ACA Timeline: Key Dates for Providers and Patients

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    traumaRUs, Altra, and herring_RN like this.
  2. 38 Comments so far...

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    My state has welcomed the ACA. Open enrollment is going to be interesting and we are counting down! My company estimates we will get as many as 18,000 new primary care patients. Medicaid reimbursement is reasonable here, and they pay promptly 100% of the time, keeping collections up. We are going to need trucks to haul the tons of money we are going to rake in, patients are going to be taken care of in a far more cost effective way than the ED. All of us are opening up our panels to prepare. I'm reserving 4 appointment slots a day strictly for new ACA patients, in addition to my 4 frozen slots for emergencies, which will likely end up being ACAs if none of my other patients needs a last minute appt. That's 1/3 of my patient day! Most of my colleagues are doing something similar.
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    I'm hoping the implementation of ACA results in fewer primary care patients in the ED; we've got enough serious stuff to keep us going.
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    Quote from ♪♫ in my ♥
    I'm hoping the implementation of ACA results in fewer primary care patients in the ED; we've got enough serious stuff to keep us going.
    I think it might require more than just rolling out the ACA to really cut the number of primary care visits to the ED unfortunately. Most importantly you have to convince people to actually use a primary care provider (insurance or not). I have not worked in EMS for years, but when I did I saw just as many people abuse the system who had insurance, and a primary care provider, as I did those who did not. It is somewhat a cultural issue I think. I still know people who believe the ED doctors are somehow "better" than a primary care provider even when it comes to treating things which can be successfully treated in a primary care provider's office. Nor is this phenomenon limited to just here in the US. I have a friend who lives in London and works for the NHS. He told me that even though they do not have to pay to see their General Practitioner they still have people show up at the A&E (what we would call ED) to be seen for things that should be being handled in their GPs office (and they are required to establish a medical home at a GPs office). So, like I say, I think it will take a very large educational push to convince people to use the ED for ED type things and primary care for primary care type things. I am sure that the ED you work in tries their hardest, same as most, to do that education now. So, I don't think people have not been trying to educate patients I just think it might take a large education push (maybe Johnson and Johnson can hold off on pushing nursing school for a while and use their education dollars to educate about the "real" use of an ED or something?).

    Anyway, just wanted to throw my two cents in there.
    Altra, lindarn, herring_RN, and 1 other like this.
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    Quote from ccso962
    I think it might require more than just rolling out the ACA to really cut the number of primary care visits to the ED unfortunately. Most importantly you have to convince people to actually use a primary care provider (insurance or not). I have not worked in EMS for years, but when I did I saw just as many people abuse the system who had insurance, and a primary care provider, as I did those who did not. It is somewhat a cultural issue I think. I still know people who believe the ED doctors are somehow "better" than a primary care provider even when it comes to treating things which can be successfully treated in a primary care provider's office. Nor is this phenomenon limited to just here in the US. I have a friend who lives in London and works for the NHS. He told me that even though they do not have to pay to see their General Practitioner they still have people show up at the A&E (what we would call ED) to be seen for things that should be being handled in their GPs office (and they are required to establish a medical home at a GPs office). So, like I say, I think it will take a very large educational push to convince people to use the ED for ED type things and primary care for primary care type things. I am sure that the ED you work in tries their hardest, same as most, to do that education now. So, I don't think people have not been trying to educate patients I just think it might take a large education push (maybe Johnson and Johnson can hold off on pushing nursing school for a while and use their education dollars to educate about the "real" use of an ED or something?).

    Anyway, just wanted to throw my two cents in there.
    I'm hoping that part of the cultural shift, and the changes in reimbursement, will lead the ED docs to start saying, "Oh, this is not an emergency... you need to see your regular doc." The wait times alone at our facility should drive a number of them away.
    lindarn likes this.
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    Well. Lets see...here in IL our last two governors ended up in jail, many of our independent pharmacies have gone under and our Medicaid payments are 2 years behind!!!!

    Hmmm. Probably not so hot for my state.
    Esme12 and lindarn like this.
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    Quote from ♪♫ in my ♥
    I'm hoping that part of the cultural shift, and the changes in reimbursement, will lead the ED docs to start saying, "Oh, this is not an emergency... you need to see your regular doc." The wait times alone at our facility should drive a number of them away.
    There is a double problem with this scenario that will probably keep it from being implemented in this manner.

    1) Once the doctor has seen the patient they have established a doctor patient relationship. Therefore, regardless of whether or not the patient "needs" emergency care to deny to provide care could be considered abandonment. As I understand law the most they could do is what they are probably already doing now. That is treat the patient, advise them (or have the nurse advise them during discharge instructions) to follow up with their primary care provider, and encourage them to obtain and make use of a primary care provider if they do not have one.

    2) If the doctor decided to allow the triage process to decide who does and does not see a provider in the ED (physician, PA, NP, etc.) then this opens a major liability for the facility as a whole. We live, like it or not, in a lawsuit happy society. And, as you are aware, patient's conditions can and do change. Therefore, it would not be too hard to envision a person showing up in the ED who, at that very point in time, does not "need" emergency care, being triaged as such and sent out of the ED. Later this patient's condition changes which leads to a more costly treatment or long term disability and, after finding an attorney, they file a successful lawsuit against the hospital for withholding of care. In addition, since this type of "triage out the door" approach would have to be approved by the Medical Director for the ED the attorney could also file formal procedures against the license of the Medical Director for causing harm to a patient with a standing order he/she issued.

    So, call me a pessimist if you want, but I do not forsee any physicians, at least those adverse to lawsuit or loss of license, telling a patient "this is not an emergency . . . go see your regular doctor" and then withholding any additional care.

    As always my two cents worth . . .
    lindarn likes this.
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    Quote from ccso962
    There is a double problem with this scenario that will probably keep it from being implemented in this manner.

    1) Once the doctor has seen the patient they have established a doctor patient relationship. Therefore, regardless of whether or not the patient "needs" emergency care to deny to provide care could be considered abandonment. As I understand law the most they could do is what they are probably already doing now. That is treat the patient, advise them (or have the nurse advise them during discharge instructions) to follow up with their primary care provider, and encourage them to obtain and make use of a primary care provider if they do not have one.

    2) If the doctor decided to allow the triage process to decide who does and does not see a provider in the ED (physician, PA, NP, etc.) then this opens a major liability for the facility as a whole. We live, like it or not, in a lawsuit happy society. And, as you are aware, patient's conditions can and do change. Therefore, it would not be too hard to envision a person showing up in the ED who, at that very point in time, does not "need" emergency care, being triaged as such and sent out of the ED. Later this patient's condition changes which leads to a more costly treatment or long term disability and, after finding an attorney, they file a successful lawsuit against the hospital for withholding of care. In addition, since this type of "triage out the door" approach would have to be approved by the Medical Director for the ED the attorney could also file formal procedures against the license of the Medical Director for causing harm to a patient with a standing order he/she issued.

    So, call me a pessimist if you want, but I do not forsee any physicians, at least those adverse to lawsuit or loss of license, telling a patient "this is not an emergency . . . go see your regular doctor" and then withholding any additional care.

    As always my two cents worth . . .
    It happens here all the time. EDs routinely refuse to treat any chronic issues at all naturally (as well they should) and for about the past year they wont treat non-emergent acute issues either. For example, they do not treat UTIs, AOM, tell the patient "this is not an emergency, go to minute clinic, urgent care or to your PCP." If the patient says they don't have a PCP and can't afford a visit, the answer is "that's a shame. save your money, go when you can."
    lindarn and chare like this.
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    I wanted to add, this is the current policy in all three major health systems in this city(1 for profit, 1 not for profit, and one major university), which collectively serve about 1 million people. Everyone here knows if it is NOT an emergency, they will be turned away.

    We are all looking forward to full implementation of the ACA, at least until someone comes up with something better.
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    Quote from BlueDevil,DNP
    It happens here all the time. EDs routinely refuse to treat any chronic issues at all naturally (as well they should) and for about the past year they wont treat non-emergent acute issues either. For example, they do not treat UTIs, AOM, tell the patient "this is not an emergency, go to minute clinic, urgent care or to your PCP." If the patient says they don't have a PCP and can't afford a visit, the answer is "that's a shame. save your money, go when you can."

    WOW! Not sure what part of the country you live in, but the area I live in does not have those types of policies.

    Discussing this with a family friend who is an attorney he offered the following opinion of this procedure (that I had not been aware of until you responded to my post and asked him). He said that in this case you mention this is most likely, as you state, the hospital policy. This means that the ER physicians are usually not liable for any negative effects that this might cause to a patient since the ER physicians have not usually at this point seen the patient and two the ER physicians are usually independent contractors working in the hospital. What can happen, he said, is that the hospital can get sued, and it is possible, hospital policy or not, that the triage nurse making the decision, if said decision is made by a triage nurse, could be sued also.

    The reason? The triage nurse is a staff member of the hospital, so they are carrying out the direct order of the hospital. Therefore, the hospital can get sued for inacting a policy that leads to a detrimental outcome for a patient. So, in other words it is sort of like a "Hold Harmless Agreement". Many people erroneously believe that signing a Hold Harmless Agreement gives away your right to sue. This is not the case. Hold Harmless Agreements only work if it can be shown that the actions that lead to the injury, harm, etc. are actions that any responably competent person in that profession would also do. As you can imagine it is not hard at all to find a professional in almost any field who is competent and would be willing to testify that they would not have done what the other professional did in that case. The same applies here. Since not every hospital ER practices this way, regardless of whether or not it is practiced at all the hospitals in your area, it would not be hard at all for an attorney to find a professional from another hospital who would testify that this was not the way they thought things should run.

    Where the problem comes up for nurses is that apparently there have been cases where hospitals have successfully argued in court that the individual nurse did not correctly follow triage protocols. From what I understand this has involved cases where patients were triaged too low, but were eventually seen; however, I can only assume that faced with a lawsuit a hospital might try to use this same tactic on the triage nurse who "triages out the door".

    The lawyer friend further posited that most likely the only reason that these facilities had not yet been sued was either 1) the people who were turned away did not have the financial resources to seek legal assistance anymore than they had the resources to seek medical help outside the ER and/or 2) the right litigation attorney just hasn't found the right patient yet.

    Either way, I still stand behind my statement that it is not the best policy at least from a legal liability reason (and in the case of the "tough luck" that can be construed as harassment). It is one thing to tell a person to leave, it is another entirely to belittle the situation they find themselves in with a "tough luck" statement.
    JeanettePNP and Esme12 like this.


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