Affordability

It started with a question from Oncology RN Tom Fought, a member of the Oregon Federation of Nurses and Health Professionals (OFNHP), at the Interstate Medical Office in the Northwest.

Why, he wondered, was primary tubing used for low-reaction drugs instead of the less-expensive short or secondary tubing?

That prompted the department’s unit-based team to start an improvement project that wound up saving $25,000 a year.

When patients come in for chemotherapy or other infusion medications, the drugs are administered via an IV: The bag holding the medication is hung on a pole, with a line that goes into the patient’s vein. When primary tubing is used, the valve to stop the flow of medication is very close to the patient’s body.

If the drugs being used have a high potential for an adverse reaction, it’s essential to use primary tubing, so that if there is an emergency and the line has to be shut, only a very little additional medication reaches the patient.

Appropriate times for less expensive options

When the short tubing or secondary tubing is used, the valve to stop the flow of medication is farther from the patient. In this situation, if the valve is closed, more medication is in the line and will flow into the patient until the tube is empty. These types of tubing are appropriate when the medication has a low potential for a negative reaction.

Primary tubing is $4.10 per unit, short tubing is $3.65 and secondary tubing is 65 cents. The costs add up if primary tubing is used when it’s not necessary.

“I had no idea that we would be saving the unit that much money by conforming the tubing,” Fought says.

This team alone was able to save $25,000 a year. If every Kaiser Permanente oncology infusion department adopted this practice, the savings would be dramatic.

“This was such an easy tweak—we just needed to think outside of the box,” says Lacey Anderson, RN, the Infusion Team Lead and a member of OFNHP, who was involved in the project. “The team realized this was such a great idea and wondered, ‘Why haven’t we been doing this all along?’”

Greater camaraderie

Heidi Rolf, the department manager and the UBT’s management co-lead, is proud of the work the team has accomplished. She attributes the success to the leadership of the team and notes that since the team has advanced to a Level 4 on the Path to Performance, team members have more camaraderie and are more engaged.

“At first it was a little difficult to change the habits of the nursing staff,” Fought says. “Within a few weeks, we had everyone on board and our tubing project took off.”

Affordable Care Act (ACA)

The comprehensive federal health care reform law enacted in March 2010.

Coinsurance

The percentage of charges a member pays when receiving a covered service. The member’s health plan coverage pays the balance up to the health plan’s allowance. Coinsurance amounts vary depending on the member’s plan and the service provided.

Copayment

The fixed dollar amount a member pays when receiving certain covered services or prescriptions. The member’s health insurance pays the rest. Copayments vary depending on the member’s plan and the service provided.

Cost share

The portion of charges for a service or prescription that the member is responsible for paying, such as a copayment, coinsurance or deductible payment.

Deductible

The fixed amount a member must pay in a calendar or contract year for certain health care services before the member’s health insurance begins to pay.

Dependent

A family member, such as a spouse, child or partner, who is covered under a policyholder or subscriber’s plan.

Federal financial assistance (subsidy)

Financial assistance in the form of reduced premiums and reduced out-of-pocket expenses to provide help for some people to pay for health coverage or care. The government will pay part of the premium and the out-of-pocket expenses directly to the health plan issuer. Usually determined by income level and family size.

Grandfathered plan

A group health plan that was created or an individual health insurance policy that was purchased on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act.

Health care reform

A general term for the major health policy changes put in place by the federal Affordable Care Act of March 2010 and any state laws passed to put it in place.

Health Insurance Marketplaces

Government-run online markets, formerly called Health Insurance Exchanges, where individuals and small businesses will be able to compare and enroll in health plans, get answers to questions, and find out if they are eligible for financial assistance or special programs.

The marketplace

A common nickname for the Health Insurance Marketplaces, also called “exchanges.”

Medicaid

A government insurance plan for the poor and disabled; in California, it’s known as Medi-Cal.

Out-of-pocket expenses

These include the copayments, coinsurance and/or deductible payments members make for the health care services they receive, as opposed to the premium they pay each month to their insurers.

Pre-existing conditions

Medical conditions that a person has before he or she applies for a new health insurance policy.

Premium

The amount a member and/or the member’s employer pays, usually each month, for health care coverage.

Q: What is health care reform?

A: The term “health care reform” refers to the Affordable Care Act—the federal law that was passed in March 2010—as well as any state laws passed to put it in place. These laws are intended to help more people get affordable health care coverage and receive better medical care.

Q: What are the Health Insurance Marketplaces?

A: Marketplaces, sometimes called “Exchanges,” will be state- or federal- run online markets where many people can buy health care coverage. It will be available to people who are uninsured or who buy insurance on their own. They will be able to compare and choose health plans offered by private companies, get answers to questions, and find out if they are eligible for financial assistance or special programs. The marketplaces will also operate a Small Business Health Options Program (SHOP) where small employers can purchase coverage for their employees. Coverage purchased there will be effective Jan. 1, 2014, or later.

Q: Does a person have to buy from the marketplaces?

A: No, not necessarily. The marketplace is just one of the ways people can shop for health coverage. People can still get coverage through their employer or directly from an insurance company. A member will have to buy coverage through the Marketplace to apply for subsidized coverage, however.

Q: Will Kaiser Permanente coverage be available through the marketplaces?

A: Kaiser Permanente intends for our plans to be available in the marketplaces, but individuals don’t have to buy from the marketplaces. A person can still buy directly from Kaiser Permanente or continue to get coverage through his or her employer.

Q: Can anyone get health care coverage?

A: Yes, the ACA requirement regarding guaranteed availability applies to all individuals. Insurance companies can no longer deny coverage because a person has a medical condition, and no one has to pass a medical exam to qualify for coverage.

Q: Who has to buy health insurance?

A: The Affordable Care Act requires most U.S. citizens and those lawfully present to have a basic level of health coverage starting Jan. 1, 2014. There will be some exceptions for financial hardship, religious objection, immigration status and certain other circumstances.

Q: What if a person can’t afford to buy health care coverage?

A: The federal government may provide financial assistance to help a person pay for health coverage if he or she can’t afford it. This is usually determined by a person’s income level and family size. Individuals will be able to find out if they qualify for financial assistance when the Health Insurance Marketplaces launch in October.

Q: What can frontline workers do to prepare for health care reform?

A: Take advantage of every opportunity to become informed. Attend trainings (on KP Learn or in person), read communications and ask questions. Visit kp.org/reform, and refer friends, family and members to the site, too.

The next step for UBTs—a step they are being challenged to take by top management and union leadership—is to make the leap from successful individual team projects to a systemic effort to implement proven practices throughout the organization.

Meantime, remember another bottom line: High-performing teams score more favorably on People Pulse questions related to efficiency and cost reduction, and high-performing teams are more likely to take on affordability projects.

Working with your colleagues to become a high-performing team is a sure step toward reducing waste and improving affordability. Being high performing will help Kaiser Permanente continue to assist and care for families and will help us ensure everyone has affordable health care.

Here are some ways that unit-based teams can help keep Kaiser Permanente affordable.

1: Build business literacy

The more teams know about the business of health care in general and of their own departments specifically, the better equipped they are to find savings. To that end, LMP’s Education and Training department is rolling out an economic literacy program in the coming year. Meantime, teams in both California regions have been using a curriculum developed by a multidisciplinary team in Northern California. The five-part course has caused some trepidation, since in the last two trainings teams go through their department’s budget line by line—but that’s exactly what gives the training its juice.

At the Fremont Medical Center in Northern California, the OR team took the training and instantly started looking for ways to save money. Co-leads Yolanda Gho, Operating Room nurse manager, and surgical tech Gus Garcia, an SEIU UHW steward, talk about the training, its benefits and how it inspired their team to do better. (For more on this team, click the Peer Advice link in the resources box.)

2: Be supply savvy

Teams that take the time to make a comprehensive assessment of their supplies—tracking inventory use, tidying up storage areas, streamlining ordering and so on—can save tens of thousands of dollars with hardly any pain.

For instance, the scientists in the Immunology department at Southern California’s regional reference lab use expensive chemicals, called reagents, to test whether patients have serious infections such as hepatitis and HIV. Cleaning out and meticulously organizing the department’s huge walk-in refrigerators allowed the team to order larger quantities of reagents at one time. Since employees have to test a sample from each shipment, fewer shipments mean fewer tests—saving staff time and expensive reagent. The work, which also means the team needs fewer rush shipments, is saving $50,000 a year.

Another example comes from the Head and Neck Surgery UBT at the Franklin Medical Office in Colorado, which kept trying small tests of change until it found a reliable way to prevent the disappearance of expensive surgical tools. Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on this team, click "Losing Streak Ends for UBT" in the resources box.)

3: Bring it home

Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on the Ohio region's work, click on "Micro-Clinics, Macro-Partnership" in the resources box.)

4: Collect the money we’re owed

Health care in general and Kaiser Permanente in particular is filled with mission-driven people. But KP can’t sustain its mission if we don’t collect the money we’re owed.

In Colorado, the Medicare Risk Business Services UBT members spotted and fixed a technical problem with incomplete physician signatures on patient charts, which allowed them to bring in more than $10 million in Medicare revenue that otherwise never would have been collected. In Santa Rosa, Calif., the patient services representatives in the Emergency Room analyzed data and did some role playing with one another to reduce discomfort about asking for co-payments.

Figuring out issues like these takes tenacity, as the Patient Financial Services team in the Mid-Atlantic States discovered when it set out to fix problems with workers’ compensation claims. (For more on this team, click "Closing a Financial Gap" in the resources box.)