Beruflich Dokumente
Kultur Dokumente
Selena Pham, Victoria Nguyen, Victoria Mignone, Brooke Limeberry, and Marty McHale
● Capacity
○ Overcrowding due to non-emergent patients
■ “There were 3,667,601 first time attendances to
Emergency Room EDs, of which 554,564 were defined as
non-urgent (15.1%)” (O’Keeffe, Mason, Jacques,
Issues ○
and Nicholl, 2018).
High flow of uninsured patients - cannot deny care
○ Patients visit the ER more on weekends to avoid
missing work
○ Admitting more patients than the amount of hospital
beds available
● Length of stay
○ Doctors utilizes Triage Assessment Form meaning that
they evaluate the severity of the patient’s conditions
○ Patients are not discharged immediately
● Staffing
○ Understaffed because more people are covered by
ACA. This result in more people visiting emergency
rooms but, not enough staffs to assess each patient
problems
■ Emergency departments are opened 168 hours
a week/365 days a year. More hours means
more burnout for doctors, resulting in less
on-call doctors
● Population:
○ Black patients
care costs, and cover for visits concerning sore throats and runny
noses because they are not life threatening.
access to health Utilization of Health Care
● ED use reduced after the implementation of ACA due
care? to young adults being covered until the age 26. This
allowed for more office visits for nonurgent illnesses
or injury, clearing up the ER
● The ACA did not decrease the burden on ER visits
because there was not enough focus on primary
care visits
Health Care Costs
● Even with less people visiting the ER, NEMJ Catalyst
How does it affect states there is no evidence that the cost of care has
been reduced as well
health status, ● The ideal situation would be improved access and
access to health
● Those with Medicaid and expanded coverage
actually utilized the ER more. This finding was
● Patients
○ A study by Dr. Leana Wen M.D. stated:
■ A total of
● 85% of patients want a doctor that listen to them
● 71% want a doctor who is caring and compassionate
● 69% want a doctor that explains well
● 47% want quick and convenient access to care
● 41% want pleasant interactions with medical staff
● 29% want to be able to talk about cost with their doctor
● 22% want a doctor that discloses financial conflicts of
interest.
Stakeholders (cont.)
● Communities (NO PROBLEMS WITH IRON TRIANGLE)
○ Communities want no issues with Access, Cost, and Quality
■ No Discrimination due to an individual’s socioeconomic status
■ Self assurance that medical services will be covered
■ Excellent quality of medical services (NO SHORTCUTS)
○ Benefits for communities near Non-Profit Hospitals
■ Providing funding and staff to community health clinics so uninsured and low-income patients with
chronic illnesses can get preventive care and avoid the emergency room
■ Sponsoring food banks and farmers’ markets in communities without grocery stores
■ Supporting to reduce youth violence or substance use
■ Offering programs that encourage healthy behaviors and lifestyles
○ If the Hospital is not a Non-Profit in the Community?
■ Some states have laws about financial assistance, billing, and community benefits but speaking up will
improve the communities health and engagement with the hospital.
Stakeholders (cont.)
Physicians
○ Patients have misconceptions of the job of an ER Physician
■ The ER is designed to provide emergent care to make sure the patient is safe, healthy and comfortable.
■ The ER is not an in-and-out clinic or primary care office
● The primary care physician will give quicker care and help you follow up on the issue, whereas ER
physicians cannot
■ If someone comes into the ER with something minor, they’ll have to wait
● If you wait, you are not dying. Feel sorry for the people who get rushed back.
■ An individual in a worse state of health will be attended first
● If you assume it's serious, contact your primary care doctor to see if they can take care of the
problem before the ER
● Patient Satisfaction?
● ER Physician Advice to Patients?
Stakeholders (cont.)
● Insurance Companies
○ INSURANCE COMPANIES LOVE MONEY
○ Access to quality health care is a concern for many Americans, due to rising premiums
and the future of the Affordable Care Act.
○ Americans also don't realize that if you can afford health insurance, quality could be
limited due to tactics practiced by insurance companies, specifically focusing on
prescription drugs and medical procedures.
○ Insurers seek to cut costs by preventing coverage for certain treatments and passing
payments onto customers. (Ginsberg, 2018)
■ Increases profitability for Insurance Companies
● What tactics do insurance companies use?
○ Questioning Doctor’s Orders
■ “Prior Authorization”?
Stakeholders (cont.)
● Delayment of Effective Treatments
■ Step Therapy
■ Fail First
● Excluding Medications
○ Insurance companies can refuse to cover a medication due to the price being too high
■ The costly medications are placed on “Formulary Exclusion Lists”.
(Ginsberg, 2018)
● Administered by Pharmacy Benefit Managers for example CVS
○ People are denied medical treatments even though they’re in a chronic health state
○ Do insurance companies think of profit?
Stakeholders (cont.)
● Messing with Success
○ Insurers can force an individual to switch medications for a non medical reason
■ How do Insurers do this?
○ Individuals with chronic illness are at risk due to medications causing their symptoms to worsen along with
taking multiple medications until their health improves. (Ginsberg, 2018)
● Forgetting about Mental Health
○ Insurance companies offer low reimbursement rates for mental health specialists.
○ Mental Health Professionals refuse to take insurance due to payors not providing a “living wage”
○ Insurance companies have refused to accept mental health specialist plans
● Due to being aware of these tactics
○ Coalitions in states formed, which were filled with patients and providers
○ 15 states passed legislation focusing on prior authorization and step therapy so patients could have access to
proper medical drugs (Ginsberg, 2018)
○ Speaking up about what you believe in could limit these insurance company tactics
■ A PERSON DOESN'T HAVE TO BE INVOLVED WITH POLICIES BUT AN INDIVIDUAL WITH A
PASSION TO IMPROVE ACCESS TO CARE CAN MAKE A DIFFERENCE!
Additional Regulations
Anthem’s New Policy ACA (Affordable Care Act)
● As stated earlier, Anthem’s new policy will essentially ● The ACA expanded Medicaid and instead of
pick and choose what they deem “necessary” as an ER those patients taking advantage of primary
visit. However, this can get tricky by certain coding that care, referral med reports that there was
is done because the coding doesn’t tell the whole story
almost a 40% increase in ER visits from
about the visit. An example used by the LA Times talks
Medicaid patients. Also with the age gap
about a patient that got hit by car, was taking to the ER
widen to 26, a lot of younger adults took to
in an ambulance and had to get a CAT scan and X-ray
and luckily found no serious injury. The only serious the ER as opposed to prior ACA. However, like
injury was to the patient’s wallet because Anthem would stated earlier the amount of uninsured
not cover the visit because no serious injury was found. decreased.
A doctor stated that out of all the complaints in his ER
45%of cases could have expressed life threatening
changes and another 5% could only be treated in the ER.
So is Anthem trying to help overcrowded ER rooms or
possibly costing lives?
What are the various remedies that could be
implemented to resolve the problem?
● Staffing to demand
○ By staffing more people it can avoid wasting
hospital resources.
■ Doctors and nurses would rather work
during the weekdays and normal
business hours, however most
Emergency Departments are under
staffed during the “off-hours”.
■ Patients usually decide to go to the
emergency rooms due to the fact that
everything else is closed.
What are the various remedies that could be
implemented to resolve the problem? (cont.)
Our Opinion ○
more home visits
Educate patients on the difference between
emergency and non-emergency cases
○ Encourage those with insurance, Medicare and
Medicaid to utilize their primary physician
before going to the ER
○ Don’t overcrowd by admitting more patients
than the amount of hospital beds - do not
exceed the limit
● Length of stay
○ Accurately place patient using the 5 R’s: right
level of care, right service, right nursing unit,
right bed and right time period
■ This will make the progress run
smoother and faster
○ Discharge patients as soon as possible - some
doctors keep their patients longer than
necessary
● Staffing
○ Increase staffing
○ Have more staff working the night shift
References
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