2 assignment link payment

Due August 21

Contact a disaster preparedness person at either a local hospital, or local city or county emergency services agency.

Interview your contact, asking the following questions:

1) "What do you consider to be the top three disasters for which you prepare?"

2) "What would you say are your top three lessons learned about managing a disaster?"

Write a paper of 1,000–1,200 words that summarizes your findings from the interview as well as from your readings.

Refer to the assigned readings to incorporate specific examples and details into your paper.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment

Top of Form Disaster Preparedness Paper 1 Unsatisfactory 0.00% 2 Less Than Satisfactory 65.00% 3 Satisfactory 75.00% 4 Good 85.00% 5 Excellent 100.00% 70.0 %Content 40.0 %Demonstrate thorough knowledge of the principles of disaster readiness and lessons about managing a disaster. Clearly develop a strong analysis of the lessons learned. Introduces appropriate examples. Does not demonstrate understanding of the principles of disaster readiness and lessons about managing a disaster. Does not demonstrate critical thinking and analysis of the material. Demonstrates only minimal understanding of the principles of disaster readiness and lessons about managing a disaster. Demonstrates only minimal abilities for critical thinking and analysis. Demonstrates knowledge of principles of disaster readiness and lessons about managing a disaster, but has some slight misunderstanding of the health care implications. Provides basic critical thinking and analysis. Does not include examples or descriptions. Demonstrates acceptable knowledge of the principles of disaster readiness and lessons about managing a disaster. (in your own words). Develops an acceptable analysis of the lessons learned. Utilizes some examples. Demonstrates thorough knowledge of the principles of disaster readiness and lessons about managing a disaster. Clearly develops a strong analysis of the lessons learned. Introduces appropriate examples. 30.0 %Integrates information from outside resources into the body of paper. Does not use references, examples, or explanations. Provides some supporting examples, but minimal explanations and no references. Supports main points with examples and explanations and includes few references to support claims and ideas. Supports main points with references, explanations, and examples. Analysis and description are direct, competent, and appropriate of the criteria. Supports main points with references, examples, and full explanations of how they apply. Thoughtfully analyzes, evaluates and describes major points of the criteria. 20.0 %Organization and Effectiveness 7.0 %Assignment Development and Purpose Paper lacks any discernible overall purpose or organizing claim. Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear. Thesis and/or main claim are apparent and appropriate to purpose. Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose. Thesis and/or main claim are comprehensive. The essence of the paper is contained within the thesis. Thesis statement makes the purpose of the paper clear. 8.0 %Argument Logic and Construction Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources. Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. 5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use) Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Writer is clearly in command of standard, written, academic English. 10.0 %Format 5.0 %Paper Format (Use of appropriate style for the major and assignment) Template is not used appropriately, or documentation format is rarely followed correctly. Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. Appropriate template is used. Formatting is correct, although some minor errors may be present. Appropriate template is fully used. There are virtually no errors in formatting style. All format elements are correct. 5.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style) No reference page is included. No citations are used. Reference page is present. Citations are inconsistently used. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct. In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error. 100 %Total Weightage Bottom of Form

Materials

The New Reality: Bioterror and Disaster Management

Introduction

Preparing for a disaster of any kind is one of the more stressful and difficult things a health care leader must do. There are so many different types of events that it is almost impossible to plan in advance for any specific one. However, almost all health care entities have plans based on basic concepts for managing a disaster event, with some specific twists for more likely events. This module will review the basic elements of a strong disaster plan and discuss some specific events that require special planning.

Types of Disasters

While some disasters may be specific to a given area, others may happen to anyone. Fires, hostile situations, community illnesses or pandemics, and possible terror attacks can occur anywhere. Hurricanes, earthquakes, and weather-specific disasters are more dependent on the location. Internal disasters can also occur to any facility, such as water line breakage, loss of heat or air conditioning, loss of power, and loss of total water supply.

Fires are one of the more feared disasters, since there are opportunities for fires to grow quickly in the oxygen-enriched environments that exist in some hospital areas. All staff are regularly trained and drilled in quick identification of fires and speedy reactions to control or extinguish any fire that occurs. Smoking in bed used to be one of the more common fires, but the ban of smoking in hospitals has helped to reduce that problem. The biggest issue with fires in hospitals, in particular, is the need to speedily evacuate patients if the fire grows out of control. This may be a horizontal evacuation to another unit on the same floor or a vertical evacuation to another floor. The most feared option is the total evacuation of the hospital. Since critical patients, patients in surgery, and patients in active labor are difficult to move, it becomes an extreme challenge to get everyone out safely. Such a mass evacuation also requires transfers of patients to other facilities, along with their medical records and staff to care for them. This is a huge endeavor and is difficult to do quickly. So the need to find fires quickly and respond to extinguish them without delay is very important.

Hostile situations are becoming unfortunately more common, particularly in hospitals. The events that can occur in a hospital are stressful and emotional at best and can become a dangerous trigger to someone with rage/anger management problems or a pre-existing mental disorder. When this is coupled with relatively easy access to firearms, the possible danger is exacerbated. There have been numerous media reports of individuals who shot patients, staff, physicians, and themselves for a variety of reasons. In one hospital in the 1980s, a man brought a shotgun into the intensive care unit (ICU) where his brother lay paralyzed and comatose after a motor vehicle accident. His goal was to discontinue the patient's life support, since he felt that his brother would not want to live in that condition. He took the entire ICU by storm, although some patients were able to be moved out by the nursing staff. A physician and nurse were held by the hostage taker in the patient's room. The police SWAT (Special Weapons And Tactics) team was called and the hospital went into disaster mode and was locked down to outsiders. The ending was a good one, as the hostage negotiators were able to talk the hostage taker out of any violent action and he surrendered with no injury to anyone. Unfortunately, it does not always end that way. During this period, however, families were escorted out of the building, patients had to be moved, and the fear and terror of all involved were very high.

A community pandemic is a less terrifying but more resource-draining disaster, and they last longer. The most commonly seen version of this is the flu. While many flu seasons pass with no more than predictable levels of illness, every so often a new strain with a high transmission factor and severe illness can devastate the health care system. Community fears can cause the "walking ill" to flood into emergency departments (EDs), hindering the provision of care to those who really need it. Such fears are intensified with media reports of high death rates from the illness, as seen in the flu epidemic from H1N1, or swine flu, several years ago. The most significant issues here are complex, due to the extraordinarily high demand for services from a frightened public, coupled with an illness that infects staff and physicians as well as the community. When hospitals and EDs are full of patients and short on staff and physicians due to their own illnesses or their families' problems, it is very difficult to manage resources to meet the demands. A particularly contagious strand of flu can also complicate hospital status, since flu patients cannot be mixed with other types of patients due to the contagion. In such a situation, communities and the public health system may have to make decisions about how to provide care for those who need it while reducing the care demands of the walking ill or just the "worried with a sniffle."

Floods can provide their own challenges. Generally, the community as a whole is affected, as seen in the situations that arose in New Orleans after Hurricane Katrina and in south Florida after any number of hurricanes that produced a flooding surge. When a hospital floods, the management of patient safety must become the first priority. If several floors are flooded, it may be impossible to evacuate patients safely, as at Charity Hospital in New Orleans, where patients had to be airlifted from the roof or taken out in boats. In addition, in such situations, the power is also usually out or had to be shut down for safety purposes, making it impossible to operate the facility. In Indiana, after a river flooded a hospital basement, the emergency generators were destroyed, since that was where they were located, and the hospital was shut down and required patient evacuation. Internal flooding can also cause a disaster. In one hospital, a sprinkler head popped off in the laboratory and water poured out of it. In the time it took to find the shutoff valves, a significant portion of the floor was flooded and water moved through it into the basement, shutting down the sterile supply area and almost flooding the hospital computer system in the basement. While this affected only a portion of the hospital and did not necessitate any movement of patients, it illustrates that disasters can come in many sizes, big and small.

Earthquakes are not common in most of the United States, but where they are, they can destroy a hospital. In California, both the Loma Prieta earthquake in San Francisco and the Northridge earthquake in Los Angeles posed serious problems for area hospitals. At a time when injured patients may be pouring into local EDs and trauma centers, those facilities may themselves be affected by structural damage, water problems, and power issues. The building codes in earthquake-prone areas are being changed to help the buildings withstand the shocks and the swaying effects, but the secondary problems of power and water interruption can still make the disaster more intense.

There are several aspects of weather that can cause a disaster in a health care facility. The most easily understood are the hurricanes and tornadoes that wrack different parts of the country almost every year. Both cause structural damage from high winds and can cause issues with flooding and interruption of community services. They also produce injuries and illnesses that require higher levels of health care access at a time when it can be very difficult to provide such services. However, there are other types of weather that can cause disaster conditions. In the Midwest and North, blizzard conditions in the winter and extreme cold can have very detrimental effects, as ice storms and high winds can cause power interruptions for prolonged periods. While all hospitals have emergency generators, they require a supply of fuel that may become more difficult to sustain or obtain in these circumstances. In the Southwest, the problem is different. Extreme heat in the summer is not a problem, until the air conditioning fails. At that point, there must be an alternative or patients must be evacuated within 24 hours. Also, with extremely high heat, aeromedical helicopters experience more difficulty with lift, especially with patients on board. In Phoenix, on days when temperatures exceed 120 degrees, planes and helicopters can be grounded until the temperatures drop below 120 degrees.

Threat Analysis

Health care facilities are all required to have disaster management plans in place, along with threat analysis. A threat analysis looks at several things:

· The type of disaster (weather, fire, flood, etc.)

· The likelihood of such a disaster occurring

· The expected frequency of such a disaster occurring

· The expected impact on the facility and the community

Based on the threat analysis, the facility can plan more specifically for its more likely or frequently occurring disaster threats and spend less time on the ones not as likely to occur.

Key Elements of Disaster Planning

Every facility should have plans for both internal and external disasters, and they can have similar elements. Plans should be reviewed and updated at least yearly and after any major event that triggers the use of the disaster plan, so as to learn key lessons. Every disaster plan should have timed components, including a plan section for the initial response to a disaster, what to consider and manage in the first 12 hours, what to plan for in the second 12 hours, and sections that deal with 48 hour periods, 72 hour periods, 96 hour periods, and longer. Disasters may be resolved in a period of hours for most internal problems but they may go to weeks in the case of natural disasters that affect entire communities. Health care entities need to be flexible in their responses.

Key elements of any effective disaster plan need to include the following:

A Defined Leadership Structure: When attempting to manage a disaster response, it is absolutely critical to have a defined chain of command, with one leader at the top. This individual, which in many plans is called the incident commander, may be one of several people in the entity's organizational structure, depending on time of day and day of week. It may also change as the disaster situation evolves and changes. For example, in an initial hostile event during the night, the administrative supervisor or house supervisor may be the initial incident commander but may pass the role on to a hospital administrator if the situation demands it. The incident commander needs to be someone with recognized authority to make decisions, allocate staff to different areas of the hospital, and direct physician responses to the disaster. Depending on the situation, the incident commander may also need to work collegially with commanders of outside agencies responding to the situation, such as fire or police. The incident commander needs to stay in the command area, which is a defined space with computer, phones, a television, and adequate desk and office space for multiple people to function. This is likely to be the administrative offices in a hospital setting. Several subcommanders will be needed to take more focused responsibilities as the disaster progresses. In a natural disaster where the hospital's functioning is at risk, an operations commander will be in charge of staff and the activities of providing care to patients. A logistics commander will be responsible to monitor and ensure that supplies, equipment, and services such as power, water, and air conditioning or heat are operational and functioning appropriately. A financial commander may be needed to ensure that medical records, admissions processes, and activities that affect the ability to be paid for services provided and to pay for additional resources to respond to the disaster are all being tracked and accounted for. A security commander will need to be responsible to maintain physical security of the facility, since it may be in lockdown. Crowd control is also a responsibility of the security commander, who may need to have the incident commander approve a request for more support from local law enforcement. A public relations liaison is essential, since any disaster situation will likely draw media attention, and the hospital's responses need to be carefully designed and managed.

A Communcations System: One of the most critical functions the disaster management group must have access to is an effective communications system. Most people who have led through disasters will tell you that communications flow is always a problem in some way. There are several aspects of communication that have to be effectively planned:

· Hardware: It is common for teams creating and revising a disaster plan to focus their communication strategies on cell phones, since most people carry them. However, in a communitywide disaster, cell phone towers will quickly become overloaded with traffic and the cell calls will not go through or they will drop. Internal telephone coverage is problematic, since it will be difficult to tell where various people are in the facility, and landline phones may be disrupted by the disaster event. Wireless communications may also be disrupted. Hand held radios can work, although if multiple people are on them at once, the channels will become overloaded with communications. If radio discipline can be enforced, this technique can work well for immediate communications. However, people who are not used to working with the radios may find this difficult and cumbersome. Some hospitals have invested in a small number of satellite phones, although the problem of being unfamiliar with how to use them continues. In a communitywide disaster, having local amateur, or ham, radio operators stationed at the hospital is very valuable, especially if cell and landline phone service is out.

· Process: It is inevitable in almost every disaster that people will come to the command center for information. It can quickly be overwhelmed by the sheer number of people who come, and thus it is important to ensure that the command center has security that can control the number of people trying to access it. Only those on the approved list should come to the command center. However, it is also important to get information on the disaster, the response to it, and the latest updates and bulletins out to staff in various areas. Different entities have planned for this in various ways: runners with updates and information who go out on a regular route to take new information to staff; printed update bulletins to be posted on each unit and department for staff; phone calls if the systems are functional; etc. This is especially important if the disaster is one that will take 24 hours or longer to resolve.

· Accuracy: Most people who have experienced a disaster will be quick to relate that accurate communications and information is one of the biggest challenges of the leadership team. Rumors develop and fly quickly, and people in a hurry do not always stop to confirm accuracy before acting on the information. It is essential that accurate information on the disaster, its impacts on the facility, and how resources are being allocated and used, be gotten to the incident commander. Unfortunately, that is frequently not the case, especially in the initial stages of the disaster. The incident commander may succumb to the need to go look for him or herself, but that takes them out of the command center at a time where data are flowing into it at a high rate and decisions must be made. Some teams have appointed a person to be the eyes and ears of the incident commander and who has no other role other than to see what the situation looks like and report back directly to the incident commander. In terms of accuracy of information and managing the rumor mill, the public relations liaison can be invaluable in sorting out rumors from fact and finding methods to disseminate accurate information throughout the facility.

Resource Management: Here is where active advanced planning can really pay off. If a disaster is going to be one of the ones that are days in duration, staff will need to be rotated home for rest periods or sent to a respite location on campus for sleep, food, and showers. A plan to manage and rotate available staff can be constructed in advance and applied by the incident commander as soon as the duration of the disaster is appreciated. Supplies will also need to be carefully managed and inventories restocked. In a community disaster, this requires advanced planning with vendors to have adequate stock delivered when requested. Such stock is not always medical care supplies. A source of clean drinking water and food supplies would be essential in a community disaster from flooding or weather, where public water may be contaminated. In one hurricane in Virginia, the local sewer system was flooded out and water was shut off. Residents flocked to local hospitals in order to have a place to use the toilet, necessitating the quick delivery of portable toilets to the parking lots. In Hurricane Katrina, the hospitals in New Orleans did their best, but it quickly became apparent that patients would need to be evacuated out of the city, including transfers to hospitals in other states. There were no resources available for prolonged periods, and evacuation was the only sensible answer. This created mini internal disasters in other hospitals elsewhere in the state, since they received large patient loads that stretched their own resources. In any major disaster where community resources are overwhelmed, the states and the federal government will respond, but it may take days for the aid to arrive. Careful planning is not guaranteed to make it all smooth, but it helps.

Terror Events

When considering disaster preparedness, the level of preparation moved to a new high after September 11, 2001. When the nation began to realize the need to prepare for a variety of terrorist activities, a new language, understanding of threats, and need for training emerged. Terms such as "dirty bomb" and "mass casualty event" took on new meanings. The federal government has committed billions of dollars to help communities around the nation prepare to respond to terrorist events, should some occur. These can vary from attacks from passenger planes, to bioterror organisms in the water or food supply, to dispersal of radioactive substances, and events we cannot yet foresee. As an example, after September 11, in the following month the final game of the World Series was scheduled to be played in Phoenix. Hospitals in the region were told to be on the alert for terrorist activities and to be prepared to receive up to 1,000 patients per hospital if a mass casualty event occurred at the ballpark. The planning to be ready for such a traumatic and major event was very stressful, but the hospitals were ready. Fortunately, no such event occurred, but there is no doubt that terrorist-inspired events continue around the world, and that health care facilities need to be in a constant state of readiness if their community is a victim.

Conclusion

Disaster preparedness is an essential part of providing for the health and well-being of patients and members of the community. It is important for every health care facility to have a plan for the management of internal disasters and community disasters of a wide variety of types. The plan must be created, updated on a regular basis, and drilled multiple times per year for several types of disasters, just to keep people in training and a mindset of preparedness. Readiness, flexibility, adaptability to changing circumstances, and careful management of resources are keys to successfully surviving disasters.

Copyright 2011. Grand Canyon University. All Rights Reserved.

http://www.cdc.gov/phpr/healthcare/planning.htm

http://www.aha.org/aha/content/2001/pdf/OKCBombing.pdf

Due August 28

1) Use your critical thinking skills to write a paper of 1,000–1,200 words that responds to the question, "Is the PPACA legislation an improvement or a liability to our health care delivery system?" Use examples to illustrate your points and include pros and cons of the changes.

2) Refer to the assigned readings to incorporate specific examples and details into your paper.

3) Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

4) This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

Top of Form PPACA Paper 1 Unsatisfactory 0.00% 2 Less Than Satisfactory 65.00% 3 Satisfactory 75.00% 4 Good 85.00% 5 Excellent 100.00% 70.0 %Content 50.0 %Demonstrate thorough knowledge of the principles of health care reform in the PPACA legislation. Clearly develops a strong analysis of the pros and cons. Introduces appropriate examples. Does not demonstrate understanding of the principles of health care reform in the PPACA legislation or the pros and cons. Does not demonstrate critical thinking and analysis of the material. Demonstrates only minimal understanding of the principles of health care reform in the PPACA legislation or the pros and cons. Demonstrates only minimal abilities for critical thinking and analysis. Demonstrates knowledge of the principles of health care reform in the PPACA legislation and the pros and cons, but has some slight misunderstanding of the health care implications. Provides basic critical thinking and analysis. Does not include examples or descriptions. Demonstrates acceptable knowledge of the principles of health care reform in the PPACA legislation. Develops an acceptable analysis of the pros and cons. Utilizes some examples. Demonstrates thorough knowledge of the principles of health care reform in the PPACA legislation. Clearly develops a strong analysis of the pros and cons. Introduces appropriate examples. 20.0 %Integrates information from outside resources into the body of paper. Does not use references, examples, or explanations. Provides some supporting examples, but minimal explanations and no references. Supports main points with examples and explanations and includes few references to support claims and ideas. Supports main points with references, explanations, and examples. Analysis and description are direct, competent, and appropriate of the criteria. Supports main points with references, examples, and full explanations of how they apply. Thoughtfully analyzes, evaluates and describes major points of the criteria. 20.0 %Organization and Effectiveness 7.0 %Assignment Development and Purpose Paper lacks any discernible overall purpose or organizing claim. Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear. Thesis and/or main claim are apparent and appropriate to purpose. Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose. Thesis and/or main claim are comprehensive. The essence of the paper is contained within the thesis. Thesis statement makes the purpose of the paper clear. 8.0 %Argument Logic and Construction Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses non-credible sources. Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. 5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use) Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Writer is clearly in command of standard, written, academic English. 10.0 %Format 5.0 %Paper Format (Use of appropriate style for the major and assignment) Template is not used appropriately, or documentation format is rarely followed correctly. Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. Appropriate template is used. Formatting is correct, although some minor errors may be present. Appropriate template is fully used. There are virtually no errors in formatting style. All format elements are correct. 5.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style) No reference page is included. No citations are used. Reference page is present. Citations are inconsistently used. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct. In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error. 100 %Total Weightage Bottom of Form

Materials

Health Care Reform and Future Possibilities

Introduction

Health care has undergone episodes of major change since the introduction of Medicare in the 1960s. All of these have resulted in fundamental changes in how health care providers were paid for services to Medicare patients and were swiftly followed by matching changes from independent insurance companies. The latest, and some might say the biggest, change since diagnosis-related groups (DRGs) were introduced in 1983 is the signing into law of the Patient Protection and Affordable Care Act (PPACA), on March 23, 2010. This law proposes to change the delivery of health care services by changing how providers are paid and what they are paid for. This module explores some of the key elements of PPACA and how health care providers are planning their changes in delivery processes and systems in response.

Major Elements of PPACA

The most significant elements of the PPACA legislation are scheduled to take place over several years. Congress still has the ability to modify some of these elements, so we will examine them with that in mind.

June 2010

Adults with pre-existing conditions were eligible to join a temporary high-risk insurance pool run by the federal government. This will be replaced by a health care exchange in 2014, which will provide access to insurance at affordable rates. Applicants must have a pre-existing health care condition and have been uninsured in the six months prior to application. Premiums will be set at rates for the general population rather than the high-risk premiums charged by insurance companies. Out-of-pocket costs will be limited to $5,950 for individuals and $11,900 for families.

July 2010

The government established the National Prevention, Health Promotion, and Public Health Council, with the Surgeon General to act as chair of the council. This council will oversee the implementation of many of the PPACA elements and will disseminate recommendations to the health care community at large in regard to best practices in prevention and health promotion. As of fall 2010, little had yet been heard from this entity. However, the National Committee on Quality Assurance, which is a private entity dedicated to improving the quality of health care services, is providing best practices and quality measures for health care providers, especially hospitals.

September 2010

Insurance companies can no longer apply lifetime dollar limits on essential benefits for patients. In addition, children may be covered under their parents' insurance plan until they turn 26 years of age. This includes children not living at home, not listed as dependents on their parents' tax returns, not students, and children who are married. Further, no patients under 19 years of age with pre-existing conditions can be excluded from health care benefits based on the pre-existing conditions, and there can be no deductibles or copayments required for provision of preventive care measures and medical screening activities for new health insurance plans. However, these may still apply to existing or grandfathered plans. There was a one-time payment of $250 to seniors on Medicare Part D to cover part of the pharmacologic payment gap in 2010. Insurance companies can no longer drop people from coverage if they become ill, and Medicare patients with chronic illnesses are to be monitored and evaluated every three months for coverage of medications prescribed to treat those illnesses.

January 2011

Insurance companies were be required to spend 85% of the premiums taken in for large groups and 80% of premiums for small groups and individuals on health care services or improvement of quality, not administrative services.

January 2012

Employers must disclose the value of the benefits they provide for each employee's health coverage on Form W-2.

January 2013

People who are self-employed and individuals making more than $200,000 per year are subject to an additional tax of 0.5% to assist in reducing the overall costs of health care reform.

January 2014

Insurers cannot discriminate or charge higher rates for patients based on pre-existing conditions, and Medicaid eligibility will be expanded to include people with incomes up to 133% of the federal poverty level. There will be two years of tax credits provided to small businesses that provide health insurance to employees, in order to partially offset those costs. Financial penalties will be applied to employers with more than 750 employees if they do not provide health insurance as a benefit. Annual deductible costs will be capped at $2,000 for individuals and $4,000 for other plans, while individuals who do not obtain health insurance will be required to pay an annual penalty of $95 or 1% of their income. Health insurance exchanges will be set up to enable individuals to shop for insurance.

There are other components in the legislation, but these are the key ones. The implications for the legislation have several points for consideration:

· What is the cost to operate this new system? Medicare is still proposing a fee-for-service payment methodology, with a shared savings bonus for health care providers who meet certain requirements. Will this be successful in reducing overall health care costs in the system? Medicare is already exploring other payment options, including the possibility of capitated payments in some areas. The current model will continue to provide payments for procedures and activities rather than the total shift to care management that capitation would require.

· With more people obtaining insurance, what will happen to demand for access to care? In Massachusetts, a model similar to the federal model of PPACA has been in place for several years. Massachusetts experienced a significant increase in demand for care, resulting in longer waiting times to get appointments with physicians and increased demand for hospital services. With primary care physicians graduating in lower numbers, the access to these physicians may become more difficult as more people obtain insurance and increase their demand for services.

· As components of the system switch to payments for keeping people healthy, the demand for procedures may lessen. However, healthy lifestyles require significant changes in behavior, as anyone who has tried to lose weight or stop smoking can attest, and it is still questionable whether the population as a whole is ready to make those changes.

· A highly controversial part of the PPACA legislation is the requirement to have insurance or pay a penalty. Younger, healthy adults have made the argument that they do not see a need to have health insurance or to pay for it. However, insurance companies need a large number of the people they insure to have a basis of good health in order to offset the higher costs to provide care for less healthy individuals. The requirement to force all citizens to obtain health insurance is very contentious and may not survive in legislation to 2014. However, failure to enforce this will result in continued higher costs for hospitals, which are mandated to provide care regardless of ability to pay.

Responses of Health Care Providers

What are the health care providers in the system doing to respond to and prepare for the changes the new legislation is imposing?

· New models of care are emerging. The concept of the Accountable Care Organization (ACO) is being tested at various sites across the country. ACOs are systems of health care delivery that include participants across the continuum of care, including primary care physicians, hospitals, specialists, post-acute care facilities, home health, and disease management clinics, among others. These providers are linked into a system of care that is tied together by an electronic health record, standardized protocols of care, a focus on management of care, case/disease management standards, reduced costs, and measurement and monitoring of quality outcomes and indicators. The formation of these ACOs is a huge undertaking, requiring major changes in current operations and systems between existing entities. Hospitals and physicians will be required to align in their approaches to care, their management of system costs, and their share of revenue. ACOs are likely to see global or bundled payments from payors for an episode of care. In this payment method, a total payment for all services is made to the ACO for a patient's episode of care (which can be defined in several ways), and the ACO will determine which provider gets what amount of the total payment for the services they rendered. The complexity of this can be appreciated when one understands that this requires the hospital, post-acute care facility, and all physicians to agree on the distribution of payment.

· Another new model of care that may operate under the ACO or as a stand-alone is the medical home concept. In this, patients select a primary care physician who assesses their health needs, coordinates the care needed by the patient among a range of providers, and monitors their outcomes and the quality of the care. The role of the primary care physician takes on a greater importance than in the existing system. This is different than a gatekeeper model, where the permission of the primary care provider was required before patients could access other services. The role in this model is more collaborative and coordinative, ensuring that patients get the care they need in order to achieve the outcomes desired and to maintain health.

· Physicians are moving toward being employed by hospitals and health systems. Many physicians are looking at the reductions in reimbursement being imposed by Medicare on Part B payments and the impacts on their ability to maintain their income. The outcome of this is, in many cases, compelling physicians to approach their local hospitals and explore employment rather than independent practice. The trade-off is the security of a salary and benefits without the headaches of billing and collections and the costs of operating the practice. For the hospitals, the advantage is to have access to that physician's pool of patients when they need care. The trick is to find a way to manage employed physicians' practices without suffering significant financial losses. An interesting concept for this that is gaining considerable traction is the rise of midlevel providers in practices, including nurse practitioners and physician assistants.

· Primary care physicians are the key to the future in an ACO. The foundation of an ACO will be the pool of patients it manages, and the key to that is a large, competent, high-quality base of primary care physicians to establish some variety of the medical home and attract large groups of patients to it. The Centers for Medicare and Medicaid Services (CMS) is already pushing this by reducing the payments going to specialists while increasing the percentages of payments going to primary care physicians. CMS is also beginning to compensate primary care physicians for managing care outside the hospital and promoting health assessments and preventive activities, such as cholesterol screens, diabetes monitoring through hemoglobin A1C testing, and regular blood pressure monitoring, among others. ACOs are experimenting with chronic disease management clinics and protocols as a method of keeping patients healthier and out of the hospital. These may be based in primary care practices.

· The role of the hospital will change in this model. Hospitals have traditionally been a revenue generator for a health care system in the world of payment for procedures. High occupancy rates by patients needing surgery or other procedures have long been an effective strategy for making money. In the new system, however, as the payment methodologies begin to shift to payment for prevention and maintaining health and to capitated methods, the hospital will become a cost center and a location of last resource. Efforts will be made to do more procedures on an outpatient basis, such as minimally invasive surgeries and outpatient imaging studies, rather than do them during a hospital admission. Hospitals will be pushed to reduce costs of care, by standardizing care protocols with groups of physicians, negotiating supply cost reductions on a large scale, and actively case managing inpatients to reduce length of stay. Elective surgeries may begin their process weeks in advance, as discharge planning and postoperative care issues are planned prior to hospitalization. The use of post-acute care facilities to provide post-procedure care may well be expanded, and patients formerly staying four days in a hospital may find themselves transferred to a lower level of care within two days. The insurance companies are beginning to refer to this reduction in hospital usage as "demand destruction," or the attempt to destroy/reduce demand for high-acuity/high-cost services. The implications for specialists whose practices are built around hospitalized patients are obvious and frightening for those looking ahead.

Conclusion

The advent of change of this magnitude to the health care delivery system is both frightening and intriguing. No one with knowledge of the current system would deny that it is fundamentally broken in many ways, with costs growing exponentially and care outcomes frequently less than desired. Access to care is limited or absent for a large number of the population, and the focus on pay for procedures assures that costs will continue to climb. The question is whether the new legislation will actually reduce costs in meaningful ways while maintaining or improving quality of outcomes and higher maintenance of people's health. One thing is for certain: the changes over the next decade will be challenging, and the final outcome is yet to be determined.

Copyright 2011. Grand Canyon University. All Rights Reserved.

1. Creating Accountable Care Organizations

View "Creating Accountable Care Organizations," which features a roundtable discussion with three experts, located on the New England Journal of Medicine website.

http://www.nejm.org/doi/full/10.1056/NEJMp1009040

2. The Patient Protection and Affordable Care Act

Read the components of the "The Patient Protection and Affordable Care Act legislation." located on the Centers for Medicare & Medicaid Services website. Given all of the mythology circulating about this legislation, pay attention to the factual information given.

http://www.cms.gov/LegislativeUpdate/downloads/PPACA.pdf

3. What Are Accountable Care Organizations?

Read "What Are Accountable Care Organizations?" located on the Healthcare Economist website.

http://healthcare-economist.com/2010/01/26/what-are-accountable-care-organizations/