reliably effective & justly efficient
HEALTH SECURITY certification
INTRODUCTION
For insurance, a group of individuals may decide to protect themselves from the financial obligations of certain possible events in the future. Insurance becomes more efficient as the insured events are more predictable and definable among the subscribing participants. For healthcare, the cost of healthcare for Basic Health Needs is much less predictable and definable as compared to the cost of healthcare for Complex Health Needs. Therein lies the current crisis in the payment and benefit structure of our nation’s healthcare. Primary Healthcare has not evolved to correct the actuarial problems associated with its traditional model of healthcare. In addition, many other institutional and social issues aggravate and complicate the insurance disparities between the health care for Basic Healthcare Needs and the health care for Complex Healthcare Needs.
Without a means to standardize the character of our nation’s Primary Healthcare, the necessary improvements in the efficiency of our nation’s entire healthcare industry have not occurred and are, for now, unlikely to occur in the future. By defining the character of the Primary Healthcare work environment, the sources of payment for healthcare will experience an improved ability of Primary Healthcare to serve the Basic Health Needs of their citizens and responsively limit their involvement in the wants and desires of these citizens that are not insurable. This is not intended to ignore the legitimate worries and concerns by anyone about their HEALTH.
The new strategy for healthcare reform describes a means to stabilize the character of Primary Healthcare as a means to improve its ability to improve the cost and quality of healthcare for Complex Healthcare Needs. Any criteria for certified Primary Healthcare should support the character of health care offered to any citizen regarding their worries and concerns as a basis for coordinating their Basic Healthcare Needs with any Complex Healthcare Needs they may have. It is important that the criteria chosen for a clinic’s HEALTH SECURITY certification promotes the responsibility of the Primary Healthcare Team to support the autonomy of each citizen by coordinating the beneficence and the occurrence of futility for the health care offered to each citizen, especially for Complex Healthcare Needs.
Elsewhere on the Initiative Page and its Sub-Pages, I have expressed my belief that the importance of certification may not be enough to improve efficiency. It is likely that each source of payment for healthcare will need to explore alternate models for reimbursement. One of these should involve a standard allocation of the premium dollar that represents the cost of Basic Health Needs, in a sense, a prepaid expense. With an allocation representing 30-35% of the total premiums for a group of insured citizens, an individual Primary Healthcare clinic should be at 100% risk for the cost of Basic Health Needs. If implemented slowly with stop-loss provisions, any Primary Physician group should be able to achieve confidence in their ability to manage the costs of Basic Health Needs for their patient panel. With a mindful attention to efficiency for Basic Health Needs, a Primary Physician would then have an improved ability to influence, secondarily, the efficiency of healthcare for Complex Health Needs, particularly the choice of providers for these needs.
HEALTH SECURITY certification
A. Criteria for any clinic offering Primary Healthcare to be certified as HEALTH SECURITY qualified.
For CERTIFICATION, the criteria are: 150-250 points for year one, 170-250 points for year two,
190-250 points for year three, 210-250 points for year four, 230-250 points for year five and thereafter.
This process is based on a five-year development process. The Board of Trustees and
the Regional Councils will develop a plan involving each District Coalition or other sources
to verify the HEALTH SECURITY status of any applicant for Certification
including unannounced reviews. The CLIA / VFC certification, as managed by each State
for these two Federally sponsored programs might be a source of collaboration. They already have
collaborative relationships with many Primary Healthcare clinics.
[ COMMENT: The criteria identified below are very preliminary. During the first five years of HEALTH SECURITY certification, it is likely that the 5 year probationary period will change to a shorter interval. In addition, the certification criteria will evolve to account for new concepts, special populations being offered health care and the financing of Primary Healthcare. ]
1. ORGANIZE SYSTEMS ( 40 points out of 250 total )
a. Corporate entity – 34
i. Ownership (one of the below) – 24
I). Profit
A) Employees own 100% of all voting stock not owned
by a 501C3 qualified non-profit Corporation.
B) A 501C3 Corporation may own up to 40% of the voting stock OR
if the voting stock is divided into CLASS A with voting privileges
restricted to appointing 1/3 of the Board of Directors or
dissolution of the Corporation with ownership this Class only
by a 501C3 Corporation and CLASS B ownership only
by employees
C) No individual who is not an employee may own stock
II) Non-profit or Profit (but operated as a non-profit)
A) 501C3 non-profit ownership of at least 60% of any voting Stock
ii. Risk-management – 2
I) A Policy regarding Catastrophic Risk Management exists
that is reviewed and revised annually by the Board of Directors.
II) The Catastrophic Risk Management Policy includes
appropriate insurance coverage for the corporation
and a relocation plan in case of a natural disaster
iii. General Operating Principles – 4
I) A Policy regarding General Operating Principals exists
that is reviewed and revised annually by the Board of Directors.
II) A Policy regarding the establishment of Policy and Procedures
exists and is reviewed and revised annually by the
Board of Directors.
iv. Strategic Projects Plan – 4
I) A Policy regarding a Strategic Projects Plan exists that is
reviewed and revised annually by the Board of Directors
II) The Strategic Projects Plan is used by the Board of Directors
to evaluate the performance of the Corporation’s Chief Executive Officer
b. Information systems – 6
i. Document Management – 3
I) A Policy regarding Document Management exists and
includes the definition of active or inactive status,
storage, and ultimate destruction for any document
or folder of documents.
II) Applicable Federal and State standards are identified and
followed in the Document Management Policy.
ii. Personal Health Record (PHR) – 3
I) Each patient’s PHR contains a Process List of inactive and
active health issues that either have previously or
currently require active healthcare supervision.
II) Each patient’s PHR contains a summary of their
Past Medical History, Social History,
Family History, and Review of Systems that can be easily revised.
III) Each patient’s PHR contains at least a Routine
Health Maintenance flow sheet along with any
treatment flow sheet as necessary to
document the use of multiple medications or
related healthcare follow-up.
2. PURSUE V I S I O N (90 point)
a. Triage – 20 points
i. Phone answered by a licensed registered nurse (R.N.) during office hours – 15
ii. Failed appointments immediately reviewed – 1
iii. Waiting times are routinely monitored – 1
iv. Appointments can be made a year into the future -1
v. Automatic call forwarding to a medical answering service after hours – 2
b. Professional Capacity – 60 points
i. All licensed health care personnel have BLS certification by the Red Cross – 2
ii. Each physician employee who is on-call after hours is scheduled
for at least 20 hours of appointment time during a regular
work week – 9
iii. 70% of physician encounter visits are with providers who take
after hours call – 9
iv. On-call schedule is limited to 2-6 physicians – 9
v. Physicians are Board Certified – 25
( 20 if 75-99%, 10 if less than 75%, 0 if less than 50%)
vi. The Vaccines for Children inventory is maintained using
NESSIS. – 3
vii. The laboratory services are CLIA certified. – 3
c. Technical capacity – 10
i. Located <½ block from a mass transit stop if urban location or
widely identifiable intersection if suburban or rural location – 4
ii. No steps between the parking lot and an exam room – 2
iii. Active medical records are continuously available – 2
iv. An easily accessible list of HYPERSENSITIVITY reactions to medications
or other health care interventions exist on each patient’s,
medical record Process List and Data Base – 2
3. BUILD TRADITION (40 points)
B. Certification management
1. A prospective Primary Healthcare clinic reviews the criteria and decides if it wants to become
HEALTH SECURITY certified. There is evidence of a resolution by the Board of Directors
of the corporation to seek certification.
2. The prospective Primary Healthcare clinic completes the application and sends it
to the applicable District Coalition office of NATIONAL HEALTH. The
self-assessment shall be postmarked on or before the 1st of the month
prior to the month for which certification is requested. The self-assessment
shall be mailed with the U.S. Postal service and by email
to the District Coalition office assigned to the location of the Primary Healthcare
clinic applicant. For the first 5 years, the self-assessment shall be performed
annually and thereafter every three years.
3. Notification of “certification status” shall be sent on or before the 15th of the month
prior to the month for which Certification will start or be renewed. Any payor
may request a list of certified Primary Healthcare clinics on the 17th of any month
that will be applicable the following month.
4. The self-assessment shall be forwarded by the District Coalition to the applicable Hospital
and State Department of Public Health for comment. The applicable District Coalition
shall also post the self-assessment on its website for public comment.