Critically ill Medicare patients, who are battling for stable health at the end of life, are victims of repeated hospitalizations, especially after being discharged to a skilled nursing facility (SNF). The cycle of hospitalizations is an indicator of poor care coordination and discharge planning – causing the patient to get sicker after every “bounce back” to the hospital. Total spending for SNF care was approximately $31 billion in 2011; with an estimated one in four patients being re-hospitalized within thirty days of discharge to a SNF.
Each readmission leads to further test and treatments, higher health care costs, and most importantly, patient suffering. It is hard to imagine that patients would prefer to spend their last few months of life shuttling from one healthcare setting to another and receiving aggressive interventions that have little benefit to their quality and longevity of life. The heroic potential of medical care should not compromise the patient’s opportunity to die with dignity. A hospital is not a place to die.
Medicare beneficiaries are eligible to receive post-acute care at SNFs, after a three day hospital admission stay. SNFs provide skilled services such as post-medical or post-surgical rehabilitation, wound care, intravenous medication and necessities that support basic activities of daily living. Medicare Part A covers the cost of SNF services for a maximum of 100 days, with a co-payment of $148/day assessed to the patient after the 20th day. If a patient stops receiving skilled care for more than 30 days, then a new three day hospital stay is required to qualify for the allotted SNF care days that remain on the original 100 day benefit. However, if the patient stops receiving care for at least 60 days in a row, then the patient is eligible for a new 100 day benefit period after the required three day hospital admission. It is evident that the eligibility for the Medicare SNF benefit is dependent on hospitalizations – many of which may be a formality and a source of unnecessary costs.
Continue reading “The Bounce Back Effect”
Filed Under: THCB
Tagged: Anubhav Kaul, Costs, Dartmouth Atlas Project, End of Life Care, Medicare, Nursing, Readmissions, Senior Care, Sindhu Kubenderan, skilled nursing facilities
May 12, 2013
For years we’ve read that the US faces a looming shortage of nurses. Shortfalls in the hundreds of thousands of nurses are routinely predicted. These predictions have been good for nursing schools, which have used the promise of ample employment opportunities to more than double the number of nursing students over the last 10 years, according to CNN.
Yet somehow 43 percent of newly-licensed RNs can’t find jobs within 18 months. Some hospitals and other employers openly discourage new RNs from applying for jobs. That doesn’t sound like a huge shortage, then does it?
But the purveyors of the nursing shortage message have an answer for that. Actually two answers: one for the short term and another for the long term. The near term explanation is that nurses come back into the workforce when the economy is down. Nurses are female and tend to be married to blue collar men who lose their jobs or see their hours reduced when the economy sours, we’re told. Nurses bolster the family finances by going back to work –or they stay working when they were planning on quitting. There’s something to that argument even if it’s a bit simplistic.
The longer term argument is that many nurses are old and will retire soon, just when the wave of baby boomers hits retirement age themselves and needs more nursing care. Don’t worry, the story goes, there will be tons of jobs for nurses in the not-too-distant future. This logic comes through again in CNN’s story:
Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage [emphasis mine] will reemerge in the United States.
Continue reading “The Nursing Shortage Myth”
Filed Under: Hospitals, THCB
Tagged: David Williams, Nursing, Nursing Shortage
Jan 15, 2013
The $200 billion skilled nursing and rehabilitation market is in the midst of a transformation and in a new world of ACOs and readmission penalties, we see these providers playing a significant role in helping hospitals reduce readmissions and providing patients with coordinated and professional care in a sub-acute environment.
In March 2012, the Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation announced the Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents. Through this initiative, CMS is partnering with seven organizations to implement strategies to reduce avoidable hospitalization for dual eligibles who are typically long-stay residents at nursing facilities. Each participant in the initiative is required to partner with a minimum of 15 dual eligible certified nursing facilities in the same state where the intervention will be implemented.
Continue reading “Skilled Nursing Providers Playing an Increasing Role in Reducing Hospital Re-admissions”
Filed Under: Health Plans, THCB
Tagged: Jonathan Hill, Nursing, Readmissions, TripleTree Research
Nov 21, 2012
Last year I graduated from nursing school and began working in a specialized intensive care unit in a large academic hospital. During an orientation class a nurse who has worked on the unit for six years gave a presentation on the various kinds of strokes. Noting the difference between supratentorial and infratentorial strokes—the former being more survivable and the latter having a more severe effect on the body’s basic functions such as breathing—she said that if she were going to have a stroke, she knew which type she would prefer: “I would want to have an infratentorial stroke. Because I don’t even want to make it to the hospital.”
She wasn’t kidding, and after a couple months of work, I understood why. I also understood the nurses who voice their advocacy of natural death—and their fear of ending up like some of our patients—in regular discussions of plans for DNRtattoos. For example: “I am going to tattoo DO NOT RESUSCITATE across my chest. No, across my face, because they won’t take my gown off. I am going to tattoo DO NOT INTUBATE above my lip.”
Another nurse says that instead of DNR, she’s going to be DNA, Do Not Admit.
We know that such plainly stated wishes would never be honored. Medical personnel are bound by legal documents and orders, and the DNR tattoo is mostly a very dark joke. But the oldest nurse on my unit has instructed her children never to call 911 for her, and readily discusses her suicide pact with her husband.
You will not find a group less in favor of automatically aggressive, invasive medical care than intensive care nurses, because we see the pointless suffering it often causes in patients and families. Intensive care is at best a temporary detour during which a patient’s instability is monitored, analyzed, and corrected, but it is at worst a high tech torture chamber, a taste of hell during a person’s last days on earth.
Continue reading “End of the Line in the ICU”
Filed Under: Commentology, THCB, The Insider's Guide To Health Care
Tagged: Cancer, DNR, DNR tattoos, end of life wishes, futile care, ICU, Kristen McConnell, Nursing, Palliative Care
Nov 16, 2012
This case is prompting a lot of comments, some of them taking issue with the concept of systemic failures and instead asserting that the young nurse was clearly incompetent, in that her error was inexplicable. So, let’s turn from a clinic in Brazil to a recent case in a hospital in the US, cited in this article on AHRQ’s Web M&M. A summary:
The order was written correctly in the electronic medical record (EMR) for phenytoin, 800 mg IV. The drug-dispensing machines stocked phenytoin in 250 mg/1 mL vials. The correct dose therefore would require 4 vials and be equal to 3.2 mL to be added to a small IV bag. The nurse misread the order as 8000 mg (8 g) and proceeded to administer that dose to the patient, which was a 10-fold overdose and 2 to 3 times the lethal dose. The patient died several minutes after the infusion.
This nurse had to work hard to make the error:
An audit of the pharmacy system revealed that the nurse had taken 32 vials out of 3 different pharmacy dispensing machines to accumulate 8 g of IV phenytoin. Moreover, the nurse had to use two IV bags and a piggyback line to give that large a dose.
Continue reading “Is the Nurse Incompetent?”
Filed Under: Hospitals, THCB
Tagged: EHR, Hospitals, Medical errors, medication error, Nurses, Nursing, Paul Levy
Oct 25, 2012
Within the next two years, if federal healthcare reforms proceed as expected, roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers.
It won’t be easy. Primary care providers are already in short supply, both in California and nationwide. That’s because doctors are increasingly leaving primary care for other types of practices, including higher paid specialties. As the demand increases, the squeeze on providers will worsen, leading to potentially lower standards of care in general and longer wait times for appointments for many of the rest of us.
Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.
Clinics like the one I direct in the heart of San Francisco’s Tenderloin district — GLIDE Health Services — offer a hopeful glimpse into California’s healthcare future. We are a federally funded, affordable clinic, run almost entirely by nurse practitioners. At our clinic, we nurses and talented specialists provide high-quality, comprehensive primary care to more than 3,200 patients each year.
Despite the special hardships of our clientele, who daily cope with the negative effects on health caused by poverty, unemployment and substance abuse, our results routinely compare favorably with those of mainstream physicians. Our patients with diabetes, for example, report regularly for checkups, take their meds as directed and maintain relatively low average blood-sugar levels.
Continue reading “Healthcare Reform’s Missing Link — Nurse Practitioners”
Filed Under: OP-ED, THCB
Tagged: Affordable Care Act, GLIDE Health Services, Nurses, Nursing, primary care
Sep 8, 2012
After entering the clinic a thought occurred to me: why do we need doctors? Then a second thought: why do we need nurses?
Ah, but I’m getting ahead of myself.
About a decade before the Obama administration started touting electronic medical records and evidence-based protocols there was MinuteClinic. The entity came into existence primarily to cater to patients paying out of pocket.
There was no need for a law requiring price transparency. In every market where the dominant buyers are patients spending their own money, prices are always transparent. MinuteClinic posts its prices on a computer screen and on readily available pamphlets. Clearly, the organization is competing on price. Entities that compete for patients based on price usually compete on quality as well. One study found that MinuteClinic nurses following computerized protocols follow best practice medicine more consistently than conventional primary care physicians. They also do a pretty good job of knowing what kind of medical problems they are competent to handle and which problems need referral to a physician.
Wherever you find price competition you usually also find that providers are respectful of your time. As the name “MinuteClinic” implies, this is an organization that knows you value your time as well as your pocketbook. I couldn’t help but wonder if the entire health care system might be this user friendly, if only the third-party payers weren’t around.
For the first 15 minutes of my 20 minute visit, the nurse barely looked at me. She was sitting in front of a computer screen typing in my answers to her questions, as she went through the required decision tree. I didn’t mind. Mine was a minor problem and I did not want to pay for more sophisticated service.
Continue reading “Lessons from MinuteClinic”
Filed Under: THCB, The Business of Health Care
Tagged: Apps, decision tree, EHR, evidence-based protocols, John Goodman, MinuteClinic, Nursing, primary care
Aug 6, 2012
Not so long ago, the air was filled with dire warnings of an impending nursing shortage. By 2020, according to one widely-cited analysis, demand might exceed supply by as many as 800,000 nurses.
That analysis was made in good faith, and it was based on not-crazy extrapolations from thirty years’ worth of economic data.
But in many local labor markets in 2012, there’s no sign of a shortage. In fact, in some regions there’s evidence of a glut. A few months ago, the California Institute for Nursing & Health Care announced that 43 percent of people who received nursing degrees in California and 2010 and 2011 were not working as nurses.
I’m going to try to make some dimly-informed comments about the nursing labor market in the next few posts. But first, a few words about what it means to say that there is (or isn’t) a nursing shortage.
In this context, “nursing shortage” is used in an unsentimental labor-economics sense. A nursing shortage exists when employers are actively trying to hire additional nurses but are rubbing against supply constraints, as evidenced by:
rapidly rising wages
heavy use of temporary “agency” nurses to fill gaps on units
a greater-than-usual willingness to hire nurses with little experience or limited training
new investments in nurse-replacing technology
desperate 3 am phone calls from hospital administrators to college presidents, begging them to launch new nursing programs
To say that there is no nursing shortage today is not to say that all hospital units are adequately staffed for patient safety and decent quality of care. There is plenty of reason to believe that patients would be better off if hospitals invested in stronger nurse-patient ratios.
Continue reading “What We Talk About When We Talk About Nursing Shortages”
Filed Under: Uncategorized
Tagged: David Glenn, Nursing, Nursing Shortage, Patient Safety
Jul 20, 2012
There are lots of losers in President Obama’s effort to remake the U.S. health care system, and chief among them are the doctors. But there are also winners, especially nurses and physician assistants (PAs). Indeed, nurses and PAs win big in part because doctors lose badly.
Surveys repeatedly show doctors are fed up with low reimbursement rates from Medicare and even lower from Medicaid, which have increasingly led doctors to no longer see new patients in those government-run plans. For example, a recent Texas Medical Association survey found that “34 percent of Texas doctors either limit the number of Medicare patients they accept or don’t accept any new Medicare patients.” Even more do not accept patients with Medicaid.
Then there’s the heavy-handed regulations and requirements from both government and private health insurers. Complying with all those requirements and paperwork creates expensive and time-consuming administrative burdens. And to top it off, there’s the looming shadow of a high-cost lawsuit if things don’t turn out well.
And that’s all before ObamaCare kicks in, which will exacerbate every one of those problems. So it’s little wonder that there are physician shortages, especially in lower-paying primary care, and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured.
The increased demand for medical care and lower reimbursements—which is one of the primary ways ObamaCare will try to hold down costs—is a recipe for a mass exodus of doctors willing to practice medicine. As “Physicians Practice” reported in August from its physician survey: “Nineteen percent say they plan to move to another position in the same field. An equal amount says they plan to leave medicine—not to retire, but to pursue something new.”
Continue reading “Health Care Future Bright for Nurses. Stinks for Doctors.”
Filed Under: Physicians, THCB
Tagged: health care reform, Medicare reimbursement, Nurses, Nursing, Obamacare, physician assistants, Physician Shortage
Jul 14, 2012
This month’s wretched jobs report tells a now-familiar tale: Employment has risen nicely in health care (a net gain of more than 340,000 jobs between May 2011 and May 2012). But almost every other sector has been flat or worse.
You might think that would mean that new-graduate nurses are having an easy time finding work. That’s still true in rural areas — but elsewhere, no.
In many U.S. cities, especially on the west coast, there’s real evidence of a nursing glut. The most recent survey conducted by the National Student Nurses’ Association found that more than 30 percent of recent graduates had failed to find jobs.
How is that possible?
While demand for nurses has been rising, it actually hasn’t risen as fast as most scholars had projected. Meanwhile, the supply of nurses has spiked unexpectedly, at both ends of the age scale: Older nurses have delayed retirement, often because the recession has thrown their spouses out of work. And people in their early twenties are earning nursing degrees at a rate not seen in decades. We’re now in the sixth year in which health-care employment has far outshone every other sector, and college students have read those tea leaves.
So what will happen next?
Here are crude sketches of two possible futures:
Continue reading “Why New Nurses Can’t Find Jobs (No, Really)”
Filed Under: THCB
Tagged: David Glenn, Jobs Report, Nursing, Nursing Shortage
Jun 4, 2012