How The Affordable Healthcare Act Will Impact Your Hospital Stay

Sharon Gauthier has built a career on helping others navigate the healthcare system.   For many years she worked in hospitals dispensing care firsthand as a Registered Nurse.   Now she uses that inside knowledge to advocate for others who can easily become overwhelmed by the complexity of the ever-changing healthcare system.

Gauthier’s company, Patient Advocate for You, is a 24-7 service available to help patients and families manage everything from middle of the night emergencies to coordination of care, transition programs and beyond.   Now, with the launch of the Affordable Healthcare Act there’s yet another puzzle for patients to decode.

“The system was confusing to begin with and now there are a whole new set of rules and 2.3 million people in CT are expected to get up to speed immediately,” said Patient Advocate For You Founder and CEO Sharon Gauthier.   “It’s often a matter of patients just not knowing what they don’t know.  This is where an advocate can step in and make all the difference in the world.”

 

KNOWING THE ABC’S OF ACO’S

A new acronym to know is ACO or Accountable Care Organization.  The definition of an ACO continues to evolve, but generally it is defined as a set of health care providers-including primary care physicians, specialists, and hospitals—that are supposed to work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients.

The designated ACOs in CT are:

  • Accountable Care Clinical Services, PC
  • Accountable Care Organization of New England
  • Hartford HealthCare Affordable Care Organization, Inc.
  • Pioneer Valley Accountable Care, LLC
  • ProHealth Physicians ACO, LLC
  • Saint Francis HealthCare Partners ACO, Inc.
  • MPS ACO Physicians, LLC
  • PriMed, LLC
  • WESTMD Medical Group, P.C.

One major flaw ACOs are seeking to solve, unsuccessfully so far, is the level of patient re-admission into the hospital after discharge.  Re-admission to the hospital within a 30-day period now creates a penalty for the hospital and for the provider. It is based on a percentage of re-admissions and the penalties are hefty.  The ACO is supposed to reassure that re-admissions do not happen, protecting the hospitals and the physicians from penalties. 

THE NEED TO NAVIGATE A FLAWED SYSTEM WITH HELP

“In my opinion, even with ACOs, there is still no accountability for the clear coordination of care for patients entering the hospital as they are using the same techniques they’ve always used and usually don’t work,” said Gauthier.   “The system uses telephonic management, paper tools and videos for training patients and families before they leave the hospital and perhaps a non-clinical person sometimes available to these patients and families to connect the dots but that often isn’t enough for those complex patients who really need micromanagement once released”

Gauthier adds that questions should be addressed such as, do the families and patients have money for medications, is there transportation to their physicians, do they have insurance, are they supported by families or alone in the community, what is their educational level to understand the process?

For years, CT hospitals have hovered above the national average for hospital re-admission levels.  The problem remains despite the introduction of ACOs as hospital re-admission levels remain alarmingly high.  In fact, twenty-three CT hospitals have already been penalized for high re-admission rates.  Only 8 CT hospitals were spared from penalties in 2012.

Patient Advocate for You is able to manage the process with a staff of seasoned registered nurses and expert navigators who offer around-the-clock access.   The continuum of care is executed by assigning team members to a specific population, which they then micromanage.   In the process of providing improved quality of care, “Patient Advocate for You” also ensures the most at risk don’t fall through the cracks. 

WHAT YOU DON’T KNOW CAN HURT YOU

There’s another side effect of 30-day re-admission penalties.  Hospitals have set up a loophole status classification called “observation status.”  For instance, someone brought to the hospital may not be truly admitted; instead, they simply might be on “observation status.”   To say the least, it’s confusing for families who believe their loved one is admitted but technically they are not.

“They could go to a unit for care just like they would for admission - the difference is that these patients are paid out of Medicare through part B and not part A and they are not “admitted,” said Gauthier.   “This, I believe, protects the hospital because they aren’t counted as re-admitted if they come back within 30 days.   It has backfired into angry families and AARP has lodged a class action suit regarding this ruling.   The ruling was adjusted somewhat but it is still a problem for patients.”

A University of Wisconsin-Madison School of Medicine and Public Health study found this guideline may work against Medicare recipients who need medical treatment.  The study included more than 36,000 hospital encounters during a 14-month period between January 2012 and February 2013.  In October 2013, the Centers for Medicare and Medicaid Services enacted a rule classifying most hospital stays of fewer than two midnights as observation and those equal to or longer than two midnights as inpatient.

The idea was to clarify the two different classifications, reduce long observation stays and reduce the financial burden on Medicare patients, who may pay greater out-of-pocket costs for observation care than for inpatient care. In addition, patients classified as “observation” may not qualify for Medicare coverage of certain follow-up care.

One constant is that we never know when we or one of our loved ones will be a patient.  Sometimes it’s a gradual process, other times it happens suddenly.   What you do have the ability to plan for is arming yourself with an advocate to ask the questions you don’t know to ask.   These questions and answers may save your life.

Founded in 2008 by Sharon Gauthier, Patient Advocate for You provides the following services:

  • scheduling and attending appointments
  • communicating to physicians an accurate depiction of a patient’s medical history
  • serving as an oversight of care that’s delivered to patient
  • support, coordination and collaboration with the entire healthcare team
  • crisis Intervention

Sharon Gauthier has nearly two decades of experience working in the healthcare profession.  She’s a graduate of the St. Francis School of Nursing, University of Hartford Bachelor’s Degree Nursing Program (BSN) and the University of Hartford Master’s Degree Public Health & Community Nursing (MSN) program.  She has also served as an adjunct faculty member at Capital Community College and St. Joseph's University.  Gauthier holds an RN Patient Advocate Certification and is the recipient of several awards for clinical excellence and care.  Gauthier is also involved in patient advocacy on a national level, serving on the planning committee of The National Association of Healthcare Advocacy Consultants.  The company has offices in Hartford, Avon, and Glastonbury.  For more information visit www.patientadvocateforyou.com or call 860.703.1575.

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Submitted by Westport, CT

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