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Employment and Obamacare

December 27, 2012
By Young Lee, Director of Training & Development at Coney Island Hospital

Severe dearth of employment opportunities for entry-level urban workers in the 1980’s and 1990’s was ushered in by systematic out location of manufacturing jobs from American cities coupled with intended diseducation of children who became young adults eager for work but utterly unprepared for emerging jobs opportunities.

During this era, I directed a worker retraining program that combined technical construction skills training with creation of new housing units for homeless young families in East Harlem.  The unique point of this effort was a teaching model that fundamentally supported young adults in an expectant environment of demanding rigors but one that also offered a wide array of training in communication skills, confidence building activities, academic preparation conducted in a manner that benefited the young adults, and daily routines that recognized the need for emotional-intelligence and critical thinking abilities.  What I would later learn defined as “soft skills,” these crucial training regimens rounded out the technical education needed for successful construction of housing units, with leadership education needed for the students to lead successful lives.  Only thing soft about these skills was the label placed upon them by larger forces that stood to benefit from once again failing these young women and men and thus protecting the status quo.


The resounding reelection of President Barack Obama now paves a way for much needed transformation of how government – that is, our society at large – succeeds in training workers to lead more productive lives.  One example of improving our society by transforming the impact made by its many systems can be found in the Patient Protection and Affordable Care Act (PPACA), sometimes called, ACA, Health Reform, or simply, Obamacare.  One major component of the law’s myriad parts is the change in the way that hospitals and health care providers are paid for the services and care they bring to sick, injured and ill people.  In previous years, payments were calculated based on amounts of care provided, particular activities completed according to what the physician felt were needed for the patient, and tests completed on their behalf through numerous visits to the physician’s office.  The rule of getting paid was to do the activities that generated payment from the government insurance – Medicare for the elderly and Medicaid for the poor – for service rendered.  The new legislation currently being implemented radically shifts the reimbursement formula from one of activity, to those based on results.  Results sought for payment in the PPACA are those linked to clinical improvements in a patient’s condition and results related to patients’ perception of the care they’ve received from the healthcare organization.  A series of new mechanisms was introduced by the U.S. Centers for Medicare and Medicaid Services (CMS, for short), which is impacting the total government reimbursement for hospitals beginning this year.  If a hospital that serves needy patients receives $500 million in government reimbursements subsidized by Medicare and Medicaid, beginning this year, the organization would have to “earn-back” a small portion of that total by demonstrating performance or improvements in the care of patients.   An annual “hold-back” of the expected reimbursement for services rendered is scaled at 1.25% of total CMS reimbursement for this year, rising to 1.5% in 2013 and incrementally higher every year after that.  For this hypothetical hospital, that amounts to $6.25 million, a tremendous amount of funds at risk of loss from what was already earned due to missing their improvement targets.  Of the 1.25% that has been withheld and can be earned back by a hospital, 70% is linked to clinical quality outcomes, that is, results that improve the health of the patient through medical care.  Remaining 30% of the 1.25% withheld this year can be earned back by achieving high scores on patient responses to independent queries about their perceptions of care and treatment received at the hospital.   Results obtained from mailed surveys containing questions that seek to assess how the patient experienced their stay at the hospital, now represents a significant part of how the hospital will be able to recover the withheld amounts.  Hospitals may also be rewarded above their expected CMS reimbursement if their improvement results exceeded set targets.  This survey process, called Hospital Consumer Assessment of Health Care Providers and Systems, or H-CAHPS, http://www.hcahpsonline.org/home.aspx, has implications for significantly affecting the bottom line dollar retention for healthcare organizations.  The complete overview of this important initiative is available at: www.hospitalcompare.hhs.gov

What this new healthcare legislation aims to do that generations of educators and advocates have up to now been only marginally successful, is to highlight the need for particular interaction skills in health workers that recognize impact beyond traditional clinical numbers.  In our new economy and projecting competencies required for future health workers, move us to consider non-traditional ways that social supports are judged to be successful and ultimately impacting.   New ideas for reaching miseducated young people, workers and disconnected communities need to be tried and voices from the neighborhoods must be given more weight, not as equal partners with leaders of the city and the health industry, but as the primary stakeholder that government and the privileged sectors exist to support.  

One such example of demonstrated flexibility and adherence to non-paternalistic efforts to assist workers to achieve their goals is The Joseph S. Murphy Center’s Health Care Administration Certificate and Degree Program of the CUNY School of Professional Studies. Through a partnership with NYC Health and Hospitals Corporation’s Coney Island Hospital, the vanguard CUNY program is currently conducting accredited university classes on the hospital’s campus, taught by full professors that understand the constraints hampering working adults.  The program offers location flexibility for workers, where demanding class materials are offered in familiar surroundings with assistance from administrative staff that pave the student’s road to success. The classes offer unparalleled flexibility to meet the needs of the students, while imparting new information, skills to negotiate new expectations unleashed by the PPACA, and teaching new insights about the changes in healthcare and professional skills that assist the worker students and the hospital to better meet changing needs.  As strange as it may seem at first, the role of society (in local points of service, such as in a hospital, a hospital system or in the local community) to conform to a vision of workforce development may be easier than creating an effective system of employment which conflicts with the realities of society.

This writing does not necessarily reflect the opinions of HHC or Coney Island Hospital.

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