Running head: MILESTONE # 4 1

Milestone # 4

Southern New Hampshire University

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Milestone # 4

Analysis of Stakeholder Needs

The stakeholders identified in Aspen County include the local hospitals, the Aspen Public

Health Department, uninsured and Medicaid patients, physicians and primary care

practices, state legislators and the community at large. Basalt Primary Care Practice, which

previously served a large percentage of the healthcare needs of the community, has now decided

to terminate patients that have Medicaid or are uninsured. Basalt Primary Care has cited that due

to financial constraint’s they can no long afford to prove healthcare coverage for this

demographic. This has resulted in a shortage of health care providers willing to care for these

patients within the community.

This lack of coverage for these patients leads to a high risk for using the emergency

department of the local hospital for their primary care needs. Patients that have opted to use the

emergency department have also cited other reasons why they choose to utilize the emergency

department over attempting to find another provider. According to (Capp et al., 2016) Medicaid

and uninsured patients have stated that they have had a negative experience with clinic’s or

primary care staff, problems with transportation, multiple life stressors that prevent regular

follow-up and a significant mental and physical disease burden that requires multiple

practitioners (Capp et al., 2016).

As a result of the decision by Basalt to restrict the patients that they will see at their

practice, other health care providers in the community have seen an increase in longer wait times

to obtain an appointment and to be seen by a provider in the community. Adjusting for patient

and appointment characteristics, Medicaid patients are 20% more likely than private patients to

wait 20 minutes or longer for appointments (Oostrom, Elnav, & Finkelstein, 2017).  Cited
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reasons for this extended wait times discrepancy includes differences in the practices and

providers whom Medicaid patients visit. Practices and physicians that disproportionately serve

Medicaid patients usually have a client base located in an economically depressed location, see

patients with lowere socioeconomic status and report patient non-compliance with scheduled

arrival times and increased appointments. Physician characteristics such as medical school

attended, years practicing, and probability of being board certified can also have an effect on the

type of coverage that a practice will accept (Oostrom et al., 2017).

The state legislators that are voted into office by the constituents of the community

should re-evaluate the need for Medicaid expansion. Medicaid is the insurance for a large portion

of the residents in Aspen County. Medicaid has been shown to improve health outcomes

compared to those that are uninsured. The expected increase in patient needs for Medicaid

coverage will be a key indicator for the legislators to change their position regarding expansion

in the state (Barnett, Clark, & Sommers, 2018).

Application of Laws and Policies

The Affordable Care Act (ACA) had provisions to expand Medicaid to cover the poorest

people in the population. When the (ACA) was signed into law, several states decided to sue the

federal government to prevent the requirement that states participation in the Medicaid

expansions be mandatory. On June 28, 2012  states participation in the Medicaid expansion

became voluntary. The state of Golden decided not to participate in Medicaid expansion at that

time (Price & Eibner, 2013).

Statistically adults in states that did not participate in the expansion of Medicaid were

found to be at a socioeconomic disadvantage. They are more likely to be overweight or obese,

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resulting in an increased risk for heart disease, diabetes, stroke and hypertension. These poor

population health outcomes will ultimately result in rising health care costs for the state (Price &

Eibner, 2013).

Health insurance is a predictor of positive population health outcomes. The ACA was

meant to provide access to health care coverage for all. States that have not expanded health care

coverage have been shown to have significant deficits in health care status that will result in poor

long term population health outcomes (Rhubart, 2018).

Explain Potential Conflicts Between Stakeholders

This higher rate of demographic and socioeconomic disadvantages can result in long term

consequences for the health of Aspen County. The leaders of this community will need to focus

on creating equitable access to healthcare and promote healthy communities to decrease the

detriments of health that are seen in that community. Especially, if they choose not to expand

Medicaid coverage. The conditions opportunities and resources that are available to members of

a community can have a profound effect on a populations health behaviors and can influence the

future outcomes of the population in a negative way without intervention (Rhubart, 2018).

In the past, the three Aspen County Commissioners decided to support the decision not to

expand Medicaid in the State of Golden. Many of the constituents of Golden have voiced the

opinion that they like to live with minimal involvement from the state and federal governments.

These strong beliefs will need to be revisited. Data will need to be compiled to support the

expansion of Medicaid through surveys and the amount of healthcare coverage that is currently

available compared to what was available in the past. 

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Due to the lack of primary care providers, the local hospital will see an increase in

emergency room visits. This increase in uncompensated care can have a negative effect on the

financial viability of the hospital. From 2013 to 2015, the nationwide uninsured rate fell 35

percent with Medicaid expansion. Nationwide hospital uncompensated care costs fell by about

30 percent. In expansion states, hospitals uncompensated care costs fell by 50 percent. This is a

large indicator for the legislators in the state to expand Medicare in the state of Golden (Schubel

& Broaddus, 2018).

Evaluation of Legal and Malpractice Risks

Under the current Medicaid program in the state, payment is made on a fee for service

basis. As the measures for the ACA continue to go forward, payment will be  directly tied to

value based care. This change in payment will directly affect the state’s ability to

provide quality comprehensive care to patients. States that have opted out of the expansions will

ultimately be subject to the reductions in payments and end up paying more in uncompensated

care (Price & Eibner, 2013).

 Many of the patients in the community have Medicaid and are uninsured. These new

patient’s will be absorbed into the Aspen County Health Department and it’s federally qualified

health center. As the Health Department takes on these patients they must be able to deliver

value based care and meet competencies to obtain payment. Due to the probability that this

demographic has been neglecting their health care needs, it could be reflected in the quality

metrics (Bees, 2017).

EMTALA violations are complaint driven and are related to emergency room care. As

the rate of emergency use increases in Aspen, due to lack of coverage, the potential for
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complaints will also increase.  Problems that can arise from this increase in volume

include, delays in hospital admissions, increased patient complaints, long wait times in the

emergency room and patient’s that leave the emergency room without being seen. This potential

for violations can place the Aspen Public Health Department and the Federally qualified health

center at risk for civil penalties and termination of Medicare participation (Gutbezahl,, 2018).
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References

Barnett, M. L., Clark, K. L., & Sommers, B. D. (2018, October). State Policies and enrollees’

experiences in Medicaid: Evidence from a new National Survey. Health Affairs, 37,

1647-1655. http://dx.doi.org/10.1377/hlthaff.2018.0505

Bees, J. (2017, May). Value- Based Readiness. Health Leaders, 26-30. Retrieved from

http://ezproxy.snhu.edu/login?url=https://search.ebscohost.com/login.aspx?

direct=true&db=edsghw&AN=edsgcl.494098833&site=eds-live&scope=site. Accessed

January 26, 2019.

Capp, R., Kelley, L., Ellis, P., Carmona, J., Lofton, A., Cobbs-Lomax, D., & D'Onofrio, G.

(2016). Reasons for frequent emergency department use by Medicaid enrollees: A

qualitative study. Journal of the Society for Academic Emergency Medicine, 476-481.

http://dx.doi.org/10.1111/acem.12952

Gutbezahl,, C. (2018). Four common EMTALA vulnerabilities hospital should know...But

probably don't. Retrieved from https://www.compass-clinical.com/four-emtala-

requirements-know-probably-dont/

Oostrom, T., Elnav, L., & Finkelstein, A. (2017, May, 01). Outpatient Office Wait Times and

Quality of Care for Medicaid Patients. Health AFF (Millwood), 36, 826-832.

http://dx.doi.org/10.1377hlthaff.2016.1478
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Price, C. C., & Eibner, C. (2013, June). For states that opt out of Medicaid expansion: 3.6 million

fewer insured and 8.4 billion less in federal payments. Health Affairs, 32(6), 1030-1036.

http://dx.doi.org/10.1377/hlthaff.2012.1019

Rhubart, D. C. (2018). Disparities in individual health behaviors between Medicaid expanding

and non-medicaid expanding states in the U.S. Population Health, 6, 36-43.

http://dx.doi.org/10.1016/j.ssmph.2018.08.005

Schubel, J., & Broaddus, M. (2018, May, 23). Uncompensated Care Costs Fell in Nearly Every

State as ACA’s Major Coverage Provisions Took Effect. Center on Budget and Policy

Priorities, 1-9. Retrieved from https://www.cbpp.org/sites/default/files/atoms/files/5-23-

18health.pdf
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