Written by Shirley Braverman   

ObamaCare Will Pay for the Care of the Chronically Ill Saving Money and Lives
Continuing with the facts that Hospital and Emergency Room Care is the most expensive available, the creators of ObamaCare had to deal with the fact that the treatment of our chronically ill citizens was abysmal and expensive. The statistics just for Diabetes and Asthma alone are horrifying.
Cost of Diabetes Updated March 6, 2013
• $245 billion: Total costs of diagnosed diabetes in the United States in 2012
• $176 billion for direct medical costs
• $69 billion in reduced productivity
After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes.
Diabetes was the seventh leading cause of death in the United States in 2010 based on the 69,071 death certificates in which diabetes was listed as the underlying cause of death.
Emergency Department Visits for Adults with Diabetes in 2010 by
Raynard E. Washington, Ph.D., Roxanne M. Andrews, Ph.D., and Ryan Mutter, Ph.D Published in November 2013.
“In 2010, there were approximately 12.1 million diabetes-related Emergency Department visits for adults aged 18 years or older (515 per 10,000 U.S. population), or 9.4 percent of all ED visits. Most (57.9 percent) were treat-and-release visits.
“Emergency department utilization among patients with diabetes is likely affected by several factors, including lack of primary care, poor adherence to care plans and lifestyle modifications, and presence of complications.”

And then from the Asthma and Allergy Foundation webpage, aafa.org,
• Asthma accounts for one-quarter of all emergency room visits in the U.S. each year, with 1.75 million emergency room visits.
• Each year, asthma accounts for more than 10 million outpatient visits and 479,000 hospitalizations.
• The average length of stay (LOS) for asthma hospitalizations is 4.3 days.
• Nearly half (44%) of all asthma hospitalizations are for children.
• Asthma is the third-ranking cause of hospitalization children.
• The annual cost of asthma is estimated to be nearly $18 billion.
Fast Facts: Every day in America:
• 44,000 people have an asthma attack.
• 36,000 kids miss school due to asthma.
• 27,000 adults miss work due to asthma.
• 4,700 people visit the emergency room due to asthma.
• 1,200 people are admitted to the hospital due to asthma.
• 9 people die from asthma.

The sad fact is that none or very little of this needs to happen. What is obvious is that patients are not being taught how to live with and manage these common condition. The facts on how to regulate a diabetic’s blood sugar have been around since the 80s and so has the prevention of asthma attacks. Yet teaching patients these facts and getting them to modify their lifestyles accordingly can be time consuming and expensive and beyond the scope of the typical 12 minute doctor’s office visit. Besides, before ObamaCare there was no financial incentive to treat a patient after they left the doctor’s office. Evidence pointed to the fact that patients with chronic illnesses were suffering from a disjointed, fragmented lack of care

And you can’t blame the patient. Care instructions to patients with a non-medical background can sound complicated, confusing and downright scary. “You just take the syringe like this, see, and plunge it into your thigh!” They don’t even know which questions to ask. Worse, diabetic coma, insulin shock and asthma attacks can happen quickly and at the worst times. If the patient can reach the doctor’s office they are advised to come in for an appointment or to call 911. Or if the doctor’s office is closed, again, no instructions or reassurance and the brain fog is rapidly approaching. Left to their own devises, what can the patient do but reach for the phone? What the chronically ill patient clearly needs is coordinated high quality care, education and advice on a 24/7 basic.

Solution: The Case Manager

Modeling the program after techniques devised by health maintenance organizations like Kaiser Permanente and Humana to manage the care of their patients, after the first of the year, Medicare will pay 46$ a month for managed health care for each patient. Patients need to have two or more chronic conditions like diabetes and obesity or asthma and depression.
Drafting a comprehensive plan of care for the patient and having the patient sign a release for use of electronic records, federal rules then guarantee these patients access to health care providers 24 hours a day, seven days a week to deal with “urgent chronic care needs.”
“Paying separately for chronic care management services is a significant policy change,” said Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services. Officials said such care coordination could pay for itself by keeping patients healthier and out of hospitals.” (CMS.gov)
And guess who these Care Managers are? Again, our Nurse Practioners and Physicians Assistants. I learned about this program the hard way. Early December of last year, I had a cold for about four days. Full of mucus, coughing and congested even after taking over-the-counter
decongestants, one night around one AM I couldn’t breathe! By the time I arrived at Emergency, my chest and neck muscles were heaving in contortions, my lips were blue, and the oximeter on my finger registered my O2 level in the high seventies. Low seventies and you’re unconscious.

In due time, IV cortisone soothed my inflamed lungs, Magnesium eased the muscle spasms, and 8 liters of Oxygen brought my O2 levels up to the 90s as did sessions of inhalation therapy. An MRI proved I did not have pneumonia. What I had, the emergency room doctor told me was “A condition that prevented my lungs from processing enough oxygen out of the air to sustain my body.” A viral thing, there was nothing they could give me. I just had to stay on Oxygen until my lungs healed, or not? It could take a few months!

Admitted to the hospital, I sank in and out of sleep while I continued to get IV cortisone, O2 and inhalation therapy sessions. Awake I was too weak to make it to the bathroom alone or to sip the tea on my breakfast tray. At 11AM I was in for a rude awakening. In came the feistiest doctor I have ever met. My medical group’s Hospitalist.

“You gotta go home,” he said. “You can’t stay here. It’s dangerous. We’re admitting flu patients and if you get the flu in your condition you could die!” I stared at him. Did he understand that I couldn’t even make it to the bathroom alone? That I couldn’t breathe if I lay down? “But what happened?” I asked. I’ve never been sick in my life. I didn’t take any medications and swam 25 laps a day. But he was not one to answer questions. Speaking to my daughter, he handed her a bunch of prescriptions and suddenly I was blinking in the sunlight, sitting in a wheelchair hooked up to an oxygen tank.

Soon I was uneasy in my easy chair hooked to an oxygen generator while my daughter, assuming I had had an allergic attack had my son ripping out all the old carpeting in my bedroom and shoving it out the bedroom windows.
That’s when the phone rang and I first spoke to Christine, my case manager. We spoke for over an hour and she answered all my questions.
I was lucky. My lab work was good. Since I had never smoked I didn’t have Chronic Obstructive Pulmonary Disease, COPD, which meant my condition probably wouldn’t get worse. You hear that all you smokers!!
But I could have had an asthmatic attack since Adult Onset Asthma was an up and coming disease or I could just have had a one-time Lower Respiratory Viral Event -- like SARS -- Sever Acute Respiratory Syndrome. Or a respiratory syncytial virus--- RSV or any
other wandering adenoviruse, parainfluenza, metapneumoviruse or coronaviruse. The name didn’t matter I just had to take it easy, stay on the oxygen and heal. They all have the same treatment. And yes, it could take a few months.

Did I have a 40 foot connector on my O2 generator? No, but there was one in the bag. My daughter attached it. Could I could make it to the frig and the bathroom with the 40 foot cord? Yes. Get up every two hours and walk about. Drink lots of fluids. When anyone comes to visit have them wash their hands. No children or people who are around children. Children are little germ machines. She gave me hundreds of suggestions on how to make my life easier.

I was on 40 mg of oral cortisone for the next ten days and I had this little thingy that I poured some liquid into and then inhaled the mist every six hours. I was going to get better and here was her phone number: call anytime, day or night. Then, like the good nurse that she was, she spoke to my daughter and I guess told her basically the same thing and sent her out to the drugstore to buy me an oximeter. My O2 levels should stay in the nineties. If it got below that raise the oxygen generator levels to eight, otherwise leave it at six. I felt better already.

For the first week she called every day. Had me order the book, Asthma for Dummies! She told me what to expect when I went off the oral steroids and onto the inhalers. The steroid inhaler was healing my lungs and was different from the albuterol rescue inhaler which was basically a muscle relaxant. I learned the signs and symptoms of an impending attack and how to prevent it. She helped me slowly wean myself off oxygen and to accept the muscle weakness when I finally felt I could get up and walk around. It took almost two months and we were in the middle of the flu season. Don’t go to the movies I was warned, recycled air, very unhealthy. Drive-ins are OK but stay out of stores and restaurants. I was basically under house arrest until the end of flu season. It was May before I got back into the pool.

Since I went through spring and summer without any allergies, we are assuming I had something like SARS. But the odds are that an upper respiratory infection, like a cold or sinusitis could possible trigger it again. So I have to continue to be careful and keep my meds handy. Christine called me last week to remind me to get my flu shot. She had scanned my record and found that I had not been to the flu clinic.

Lucky for me my health care group already employed Case Managers. But by January with the new payments to keep chronically ill patients healthy, Nurse Practioners and Physician Assistants are banding together to form their own groups of Critical Care Associates under the Accountable Care Organizations (ACOs) part of ObamaCare. (CMS.gov)

ACOs are groups of health care providers, who come together to give coordinated high quality care to Medicare patients. Medicare is encouraging and accepting new innovative models and is giving grants for programs that have proven they work--- and constant care for the critically ill has proven its efficiency. In California the grants are already written and ready to submit. And old nursing buddy and I fanaticize about it.

“My God, with the EMRs (electronic medical records) and a phone a nurse could stay at home with her kids, work on her own time and care for 50 patients collecting $2300 a month.”
“She’d work for a nurses’ group and would never even see a hospital. She’s be her own boss.”
“She could pick her own patients. Get rid of the nasty ones.”
“And the patients, this army of desperate patients cursed with sicknesses that won’t go away will at last get the help they need. The instructions and reassurance they need to stay healthy. It’s wonderful! A dream come true!”
Revolutionary is the word I hear a lot of nurses using. A blessing! Monumental! Life changing! Yet, the general public seems completely disinterested, unaware. It hasn’t been on any of the news services or been written about in any articles. Who reads the announcements of the Center for Medicare Services anyhow? Just a few health writers like me and the big heads of large health corporations. But they’re not talking. This means lost business for them.
But this blessing for the chronically ill, this financially feasible bargain for the community is the wave of the future----at least in California!