As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation. While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base. They should not identify themselves as “doctors” despite having a Doctor of Nursing Practice (DNP) degree. It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP. Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.
After residency, a physician has accrued a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate. As healthcare reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower healthcare spending overall should be revisited. While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.
“I just want you to know, I won’t have a colonoscopy”, my new patient said with some amount of fervor in his voice. “And I don’t want to take a lot of medications.”
I looked him straight in the eyes and said “This is America, you don’t have to do anything, and I work for you. My job is to help you know your options.”
He seemed to relax. I reflected on the words I had just uttered, yet another time – it is the way I often try to set the tone as a non-authoritarian, patient focused physician.
“You don’t have to do anything”, of course, only applies to the patient.
The doctor has to do a lot of things, like document a treatment or follow-up plan for Medicare patients with a BMI over 30, or provide computer generated patient education to a minimum percentage of patients, and achieve a certain percentage of e-prescriptions. And right about now, we are starting to see financial consequences if too many of our patients, like the man I had just met, don’t want to take the medications that can bring their blood pressures or blood sugars below certain targets.
Today, an intensive care unit patient room contains anywhere from 50 to 100 pieces of medical equipment made by dozens of manufacturers, and these products rarely, if ever, talk to one another. This means that clinicians must painstakingly review and piece together information from individual devices—for instance, to make a diagnosis of sepsis or to recognize that a patient’s condition is plummeting. Such a system leaves too much room for error and requires clinicians to be heroes, rising above the flawed environment that they work in. We need a heath care system that partners with patients, their families and others to eliminate all harms, optimize patient outcomes and experience and reduce waste. Technology must enable clinicians to help achieve those goals. Technology could do so much more if it focused on achieving these goals and worked backwards from there.
This week marks a step that holds tremendous promise for patients and clinicians. On Monday the Masimo Foundation hosted the Patient Safety Science & Technology Summit in Laguna Niguel, California, an inaugural event to convene hospital administrators, medical technology companies, patient advocates and clinicians to identify solutions to some of today’s most pressing patient safety issues. In response to a call made by keynote speaker former President Bill Clinton, the leaders of nine leading medical device companies pledged to open their systems and share their data.
Lack of interoperability between medical devices plays no small role in the 200,000 American deaths caused by preventable patient harm each year, such as in the case of 11-year-old Leah Coufal. After undergoing elective surgery, Leah received narcotics intended to ease her pain.
When Leah received too much medication, it suppressed her breathing, eventually causing it to stop altogether. Had she been monitored, a device could have alerted clinicians when Leah’s breathing slowed to a dangerous level.
But as we know, clinicians are busy and unfortunately don’t always respond to alarms from bedside machines. If a machine measuring her breathing had been linked with the device delivering her medication, it could have automatically stopped the drugs from infusing into her blue, oxygen-deprived veins.
All of this is possible today; technology is not a barrier. Until now, the only thing that’s stood in the way is a lack of leadership and a lack of willingness for device manufacturers to cooperate.
Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.
In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.
But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.
Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.
But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.
The U.S. Supreme Court ruled on Jun 28th by a 5-4 vote to let the individual mandate portion of the Affordable Care Act (Obamacare) stand. Immediately following, a CEO of one of the nation’s largest insurance companies was asked if people can expect their premiums to go up as this law is implemented. The answer was yes. So what can employers do to protect themselves from the inevitable?
One strategy for driving market incentives back into the healthcare system and driving down costs is called consumer-driven health insurance, and it is growing in popularity. Historically, the consumer or patient has had very little monetary skin in the game when it comes to the cost of healthcare. We go to the doctor and pay our copay, and never have to worry about what it really costs for health care.
Many employers are now trying to incentivize their employees to be as prudent a purchaser of health care as they are of any other product or service. And they’re doing this by offering high-deductible health insurance policies combined with health savings accounts, or HSAs.
For the 50 percent of patients who collectively spend only 3.5 percent of all healthcare dollars, it’s a fantastic alternative. Instead of paying the high premiums for a lower-deductible plan to the insurance company for care you don’t use — that’s money that goes out the window unnecessarily — you can store the money away, accumulating it every year until a health event occurs when you really need it.
To be sure, a big drawback to these high-deductible insurance plans is the negative impact they can have on the five percent of patients who spend 50 percent of all healthcare dollars. Many worry that high-deductible plans will increase the total cost of healthcare because those with chronic healthcare problems won’t get the help they need until their condition gets so bad that they are forced to seek help — when obviously the cost will be much greater. They have a very valid point.
Us and Them
And after all we’re only ordinary men
The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face. ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry. ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”
My wife grabbed my arm, restraining me from throwing the nearest object at the television. I cursed under my breath.
No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society. I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.
It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving. If only we could get rid of the bad people, we could make everything work. If only those people weren’t oppressing us. If only those people weren’t so lazy. It’s the radical religious people who are the problem. It’s the liberal atheists. It’s the corporations. It’s the government. All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.
As health reform evolves, I’ve been watching multihospital systems grow in size and power and speculating what their gigantic size means.
Here, as of 2008, were the 10 largest systems in revenue size
1. Veterans Administration Hospitals, $40.7 billion
2. Hospital Corporation of America, $28.4 billion
3. Ascension Health, $12.7 billion
4. Community Health, $10.8 billion
5. New York Presbyterian, $8.4 billion
6. Tenet Health, $8.3 billion
7. Catholic Health Initiatives, $7.8 billon
8. Catholic Health West, $7.6 billion
9. Sutter Health, $6.9 billion
10. Mayo, $6.1 billion
What strikes me about this list are that such giant systems like Kaiser, the Cleveland Clinic, Johns Hopkins, Duke, and Health Partners in Boston don’t even appear, and the large number of Catholic multisystem chains. The revenues of multihospital systems has undoubtedly grown since 2008. In 2011, hospital mergers and acquisitions hit an all time high.
Kathy heads to surgery tomorrow at 7am. She’ll be NPO (nothing by mouth) after midnight. She’ll wake at 5am, shower with Hibiclens (a antibacterial prep), and I’ll drive her to surgical check in. Prior to surgery, the radiology department will insert a wire adjacent to the titanium markers that were placed in her tumor at first diagnosis. Her surgeon will use this wire to guide the lumpectomy.
Her left breast will become smaller than her right. She jokes that her career in exotic dancing will come to an end.
The operating room will call me at the end of her procedure and I’ll pick her up. Since she’ll not have had general anesthesia, we’re presuming she’ll feel good enough for a bit of an extended ride home. The last of our chickens arrives on Friday (Buff Orpington’s) and we’ll pick them up as we drive back to our new farm.
We’ll anxiously await the results of pathology. If the margins on the lumpectomy tissue are clear, Kathy will start Radiation Therapy 1-2 months after surgery, likely late June or early July.
By Labor Day, if all goes well, this phase of our cancer journey will end, although our continued vigilance for reoccurrence will be lifelong.
Today a dear friend of mine told me a horror story about her recent trip to a hospital ER. She has kidney stones, with rare bouts of excruciating pain when they decide to break off from their renal resting place and scrape their way down her ureters.
My friend is a stoic person who also doesn’t like to cause trouble for others – so when she was awoken at 4am with that same familiar pain, she decided not to call an ambulance but rather drive herself to the ER. She also chose not to call her doctor out of consideration for his sleep needs.
She managed to make it to the triage desk at her local hospital and was relieved to see that the ER was quite empty. There were no ambulances in the docks, no one in the waiting area, and no sign of any trauma or resuscitations in the trauma bay. She approached the desk trembling in pain and put her health insurance card, driver’s license, and hospital card on the desk and let the clerk know that she was in incredible pain.
My readers know how passionate I am about
protecting the public from misleading health information. I
many well-meaning attempts to “empower consumers” with Web 2.0 tools.
Unfortunately, they were designed without a clear understanding of the
scientific method, basic statistics, or in some cases, common sense.
Let me first say that I desperately want my patients to be
knowledgeable about their disease or condition. The quality of their
self-care depends on that, and I regularly point each of my patients to
trusted sources of health information so that they can be fully
informed about all aspects of their health. Informed decisions are
founded upon good information. But when the foundation is corrupt –
consumer empowerment collapses like a house of cards.
In a recent lecture on Health 2.0, it was suggested that websites
that enable patients to “conduct their own clinical trials” are the
bold new frontier of research. This assertion betrays a lack of
understanding of basic scientific principles. In healthcare we often
say, “the plural of anecdote is not data” and I would translate that to
“research minus science equals gossip.” Let me give you some examples
of Health 2.0 gone wild: