Monthly Archives: July 2016

4 Important Provisions of the Affordable Care Act

The 2010 passage of the Affordable Care Act changed the landscape of American healthcare. On a large scale, it addressed longstanding systemic concerns while also attempting to bring down costs.  Nearly everyone has an opinion on the bill, yet few people really understand some of the significant changes that it ushered in.  Since 2010, much of the media coverage of the bill and the associated outcry has been reduced to 140 character summaries and soundbites.  Before forming an opinion, take time to learn about some of the things the bill did.

Young Adult Coverage: Before the Affordable Care Act, health insurance companies could remove enrolled children when they turned 19.  Some insurance plans allowed for enrolled children to stay on the insurance plan while they were enrolled as a full time student.  Under the Affordable Care Act, children can remain on a parent’s insurance plan until they turn 26.

Pre-existing Conditions: Prior to the Affordable Care Act, health insurers could deny (or charge more for) coverage because of a pre-existing condition.  Often this meant that people with chronic health conditions, like cancer, had significant trouble getting new health insurance coverage.  Some insurers even classified pregnancy as a pre-existing medical condition and would refuse to pay for related care.  Under the Affordable Care Act, health insurers can no longer charge more for or deny coverage for pre-existing health conditions.

Annual and Lifetime Limits: Health insurance plans used to be able to set annual and lifetime limits for coverage as long as someone was enrolled in the plan.  If a participant exceeded the limit, they would be responsible for all charges.  Under the Affordable Care Act, health insurance plans can no longer place limits on medically necessary care.  Limits on “non-essential” health benefits are still allowed.

Plain Language Benefits Information: Details about health insurance plans used to be hidden behind small fonts and legal language.  For many people, it was tough to understand and even tougher to compare plans side-by-side. The Affordable Care Act requires that health insurers provide participants with an easy-to-understand summary.  This mandatory standardization now allows people to easily compare the benefits and costs of medical plans.

Without realizing it, all Americans already know someone who has benefited from these four changes made by the Affordable Care Act.  Teenagers can now keep health insurance until age 26.  People with chronic conditions no longer fear being denied health insurance—or the associated extra costs of medically necessary treatment that isn’t covered.  Annual and lifetime limits are gone.  Insurances now explain their benefits and costs in an easily understandable format.  The Affordable Care Act has changed the American healthcare system in ways that have already benefited all Americans, regardless of political opinion.



U.S. Department of Health and Human Services. “Lifetime & Annual Limits.” December 5, 2014. (http://www.hhs.gov/healthcare/about-the-law/benefit-limits/index.html)
U.S. Department of Health and Human Services. “Plain Language Benefits Information.” September 8, 2014. (http://www.hhs.gov/healthcare/about-the-law/plain-language-benefits-information/index.html)
U.S. Department of Health and Human Services. “Pre-Existing Conditions.” November 18, 2014. (http://www.hhs.gov/healthcare/about-the-law/pre-existing-conditions/index.html)
U.S. Department of Health and Human Services. “Young Adult Coverage.” March 12, 2013 (http://www.hhs.gov/healthcare/about-the-law/young-adult-coverage/index.html)

Rural Healthcare: the Shortage and the Benefits of Working Outside the City

There are over 908,000 actively practicing doctors and 141 medical schools in America.  Although these are large numbers, medical schools are typically located in big cities.  Since graduates often practice close to their medical school, there are more doctors in cities than in the country.  Statistically, only 1 in 10 doctors practice in rural areas.  Yet 1 in 5 Americans live in rural areas.

As the baby boomer generation ages, the shortage of doctors in rural areas is projected to grow. Although it’s a national problem, regional organizations are approaching solutions differently

The 5 state WWAMI region (including Washington, Wyoming, Alaska, Montana, and Idaho) has 27% of the landmass in the United States.  With only 3.3% of the American population, these states encompass some of the most rural areas in the nation.

In response to the shortage of rural providers, the region’s only medical school, the University of Washington School of Medicine, started a program intended to place more medical school graduates into rural healthcare settings.  The new TRUST (Target Rural Underserved Track) gives medical students the opportunity to partner with a rural healthcare provider throughout their entire time in medical school. This “cohesive experience” differs from the traditional route of rotations in different offices with different providers.  Although TRUST was only launched in 2009, students have already noted the positive impact of their continuing relationship with their assigned rural healthcare provider.   The TRUST program is only one response to this shortage.  Throughout the country, medical schools and organizations are organizing innovative responses to persuade providers to work in rural areas.

A 1978 study of Washington state rural physicians highlighted the benefits of working in a rural community.  Each provider had different answers, but three of these benefits were frequently listed.  In a 1978 study that interviewed rural physicians in Washington state, there were two frequently listed benefits of working in rural communities.

Rural providers see patients with a variety (and complexity) of medical issues.  One doctor was quoted saying that she relies on all aspects of her medical training, because she never knows what her patients will need care for.  The variety keeps her job interesting.

The same 1978 study noted that the small town communities often welcome the rural providers.  Many of the doctors interviewed noted that the friendly atmosphere of these communities was a huge benefit.

The shortage of doctors practicing in rural communities is an issue without a simple solution.  Instead, the answer will lay in a combination of programs and initiatives to recruit providers to work in rural communities.  Yet the first step is education.  It’s important to understand the macro factors of what is happening at the national level, and the systemic solutions being suggested.  However, it would be most beneficial to start more conversations like the ones that the TRUST students are having.  Opinions can be changed when more people take the time to learn about the life of a doctor in a rural setting and the communities they serve.


Bernstein, Lenny. “US faces 90,000 doctor shortage, medical school association warns.” March 3, 2015.  https://www.washingtonpost.com/news/to-your-health/wp/2015/03/03/u-s-faces-90000-doctor-shortage-by-2025-medical-school-association-warns/

Getsinger, Annie. Herald & Review. “Rural doctors enjoy the challenges, benefits of small town practice.” May 8, 2012. http://herald-review.com/news/local/rural-doctors-enjoy-the-challenges-benefits-of-small-town-practice/article_9756ab74-98d0-11e1-bc2c-0019bb2963f4.html

Hewett, Chanelle. “5 Benefits to Practicing in Rural Areas” July 12, 2012. http://healthcare-executive-insight.advanceweb.com/Features/Articles/5-Benefits-to-Practicing-in-Rural-Areas.aspx

Kaiser Family Foundation. “Total Professionally Active Physicians.” April 2016. http://kff.org/other/state-indicator/total-active-physicians/

Khazan, Olga. The Atlantic. “Why Are There So Few Doctors In Rural America?” (August 28, 2014) http://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to-rural-america/379291

National Conference of State Legislatures. “Meeting the Primary Care Needs of Rural America: Examining the Role of Non-Physician Providers” (2016)  http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-rural-america.aspx

US National Library of Medicine, National Institutes of Health. “Opinions of rural physicians about their practices, their community medical needs, and rural medical care. (July-August 1978)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1431908/

Vassar, Lyndra. “How one school is training students for rural medicine.” January 7, 2016. http://www.ama-assn.org/ama/ama-wire/post/one-school-training-students-rural-medicine

8 Common Questions about Medicare

Medicare is another popular health coverage provider.  As most Americans already know, Medicare is a federal program that provides insurance coverage to adults ages 65 and older.  There’s so much more to the program than can be summarized in one sentence.   The article below answers some common questions that people have about Medicare.

  1. What is it? Medicare is a federal insurance program that covers adults ages 65 and older, people with certain disabilities, and people with End-Stage Renal Disease.
  2. When did it start? After its 1965 passage, Medicare began on July 1, 1966.  On that date, all adults ages 65 and older were automatically covered under Medicare Part A.   The voluntary Medicare Part B program started at the same time.
  3. Why are there so many letters? In the past 50 years, Medicare has morphed into a four part program.  The letters represent the different parts of the program.
  4. Medicare Part A: Offered since 1966, Medicare Part A provides insurance that covers medically necessary hospital visits and skilled nursing home stays.
  5. Medicare Part B: Also offered since 1966, Medicare Part B provides health insurance that covers medically necessary doctor’s visits and many other services.  Enrollees pay a monthly premium for this coverage.
  6. Medicare Part C (a.k.a. Medicare+Choice, or Medicare Advantage): These plans began after the passing of the Tax Equity and Fiscal Responsibility Act of 1982.  The plans were created as a partnership between private insurance companies and the federal government.  Enrollees in these plans pay their premiums to private insurance companies who contract with the federal government to provide Medicare coverage.
  7. Medicare Part D: Part D began with Medicare Prescription Drug, Improvement, and Modernization Act of 2003.  Effective in 2006, it provides prescription drug coverage to those enrolled in Medicare.   Participants can get prescription drug coverage by signing up for a Prescription Drug Plan as an add-on to original Medicare.  Some participants may choose to get prescription drug coverage through their Medicare Advantage Plan.
  8. How many people use it? As of 2015, over 55.5 million Americans are enrolled in Medicare which is almost equal to the 2013 population of the Northeastern states.  (In 2013, approximately 55.9 million people lived in Massachusetts, Connecticut, New Hampshire, Maine Rhode Island, Vermont, New York, Pennsylvania, and New Jersey.

In its 50 years of existence, Medicare has provided medically necessary health insurance coverage to adults ages 65 and older and certain populations with disabilities.  With the addition of Parts C & D, Medicare has expanded its reach to assist eligible participants to provide more health coverage.  As a federally run program, Medicare is susceptible to political will.  It will be interesting to see where the program is after the next 50 years.


Kaiser Family Foundation. “Medicare Beneficiaries.” (http://kff.org/medicare/state-indicator/total-medicare-beneficiaries/)
Kaiser Family Foundation. “Medicare Timeline.” March 24, 2015. (http://kff.org/medicare/timeline/medicare-timeline/)
Medicare.gov. “How to get Prescription Drug Coverage.” (https://www.medicare.gov/sign-up-change-plans/get-drug-coverage/get-drug-coverage.html)
Medicare.gov “Medicare Advantage Plans.” (https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/medicare-advantage-plans.html)
Medicare.gov. “What’s Medicare?” (https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html)
Medicare.gov. “What Medicare Covers.” (https://www.medicare.gov/what-medicare-covers/index.html)
MedicareInteractive.org “What Does Medicare Cover?” 2016. (http://www.medicareinteractive.org/get-answers/introduction-to-medicare/explaining-medicare/what-does-medicare-cover-parts-a-b-c-and-d)
McGuire, T.G., Newhouse, J,  & Sinaiko, A. “An Economic History of Medicare Part C.” US National Library of Medicine. National Institutes of Health. June 2011. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117270/)
Wikipedia. “List of states and territories by population.” July 6, 2016. (https://en.wikipedia.org/wiki/List_of_U.S._states_and_territories_by_population#Summary_of_population_by_region)

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Talking to Health Insurance Companies

Image by Wellness Corporate Solutions (www.wellnesscorporatesolutions.com)Regardless of your role, health insurance is an unavoidable part of working in healthcare. Schedulers ask for insurance information when a patient makes an appointment. Front desk staff ask for insurance cards at check in. Nurses use it for medication pre-authorizations. Doctors write appeal letters to convince an insurance organization that something is medically necessary. In clinical settings, all staff are guaranteed to encounter health insurance questions, concerns, or issues frequently.
Some ways that clinics structure themselves to be able to handle the barrage of insurance related questions are listed below.

 

  • Have an Expert: Many clinics have one staff member who designated as the insurance expert. Larger healthcare organizations may have a centralized department that is responsible for getting authorizations. Since health insurance is a complex and perpetually changing, it benefits organizations to designate a staff member or a department to serve as experts. This allows the people in those roles to gain a deep knowledge in insurance, rather than a broad knowledge in all areas of clinic operations.
  • Be Prepared: When calling an insurance company, know what to request. Most insurance companies will need to know the full name of the requested service along with any associated CPT codes. Be prepared to offer the full name of the provider making that request and the provider’s NPI number. This information is normally required before an insurance company will be able to authorize a visit.
  • Take Notes: When talking with an insurance company agent, write down their name, the time and date of the conversation, and a summary of the discussion. It’s important to have notes particularly if there’s a question about the insurance authorization later.
  • Appeal: If an insurance denies an authorization request, there may be options for the patient to appeal the decision. Specific information varies depending on the plan.
  • Take Responsibility: Encourage patients to directly contact their insurance to confirm that services will be covered. Staff at most clinics will do their best to find out what an insurance plan covers. Due to the complexities of insurance and high volumes of patients, this may not be possible in every scenario.

Regardless of job position, all healthcare staff will be presented with insurance questions, issues, and challenges. It’s important for staff to be aware of this, and prepared to assist. Each organization had different policies, but all of them face similar challenges due to the complexities of health insurance. These are simply some tips to make contacting health insurances easier.

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Health Insurance 101: Introduction to Healthcare Insurance

By Emily Manahan

It’s important for all people who work in healthcare to be familiar with the different types of health insurance.  Even if your position doesn’t routinely deal with it, all staff—particularly those in clinical settings—will encounter health care questions, concerns, and challenges.  To build your knowledge, use this list of common health insurance categories.

Types of Insurance Plans

Health Maintenance Organization (HMO)  Patients with these types of insurance plans have to see their primary care doctor to get a referral.  Unlike their PPO counterparts, these people would not be able to go straight to see a specialist.  Instead, they would have to be examined by their PCP first.  Then they could be referred, if deemed appropriate.

Medicare is a federal insurance program that covers people 65 years and older.  It also covers people with specific disabilities.

Medicaid offers insurance to people who meet certain income requirements.  Medicaid programs are jointly operated by the state and federal governments.

Motor Vehicle Claims are selected as insurances for patients who have been injured in a motor vehicle accident.  Typically the clinic will require written or verbal confirmation that the particular claim is still open and billable.

Preferred Provider Organizations (PPO).  Patients with these type of plans usually have more flexibility.   Unless required by a particular office, this patient can typically go to any provider in their preferred insurance network without a referral.

Self pay patients pay the entire cost of their medical care out of pocket.

Veterans Administration and Tricare are health insurance plans offered to active and retired military and their families.  If a patient is seeking care outside of the VA system, their health insurance plan will often require a written authorization.  Different requirements vary.

Worker’s Compensation comes in a variety of forms including private, state, or federal claims.  These plans cover patients who had a job related injury or accident.
Within these eight categories of health insurance, there are many different plans.  Each individual plan has different requirements.  If patients have specific questions about their type of health insurance, please encourage them to call their company directly.


Resources
Blue Cross. Blue Shield. Blue Care Network of Michigan “What’s the Difference between HMO, PPO, and EPO Plans?
Medicare.gov. “Medicaid
Social Security Administration. “Medicare” October 2015
US Department of Veterans Affairs. “I am an Active Duty Servicemember.”  November 10, 2014. (http://www.va.gov/opa/persona/active_duty.asp)

Listen, then Ask. Communication Tips in Healthcare

By Emily Manahan

When I first started working at the clinic, I spent time chatting with my new coworkers in the break room. During one of these conversations, one of the psychiatrists asked if I had any trouble communicating with the patients. I shrugged my shoulders, “Nope, not really.” Then I finished my sandwich and went back to work.

A week later, one of the nurses complimented me on how I talked with a frustrated patient. She asked me how I became so good at communicating in these situations. What was my secret?
The truth is, I had to take annual communication trainings at my previous job. At the time, I thought nothing of it. We all attended, enjoyed the free food, and returned to work. Each training was self-contained, but we were all expected to integrate the training principles into our communication.

About a year ago, I ran into a former coworker. Within thirty seconds, he laughed as he pointed out the training tips I had just used in conversation. Some of those tips are listed below. Each tip is simple. Implementing the tips is the difficult part. So take the time to try each out. Test what works. Revise as needed. Use what works and build from there.

Say “Hi”

A front desk staff member will have patients come to them. Most other staff members will be visiting patients. In either case, smile and say hello.
Learn their name: Introductions are easy to do. Still many people forget. Knowing the other person’s name puts both people at ease.

Explain

The person who started the conversation usually takes responsibility for this. If a patient comes to the desk to check in, they’ll be offering the explanations. If a staff member walks into a patient’s room, they’ll be the ones explaining why they’re visiting.

Listen

It is not appropriate to multitask while someone is talking. If a staff needs to finish something before engaging in conversation, acknowledge the person and ask them to wait a moment.
Summarize and reflect. To ensure that the request has been correctly understood, summarize what was said and reflect it back. For example, I could say “So it sounds like you’re hoping to make another appointment for June 26, am I understanding correctly?”

 

Since emotions run high in healthcare settings, it’s important to learn how to calmly and effectively communicate. These are some tips that work for me. Find what works for you and build from there.