an Inova promise story.”

On the ground, the focus is doggedly practical. One common innovation is hourly rounds, a system where nurses are expected to check in on each patient regularly, not wait for the person to use the call button. And the interaction is supposed to be meaningful and thorough.

“This doesn’t mean just pausing at the door, saying, ‘Are you okay? Can I get you anything?’ and off you go,” said Susan Eckert, chief nursing executive at MedStar Washington Hospital Center. “We’re telling our nursing staff that you should actually sit down, look at the patient, talk a little bit, and give them several
minutes of time during which they are the only thing that exists in the world . . . It’s a very powerful experience.”

Hospitals that have put hourly rounding in place say the practice does not require extra staffing because it is more efficient to prevent problems before they occur. Taking time to reposition a patient prevents bedsores, for example, and helping patients to the bathroom prevents falls.

Another priority is having nurses call patients at home within 48 hours of their discharge, to keep their recoveries on track. (One Medicare question specifically asks patients whether they got good instructions about what to do when they get home. Hospitals can also be penalized if too many patients bounce back to them.)

Hospitals are increasingly taking their cues from patients, both by listening to the advice from new patient and family advisory councils and by using the surveys to identify weak spots.

At Yale-New Haven Hospital, where an executive director of patient relations and a medical director work together to improve the patient experience, officials have made a concerted effort to lower noise so patients can get optimal rest. Hospital staff are told to use “library voices 24/seven” and not to “vent” where patients might hear them. Overhead page calls have been eliminated, beepers are kept on vibrate, doors are closed when staff discuss cases and efforts are made to reduce alarms, pings and beeps at the bedside.

The Cleveland Clinic requires all 3,000 staff physicians to take a day-long relationship and communication class. In 2010, the hospital showed each doctor what patients had said about him or her in surveys. About half the comments were negative — and most of those had to do with how physicians talk to patients.

Doctors were stunned when they saw the results, said James Merlino, a surgeon who is Cleveland Clinic’s chief experience officer.

“Physicians were shocked, dismissive, disbelieving. They said, ‘This isn’t true, the methodology is bad, the sample size is too small,’ ” he said.

Now, he said, “we put physicians through communication training so they learn how to listen better, let the patient set the agenda and organize the encounter better.”

The result is a big increase in physician communication scores since 2008.

At UCLA Health System, parents of pediatric patients created an educational video about central-line catheters that is shown to physicians and nursing staff “to remind them how scary that catheter is for patients and their family members,” said Tony
Padilla, UCLA’s chief patient experience officer, adding that catheter-related infections can be
dangerous and even fatal.

“It drives home the message that during your very busy day as a nurse or physician, please remember: You’re accessing the child’s lifeline.”

Moving The Needle

Moving the needle on Medicare surveys can be a hard slog. Inova Mount Vernon’s composite score went up from 66.6 percent to 68.4 percent from 2010-11 to 2012-13. That means that on average, 68.4 percent of patients gave top marks to the hospital on survey questions in 2012-13. Scores at Inova Fairfax dropped and scores at Inova’s other three hospitals remained about the same.

Hospitals face a balancing act.

“We want to be attentive to a patient’s needs and wants, yet not do things just to please the patient, like overprescribing pain medication,” said Atul Grover, chief public policy officer for the Association of American Medical Colleges, which represents nearly 400 major teaching hospitals and health systems, in addition to U.S. medical schools. “You want to make sure patient satisfaction isn’t driving patient care.”

Some question whether the hospitals that score best on patient surveys are also the ones that provide the best care. Grover, for example, worries that hospitals that don’t offer amenities, such as single rooms, will be dinged in the surveys.

But some research suggests a strong correlation between patient satisfaction and outcomes, said Richard Staelin of Duke University’s Fuqua School of Business.

One of his studies, published in the journal Circulation in 2013, found that the death rate among heart attack patients was lower at hospitals where patient satisfaction scores were high, even when researchers controlled for the quality of care, meaning the care was equivalent.

Another study found higher overall patient satisfaction was associated with lower readmission rates a month after patients were discharged.

Studies have also found that hourly nurse rounds result in more-satisfied patients, with fewer falls and pressure sores.

“Patients co-produce the service,” Staelin said. “What I mean by that is that when someone is sick, the doctors can’t solve the problem without their help. … As a patient, I have to communicate with the doctor or nurse, I have to listen to the
doctor, I have to follow the instructions.”

“There are still lots of doctors who don’t believe it, but gradually the medical profession is coming around,” he added.

Indeed, several patient experience officers said some physicians at their hospitals resisted doing things differently until it was no longer an option.

The financial penalties “are brilliant,” Westbrook said. “That’s what’s driving change.”

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

Holly Dawson believes her job is a calling.

She is one of about 2 million home care workers in the country. The jobs come with long hours and low pay.

Each workday, Dawson drives through the Cleveland suburbs to help people take their medicines, bathe and do the dishes. She also takes time to lend a sympathetic ear.

George Grellinger, a former client of hers, has dementia. He recently fell down the back steps of his home. Dawson remains friends and regularly stops in to check on him. To remain living at home, Grellinger had to switch to an aide who is covered by his veterans’ benefits.

When Dawson worked for him, Grellinger paid an agency $37 for two hours of her time each day. Dawson received $13 an hour, higher than the national average for home health aides. She had to pay her own taxes and health care benefits. Dawson says she can’t remember the last time she could afford health insurance.

Dawson says she has been a home health aide for 31 years. She has never done it for the money, rather to help people like Grellinger, she says.

But the conditions of home health work are leading many aides to seek better pay and benefits.

On an early September morning, home health workers held a rally in Cleveland. Jasmine Almodovar, 35, chants with the crowd: “We want change and we don’t mean pennies!”

She says she earns $9.50 an hour, which is actually just above average for a home health worker in Ohio.

“We work really long hours, really hard work,” she says. “A lot of us are barely home because if we don’t go to work, we don’t get time off. We don’t get paid vacations. And some of us haven’t had raises in years.”

Almodovar says her last raise was four years ago. She makes about $21,000 a year so she makes too much to qualify for Medicaid, but paying for a plan on Ohio’s federal exchange doesn’t fit in her monthly budget.

“I don’t have a retirement plan, I don’t have life insurance, I don’t have medical,” she says. “Because by a government basis, I’m 90 percent above the poverty level — but I’m in poverty.”

Home care workers are mostly women. More than half are women of color, and 1 in 5 are single mothers. A recent analysis by the Brookings Institution found that while the ranks of home health workers grew exponentially over the past decade, their earnings dropped when accounting for inflation, says Martha Ross a researcher at Brookings.

“People aren’t shocked about a fast food worker not having health insurance,” she says, “But someone who is in the health care sector providing necessary health care who does not have health insurance? Just on the face of it, it’s wrong.”

Under the Affordable Care Act, there are financial incentives for hospitals and doctors to keep patients healthy. Ross says home care workers should be considered – and compensated – as vital front-line personnel in reaching the new goals.

And the U.S. Labor Department says more than a million new home care workers will be needed in the next decade.

“They can contribute to better care,” Ross says. “Down the line that can contribute to reduced costs through reduced hospitalizations or going back into a nursing home and over time you can take those savings and put them into increased earnings for that home care worker.”

Home care workers are often trusted advisors for the patients, says Lisa Kristosik with the Visiting Nurses Association of Ohio.

“People get real confused about how to navigate the health care system,” she says. “And they know because they’ve seen it. Because they’re in the homes. And they are in the homes for hours on end.”

This story is part of a partnership that includes WCPN Ideastream, 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.

HHS Secretary names members for federal Health Information Technology Policy and Standards Committees

California’s public health department has failed to adequately manage investigations of nursing homes statewide, resulting in a backlog of more than 11,000 complaints – many involving serious safety risks to patients, according to an audit released Thursday.

California State Auditor Elaine M. Howle found that the complaints had been open for a year on average – a time frame she called unreasonable and “very concerning.” Nearly 370 open complaints arose from situations that put patients in “immediate jeopardy,” meaning they caused or were likely to cause serious injury or death, according to the review, which looked at cases open as of April 2014. In the Los Angeles County district, 65 immediate jeopardy complaints were open an average of 514 days.

The public health department, which is responsible for ensuring safety for residents at more than 2,500 facilities statewide, doesn’t require investigations to be completed within a certain time, leading to wide discrepancies from office to office, according to the audit.

“Holding district offices accountable for promptly completing investigations is critical to ensuring the safety and well-being of the residents in long-term health care facilities,” Howle wrote in the 82-page report.

State public health officials said in a written statement that they would be reporting on their progress to the auditor. “We appreciate the opportunity to improve our operation,” the statement read.

The state audit was prompted in part by Kaiser Health News reports that the Los Angeles County Public Health Department was ordering inspectors to close cases without fully investigating them. The reports, published by the Los Angeles News Group, also led to a critical county audit.

The state auditor found that the quality of investigations was inconsistent across California. For example, inspectors in the San Francisco office closed cases without having them reviewed by supervisors as required, the report said. And inspectors elsewhere failed to follow state laws requiring investigations to begin within 10 days. In one Sacramento case involving a 97-year-old resident who fell, the inspector didn’t begin the investigation until nine months later.

Mariko Yamada, a member of the state assembly who requested the audit, called the nursing home investigation process “mangled” and said the department has failed to do its job to protect some of the state’s most vulnerable residents. As many as 300,000 residents in California receive care each year in the facilities.

“There has been almost a culture of indifference,” she said in an interview.

The audit found particular problems with investigations into incidents reported to the state by the facilities themselves. In Orange County and most of Los Angeles County, for instance, the inspectors performed on-site investigations in less than 20 percent of such cases reported in 2012 and 2013.

In general, when inspectors found problems at nursing homes, they didn’t always follow up within the required time to ensure the facilities filed plans to fix the problems, according to the audit.

The audit recommended that the department establish a formal process to monitor investigations into open complaints and incidents reported by the homes and that it set a time frame for their completion. The auditor also urged that the department determine how many inspectors are necessary to reduce the backlog and keep up with new complaints.  The department has repeatedly said that it lacks enough resources.

In a response to the audit, state Public Health Department Director Ron Chapman pledged to increase supervision of the district offices, noting that the state already had made improvements to its oversight of Los Angeles County. But the department said that it did not agree with the auditor’s recommendation to set a firm timeline for finishing cases, saying instead that it would work to improve timeliness.

The findings didn’t come as a surprise to Joe Rodrigues, the long-term care ombudsman for the state. Rodrigues said there has long been “questionable oversight and management” of the department’s licensing and certification division.

“It is a flawed system,” he said. “It isn’t doing everything it can do to protect residents.”

Carole Herman, president of the Foundation Aiding the Elderly, agreed. The number of open complaints is “horrific, “she said.

“How many reports are there going to have to be before the governor and the legislature pay attention?” she said.

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

2015 Joint Board & Labor Council Election and Consent to Serve

DEADLINE EXTENDED: The deadline to submit your consent to serve form has been extended until November 14, 2015.

Are you interested in serving on the Alaska Nurses Association Board of Directors and Labor Council? Elections are quickly approaching! AaNA is in need of individuals to fill five joint seats on the Board and Labor Council. Please select the appropriate form below to fill out and return to AaNA by November 14, 2014.

Board Vice President / Labor Council Director
Open to any Alaskan Registered Nurse who is a member of an AaNA Bargaining Unit
Term January 1, 2015 – December 31, 2016

Board Labor Council Designee / Labor Council Director
Open to any Alaskan Registered Nurse who is a member of an AaNA Bargaining Unit
Term January 1, 2015 – December 31, 2016

Board Director At Large / Labor Council Director
Open to any Alaskan Registered Nurse who is a member of an AaNA Bargaining Unit
Term January 1, 2015 – December 31, 2016

Board Director At Large / Labor Council Director
Open to any Alaskan Registered Nurse who is a member of an AaNA Bargaining Unit
Term January 1, 2015 – December 31, 2016

Board Director At Large / Labor Council Director
Open to any Alaskan Registered Nurse who is a member of an AaNA Bargaining Unit
Term January 1, 2015 – December 31, 2016

Download the Consent to Serve form here.

Please submit Consent to Serve form to Andrea Nutty by November 14, 2014.

Jessica Bravo walks house-to-house in the piercing Southern California heat. Over and over, at doorsteps around Orange County, she asks the same question: “Are you insured?”

Getting an answer isn’t always easy. Doors slam in her face. She gets shooed from porches. And sometimes people cut her off mid-spiel.

Bravo is a paid health outreach worker for the Orange County Congregation Community Organization, a faith-based nonprofit. Her job is to inform people about getting health insurance under the nation’s landmark health law, the Affordable Care Act.

“A lot of people don’t know about this new law … this opportunity for health insurance,” said Bravo, a 19-year old Costa Mesa resident.

Until a few months ago, Bravo didn’t actually know coverage was an opportunity for her, as well.

She is an undocumented immigrant from Mexico. Most people without papers can’t get health insurance under the ACA. But last year, Bravo and her 21-year-old brother Daniel qualified for the Deferred Action for Childhood Arrivals (DACA) program – a 2012 initiative that grants temporary legal status to certain undocumented immigrants who were brought to the United States as children.

The law applies to people who came to the U.S. before turning 16, are in school or a high school graduate and are now under the age of 33.

They can obtain a work permit, a driver’s license, a Social Security number, a two-year reprieve from deportation and — as Bravo now realizes — the opportunity to get health insurance through Medi-Cal, California’s insurance program for poor and disabled people.   Only a few other states offer similar options.

Now studying politics and ethnic studies full time at Golden West College in Huntington Beach, Bravo can’t work as much as she used to. Her monthly income of $960 likely would make her eligible for Medi-Cal.

Figuring out her options under the law was especially difficult for Bravo, whose family is of “mixed status.” That is, some have federal authorization to be in this country and others don’t.  While anyone can buy insurance privately, people without legal status are not allowed to buy insurance on the exchange or participate in most government program such as Medicare, non-emergency Medicaid or the Children’s Health Insurance Program.

Her parents are in the country without permission, as is her older brother Luis, 22, who did not qualify for DACA. Her other brother Daniel, 21, was granted DACA status and qualifies for the same benefits she does. And her brother Alex, 11, is a U.S.-born citizen, covered through California Kids – a nonprofit health insurance plan.

‘Stuck In The Middle’

The family’s history is complicated. After several failed visa attempts, her father Enrique Bravo crossed the border illegally in 1996. His wife, Virginia, tried to cross by hiding in a car but was caught by border patrol agents. Desperate to join her husband, she tried again and made it across six months later. Three-year-old Jessica and her older brothers later crossed with legal-resident relatives in a car.

“I’m 100 percent Mexican…but all my memories growing up are from the United States,” said Jessica. “It’s like I’m stuck in the middle…I’m neither from here or there.”

As the older children grew up, getting health care proved dicey. The family tried to stay below the radar. This meant visiting the doctor only when absolutely necessary — and always paying cash.

They were, like many immigrants, fearful of exposing the family’s unauthorized status and risking deportation, for themselves and their children.

Eventually Enrique, an electrician, found a job that offered health insurance, and for several years the family was insured. But he got laid off in 2006. From then on, they were forced to rely on local community clinics that provide care on a sliding pay scale.

“I remember my parents telling me that I was no longer going to be insured under their plan,” said Jessica. “I just tried to eat healthy.”

Her biggest concern now, she says, is that one of the others will get sick and the family won’t be able to pay for care.

“Even though that fear is gone for me, it’s still very real for my family,” said Bravo, who is in the process of renewing her DACA status for another two years.

“It’s difficult to grasp that I have this privilege, yet my parents who worked twice as hard, don’t have anything.”

Recent events have compounded the family’s worries.

Jessica’s brother Luis was recently detained by agents from Immigration and Customs Enforcement as a result of a tip arising from a prior conviction for driving under the influence. It’s unclear what will happen until the immigration court hears his case and decides whether he can remain in the U.S.

“It all seems like a dream…it happened so fast,” said Jessica. “We’re doing everything we can to stop his deportation.”

One Fall Can Change Everything

Weeks ago, Jessica’s mother Virginia stumbled and fell to the ground in front of their Costa Mesa apartment, spilling the milk she’d just bought. The 48-year-old former hairstylist hurt her arm, but despite feeling a sharp pain she won’t be visiting the emergency room.

“We can’t afford it,” Virginia Bravo said. The mother of four has been unemployed for over a year and is more concerned about stocking the empty refrigerator than seeking treatment.

She knows all too well that without insurance an unexpected injury could leave them bankrupt.

Last year, Enrique had to be rushed to the emergency room. He woke up in the middle of the night with extreme paranoia, unable to catch his breath, and feeling numb.

He was having a panic attack. The bill for the two-hour hospital stay was about $6,000. Already struggling financially, the family had to find a way to pay cash.

“At first I refused to go to the hospital,” he said. “I knew it would be expensive.”

The 44-year-old says he struggles to earn at least $2,250 each month as a self-employed electrician – the exact amount he needs to pay rent.

Any extra money is used to buy food and pay bills. Saving for an emergency is impossible, the family members said.

“We’re poor, but rich in health and family unity,” Virginia Bravo said.

Living in a mixed-status family has been challenging, but it has also brought them closer, she said. The whole family has been involved in campaigning for immigration reform and hopes the ACA will eventually include coverage for undocumented immigrants.

“People don’t know what we had to go through to get here,” said Virginia. “We made it across … we’re the lucky ones.”

“We don’t want anything for free,” she said. “If we had an opportunity to buy health insurance, we would find a way to pay for it.”

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

They know less than they think they know. That’s the finding of a recent study that evaluated people’s confidence about choosing and using health insurance compared with their actual knowledge and skills.

As people shop for health coverage this fall, the gap between perception and reality could lead them to choose plans that don’t meet their needs, the researchers suggest.

“There’s a concern that people who don’t have much experience with health insurance don’t protect themselves financially, and then something happens,” says Kathryn Paez, a principal researcher at the American Institutes for Research who co-authored the study. “So they’re learning through hard knocks.”

The nationally representative survey of 828 people aged 22 to 64 is part of a project to develop a standardized questionnaire that researchers, health plans and providers can use to assess people’s health insurance literacy.

The study found, for example, that while three-quarters of Americans say they’re confident they know how to use health insurance, only 20 percent could correctly calculate how much they would owe for a routine physician visit. Many people don’t understand commonly used terms such as “out-of-pocket costs,” “HMO” and “PPO,” according to the study.

The study also found that certain groups of people tended to have a tougher time using health insurance, including young people, minorities, those with lower income or educational levels and those who used health care services infrequently.

People who visit the doctor occasionally but have never been hospitalized or visited the emergency room may be overconfident they understand how health insurance works, says Paez. Likewise, people who belong to integrated health care systems where providers are generally on staff may not realize the potential complications of in-network and out-of-network coverage, among other things, she says.

More comprehensive education could help close the gap between what people think they know about health insurance and what they actually know. In the meantime, the issue brief about the study includes a consumer checklist to aid consumers in choosing a plan.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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