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Nurse Admitted to Hospital After Literally Working Her Ass Off.

Houston, TX - After years of mandatory overtime, 16-hour days without a restroom break and a revolving door of understaffed and overworked conditions as a hospital nurse, it finally happened. Jan Stevens, R.N. was admitted to the hospital last week shortly after her ass literally fell off during a busy day in which two nurses called in sick at the last minute, without explanation, on a sunny Friday afternoon.

"I tell my husband and kids all the time that I'm exhausted after working my ass off at work , but I never thought it would actually happen," said Jan.

The strange event occurred while Jan was giving Ativan to an old and naked demented guy trying to ask her out on a date while two young Facebookers demanded more Dilaudid for their abdominal pain of no possible cause, one patient's out-of-town physician daughter was on hold waiting to reverse an end-of-life DNR and two smokers descended on the nurses station, in their street clothes, asking when the doctor would be there to discharge them.

"I was just standing there, overwhelmed with nonsense, when I felt a sudden weight lifted off my pelvis. I turned around and there was my ass laying on the floor in a pool of c diff.," said Jan.

Rapid response team members transported the hard working nurse to the ER where Emergency physicians worked for hours to try and find an admitting physician.

"The ER doctor told me he was working his ass off to find a surgeon to admit me and I just looked at him and shook my head. I told him 'You don't get to say that to me today.'"

Surgeons working their asses off to fix Jan's ass.

Hospital officials were stunned by the work related injury, but they admit it was only a matter of time before something like this was bound to happen.

"We've got some pretty hard workers here at the hospital but Jan is one of our best. We'll have to take this incident back to our 12 committees to start a root cause analysis," said Wendy Stenson, Vice President of Meetings.

"But regardless of what we find, we just don't have the money to increase staffing ratios. Maybe we'll think about implementing mandatory prophylactic ass taping for all our staff."

Since Jan's remarkable event went viral, she has received hundreds of job offers, but Jan is thinking about taking advantage of the workers' compensation lifestyle for awhile instead.

"I think I've earned it."

ACA, Medicaid and Unintended Consequences for People with Disabilities

People with disabilities who are eligible for healthcare through Medicaid may experience painful gaps in coverage during transitions. There are groups of people with disabilities that are particularly vulnerable: those who need long-term care services, those who apply but are not yet found eligible for SSI in 209b states with expanded Medicaid and youth transitioning to the adult system.

Long-term care services and supports, such as personal assistance services or durable medical equipment, are critically important to some people with disabilities. Medicaid packages for people with blindness and disabilities, or AABD or SSI Related Medicaid, offer comprehensive coverage, including long-term care supports and services. For those who need them, these services are a lifeline to independence, living in the community and employment. Either not affordable or available through the private insurance market, Medicaid has been the sole access point for people with disabilities who need long-term care services. The Adult ACA Medicaid group, or expansion group, is a Medicaid program that may or may not provide an individual with long-term care services in any given state.

209(b) Expansion States Facing Challenges with Transitions

One key difference across states is the option to automatically provide SSI Related Medicaid to recipients of the federally-administered state supplementary payments though the Supplemental Security Income (SSI) program. Ten states use at least one eligibility criterion that is more restrictive than the SSI program for Medicaid eligibility and are referred to as 209(b) states. This means that an individual in these states who applies and is found eligible for SSI must make a separate application for Medicaid coverage.

The following states are currently 209(b) states: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma and Virginia. All but Missouri, Oklahoma and Virginia have expanded Medicaid eligibility through the ACA.

Limited Access to Long-Term Care and Providers in the ACA Adult Group

Because many SSI applications take longer to process than Medicaid applications, people with disabilities can frequently be found eligible for ACA Adult Medicaid while waiting for SSI eligibility to be approved. While this group of individuals who have been approved as ACA Adult Medicaid eligible has access to healthcare, they may not have access to long-term care services.

Once SSI eligibility is approved, however, the beneficiary is no longer eligible for the category of Medicaid (ACA Adult) they are currently receiving. When they are put into the correct category for coverage (SSI Related Medicaid), they are sometimes dropped from one health plan and put into another without their knowledge. The end result is a current Medicaid beneficiary who is denied or faces delayed access to long-term care services he or she should be receiving under SSI Related Medicaid, as well as potentially losing access to providers and being forced to reapply altogether.

In addition to the lack of access to needed long-term care services, people may also experience challenges related to accessing medical service providers. In some states, the integration of the ACA and managed care has vastly changed provider infrastructure, with managed care plans for SSI Related Medicaid offering different provider networks and services than ACA Adult Medicaid managed care plans.

Many individuals, especially those new to SSI Related Medicaid, will not be aware that they are in a different category until another action is taken, such applying for a Medicaid waiver service, attempting to contact their managed care plan or going to see their providers. Both of these issues can result from the timing of an individual’s Medicaid application and approval.

Youth with Disabilities Facing Challenges with Transitions

Youth with disabilities can also potentially face significant unintended consequences around access to appropriate healthcare coverage. Children with disabilities are found eligible for SSI due to a reduction in both Activities of Daily Living and Instrumental Activities of Daily Living. This means a youth can be eligible for SSI under a broader context of criteria, like an inability to socialize or play with others.

Adult disability determinations, by contrast, are made based on a disabling condition that impacts employment—not only current employment, any employment in the country that may be available to someone with such impairments. These are vastly different criteria.

As a result, many children are found eligible and begin receiving childhood SSI and SSI Related Medicaid. However, when they turn 18, they are required to meet the adult disability guidelines in order to remain eligible. Many children fail to meet those adult requirements and their benefits are terminated. Of those that are found ineligible when they turn 18, a number are later found to be eligible in further review or appeal processes. Because Medicaid waiver programs are available only to individuals who are current Medicaid recipients, a child may have waited years to be eligible for Medicaid waivers, be found eligible, only later to be denied eligibility for adult disability—which results in losing benefits under SSI Related Medicaid and SSI eligibility. If, upon later application, the individual is once again found eligible for both adult SSI and SSI Related Medicaid, he or she must now go to the back of the waiting list for the same waiver services previously lost under a youth determination. This can result in years without necessary, critical services and care.

Experiences in the States

Health & Disability Advocates conducted a short, informal survey of seven 209(b) states that have expanded Medicaid to learn more about how states identify people who are in the “wrong” eligibility category and the processes states have in place to prevent this from happening. With six of the seven states responding to the survey, HDA found that:

• Three of six respondents offer Medicaid provider packages that are different depending on whether you are in SSI Related Medicaid or ACA Related Medicaid.

• Three of the six responding states offer some variety of waivers to individuals even if they are placed in ACA Related Medicaid.

• None of the responding states have a formal process for coordinating information about individuals who transition eligibility from one service package to another.

• Four of six states are unaware of whether individuals have been improperly placed in the wrong Medicaid eligibility package; the remaining 33% have implemented trainings, but know that individuals continue to get placed into the wrong eligibility group.

• Five states (all but North Dakota) were not aware of specific alerts that notify the Medicaid beneficiary that their eligibility for one program has ended and another started.

Upon further contact, roughly half of the states were in the early stages of identifying the issue of individuals being inappropriately placed and noted a need to develop a process for re-engaging the beneficiary to get them connected to appropriate providers for maximized health.

Recommendations Going Forward

While states are currently uncertain about the scope and breadth of these issues, it is important to identify individuals who have fallen through the cracks and may experience a significant disruption in services and eligibility. At a minimum, requiring states to create an automated notification system for changes to eligibility would provide beneficiaries greater clarity and time to plan. In North Dakota, for example, individuals receive a notice as they leave eligibility under one Medicaid group and become eligible for another. Notice of and clear information about the ramifications of the change is critical.

Another recommendation for states is to look at integration of its systems and data tracking of disability populations. Data exchanges between the state and federal systems, along with the differing eligibility criteria among various programs, should make tracking persons with disabilities a high priority for states. Minnesota, for example, is developing a new integrated system with the capacity to match data sets to a broader context of information, such as employment status. This will greatly enhance the ability of the state to make sure that people with serious health needs receive the proper services and have access to the supports they need for the greatest possible independence.

Joe Entwisle, MS, CLCP
Sr. Policy Analyst
Health & Disability Advocates

The Future of Enrollment in Illinois: Where We’ve Been and Where We’re Going

When Get Covered America came to Illinois before the first open enrollment period for the Affordable Care Act in 2013, there was a lot of work to be done. At that time 78% of the uninsured had not heard of the health insurance marketplace and were unaware of the new health coverage options or opportunities for financial help available to them for the first time. The initial awareness gap was daunting, but hundreds of thousands of Illinoisans stood to benefit from the marketplace and needed to know how the Affordable Care Act could help them.

Many Milestones Through Collaboration

Fortunately, there were a number of stakeholders like Health & Disability Advocates (HDA), the Campaign for Better Health Care (CBHC), Alivio Medical Center and the AIDS Foundation of Chicago, among others, eager and ready for the challenge ahead. This commitment helped achieve many of the goals laid out in the beginning. After two successful open enrollment periods, nearly 350,000 Illinoisans have enrolled in health insurance through the marketplace, and hundreds of thousands more have received coverage through expanded Medicaid and CHIP. Working together towards the same mission, Get Covered America and its partner organizations increased awareness and provided enrollment resources for consumers across the state.

Stepping Back to Move Forward

Because of the great work that has happened on the ground in Illinois, Get Covered America will be stepping back with full confidence in capable partners like HDA, CBHC and many others—such as Family Guidance Centers and Ada S. McKinley—to continue this important work to make health care enrollment a permanent part of communities. It’s clear that the coalition of partners who have come together on this issue have made great strides over the past two years. As the insurance landscape changes and the number of uninsured Illinoisans continues to decrease, Get Covered America wants to make sure that resources are allocated in the smartest and most effective way.

While Get Covered America won’t have an active outreach presence on-the-ground in Illinois moving forward, the organization will continue to support partners in the state with cutting edge data, best practices, tools and resources. Get Covered America will refine and continue to offer digital tools like the Get Covered Connector while also introducing new programs, like training and support for local partners and health insurance literacy resources for the newly insured.

The Enrollment Challenge Ahead

Just released by Get Covered America, the State of Enrollment Report takes a critical look at the lessons learned and what still needs to be done to get Illinois covered. Using on-the-ground knowledge and data analysis, the report identified several key initiatives integral to maximizing the number of Illinoisans who enroll in coverage. This is a great resource for partners on the ground and the foundation for a sustainable coalition for years to come.

The Get Covered America team is thrilled at what has been accomplished in Illinois so far, but there’s still important work to be done. While more Illinoisans have health coverage than ever before, there are still too many who remain uninsured and need the facts about how the Affordable Care Act can help them and their families. On-the-ground partners like CBHC, Family Guidance Centers and Alivio Medical Center will continue this work and make health care enrollment an institutional reality for years to come. And Get Covered America looks forward to supporting their efforts.

David Elin
National Fundraising Director
Enroll America

Joint Commission Implements Mandatory Universal Patient Helmet Regulations.

Baltimore, MD - In an effort to reduce injuries and deaths related to in-hospital falls, the Joint Commission notified hospitals last week of strict new universal helmet regulations for all hospitalized patients, without exception.

Patient death or serious injury associated with a fall while being cared for in a health care setting has been a recognized since 2002 as one of 27 original never events as defined by the National Quality Forum (NQF). The complete list was revised in 2011 to include 29 never events, but falls by confused old naked men have continued to result in serious injuries despite endless attempts to counteract natural traumatic hospital acquired deaths.

"We've heard from hospitals loud and clear. They've tried everything from 4 point leather restraints and putting on fall-risk arm bands to Ativan drips with soothing country music and we have concluded that patients are just gonna fall. So we figure it makes sense for us to force all patients to wear a helmet," said Mark R. Chassin, M.D. FACP, M.P.P, M.P.H, president and chief executive officer of The Joint Commission (TJC).

"In a few years, universal helmet use will be as normal as universal hand washing is today."

Hospitalists were thrilled to learn about mandatory helmet regulations in the hospital. "I get at least two calls a night from the night nurse letting me know they found a patient laying unresponsive on the floor in a pool of blood at 2 a.m. with a large pulsating scalp bleeder and do I want to do anything about it," said Hospitalist James Fleming.

"But now with mandatory helmet regulations, I think we'll be more comfortable not ordering the stat CT head. It's just going to take some time getting used to."

While hospitalists were thrilled with their new found nocturnal freedom, not all specialities were equally excited. Stan Bedlow, a prominent local Neurosurgeon was concerned the new policy would interfere with his ability to operate effectively and efficiently.

"We asked The Joint Commission to waive their tough new standards for neurosurgical patients, but they said no. "I'm not really sure how I'm going to access the brain through a helmet, but we believe The Joint Commission is the gold standard in safety, so we'll probably just consult the hospitalist to manage it.

Hospitals prepare for mandatory patient helmet use.

Some surgical nurses were happy to hear the hospital was finally going to counteract unsafe operating practices. "We've had a few patients roll off the table and die while the anesthesiologist was doing advanced sudoku puzzles and trading stocks and the orthopedic surgeon was blasting Guns N' Roses and singing Sweet Child o' Mine, " said one surgical nurse who wished to remain anonymous for fear of telling the truth and losing her job.

Even the Obstetricians were left scratching their heads on the new mandatory helmet policy. "We've been told by our hospital quality officials that all expectant mothers and their newborns will be required to have a helmet secured prior to the baby exiting the birth canal or C-section. We figured this was a perfect job for the third year medical student so we've decided to base their whole clerkship grade on how well they perform retraction-helmet duty," said Academic Obstetrician Dr. Michelle Johnson.

The Joint Commission expressed confidence their strict new safety measures would be accepted kindly by physicians who understand the importance of universal safety precautions in the hospital. "We anticipate physician experience with our helmet regulations will help them fully embrace our anticipated full body Charmin wrap requirement planned for next year's accreditation process," said Dr. Chassin.

Walmart Rounds Helping Train Nation's Young Doctors.

Little Rock, AK - Doctors at the University of Arkansas Medical Center celebrated the three year anniversary of Walmart Rounds on Friday, a one-of-a-kind initiative exposing student doctors to a wide variety of conditions rarely seen anywhere else in the world.

Attending physicians, residents, interns and medical students from most specialities have donned their white coats and headed to their favorite local Walmart isle for the last three years to observe the stunning pathology of Walmartians in their natural environment.

"During Walmart rounds, we try and tell our students to be as discrete as possible whenever they discover a horse or a zebra, but sometimes their excitement overcomes them," said attending Neurologist Dr. Krzesimir Bednarczyk.

"Just last week one of my gunners in isle three started yelling back to the team 'Here comes a hemochromatosis with a lupus rash, even though it was clearly just an old lady with a bad tan.'"

When the Rheumatologists heard about a possible case of lupus heading their way, they laughed and chuckled arrogantly. "I teach all my fellows that nobody has lupus unless we say they do," said Dr. George Bostinza, the Rheumatologist known best for his shirt 'Why the Hell did you order a sed rate anyway?'

"We also had to put up a sign that says 'If you're here for fibromyalgia, STOP! Turn around and go back. Fibromyalgia is a primary care disease.'"

But FP would have no part of it. By punting every shopper to another service, attending physicians used Walmart rounds to educate student doctors on the financial aspects of medicine. "We always thought our young Medicaid clinic patients rolling up in their fancy rims and newest iPhone were a bit on the entitled side, but we were shocked to learn how belligerent they became when the cashier wouldn't accept their Medicaid card as payment in full," said Dr. Alan Fenwick.

ER doctors hanging out in deli hated Walmart rounds because of the never ending stream of shoppers sent over by other teams telling them to go see ER without even a courtesy call overhead. "Just last week some old guy showed up with Dizziness of No Possible Cause to get a stat MRI and wondered why the neurosurgeon wasn't waiting for his immediate arrival," said Dr. Brenda Dresser, an Emergency Medicine doctor who has since authored a case series in the NEJM titled Turkey Sandwich Request as a Sign of Homeless Dilaudopenia.

"We're also thankful that I.D. chose to hang out in produce so we could them all our toxic sock syndromes."

After just one week of Walmart rounds, the Infectious Disease teams started handing out gloves and yellow gowns after seeing dozens of their C. difficile and MRSA patients man-handling the grapes. "Less than six months after starting our infection control program in produce, we noticed a statistically significant 76% reduction in mold on Walmart strawberries," said Dr Daniel Messer, the ID doctor who routinely refuses consults for bilateral cellulitis on principle.

Walmart helping train young doctors.

Over the last three years, the Pulmonologists working cigarette checkout discovered 87% of their patients did not quit smoking last week, 92% forgot to bring their oxygen with them and 98% did in fact have $30 lying around for their copays. "They're basically just a bunch of liars," said Pulmonologist Dr. Stan Spencer, himself a two pack-per-day smoker.

While hanging out in baking, ortho routinely spilled olive oil and waited for a fracture in unsuspecting lol's. Appalled by the caveman like approach to medicine, many ortho students tried to escape to Dermatology hanging out in skin care, but realized they didn't usually show up until 11:00 am and were usually gone by noon for a long F.A.C.

Not so for the trauma doctors. They found Walmart to be fertile training ground for excited young surglings. "The Walmart Scooter Club has been a gold mine for our young trauma doctors. We see at least at least one high impact scooter-scooter collision every Friday. Anything can happen when you've got two 500 pound objects colliding at break-neck speed," said trauma surgeon Dr Stan Harlow.

Even the Hospitalists used Walmart rounds as a quality improvement project after they discovered none of their patients ever showed up to their PCP follow-up appointment
within a week of discharge. "We started scheduling follow-up at our Walmart rounds and discovered a 72% reduction in 30-day readmission rates over the last three years," said Dr John Fender, Director of Outpatient Hospitalist Medicine.

Two specialties in particular, Psychiatry and Pediatrics, have both abandoned their hospital training programs all together for a full time Walmart residency experience. "We just couldn't replicate the level of pathology seen at Walmart in our hospital," said the hospital CEO.

Rauner's Budget is Bad Medicine for State's Health Services

The following post originally appeared on Crain's Chicago Business.

The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:

• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding

It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:

• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.

As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:

• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).

We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.

Barbara A. Otto
CEO
Health & Disability Advocates

Illinois Cooperative Brings Competition, Lower Costs for Small Businesses

Taking Advantage of Land Of Lincoln Health

Consumer Operated and Oriented Plans, or CO-OPs

for short, are a new health insurance option for small business owners. Created by the Affordable Care Act, CO-OPs are consumer-directed and required to engage members in plan oversight. Only insured members can vote for and run for a seat on the CO-OP’s Board of Directors.

What is a CO-OP?

The federal CO-OP program offers low-interest loans to eligible nonprofit groups to help set up and maintain these issuers. CO-OP loans are only made to private, nonprofit entities that demonstrate a high probability of financial viability. All CO-OPs receiving loans were selected by the Centers for Medicare & Medicaid Services on a competitive basis based on external independent review by a multi-disciplinary team. As CO-OPs meet or exceed developmental milestones, funds are allowed to be incrementally drawn down.

Taking Advantage of a CO-OP'portunity

The Illinois small business community capitalized on the CO-OP option. Small businesses in Illinois had been confronting high health insurance costs that threatened their ability to offer employee coverage. Illinois was previously dominated by one major health insurance carrier, who in 2014 wrote over 90% of the public health insurance marketplace policies in state. This market dominance gave small business owners few options in terms of obtaining and providing their employees with affordable health insurance. With CO-OPs offering the promise of increasing competition and lower rates, small businesses and individuals formed a CO-OP owned by its members and operated by its advocates.

Small Business Have More Choice

CO-OPs are following through on that promise. The Illinois CO-OP has enrolled over 50,000 businesses in 2015. During the second open enrollment period, one of every four new enrollees to the 2015 public marketplace is choosing a CO-OP. This additional competition is fantastic news for small business owners and their employees.

And High-Quality Plans

The Illinois CO-OP has been able to roll out innovative and transparent plans that connect consumers with provider choices they know and trust, because of the CO-OP's close relationship with the medical community. A consumer’s commitment, as an individual or employee, to choose the provider on the front end and at the time of selecting insurance coverage motivates the provider to build a strong relationship with that consumer. As a consumer-focused company, The CO-OP's small business insurance offerings are also designed by individuals who are attuned to the unique needs of this community.

The Bottom Line

The majority of small business owners value and care about their employees. Moreover, healthy employees with access to quality medical care are happier, more motivated and productive. Stabilizing health insurance premiums for small businesses while at the same time enabling them to procure quality coverage for their employees is a true game-changer. Small businesses drive our economy. Providing them access to affordable health insurance will benefit not only the small business community, but the entire Illinois economy.

Elliot Richardson
Founder and CEO
Small Business Advocacy Council

HEALTH FOR ALL

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