In my last post on California and Texas’s imminent expansion of their scope of practice regulations, I didn’t cover one important question: what do patients actually want?
Fortunately, a study just released in Health Affairs looked into it, and the results are clear: many patients want to be seen by nurse practitioners (NPs) and physician’s assistants (PAs) – especially if it allows them to be seen sooner.
To be clear: generally, Americans still prefer being seen by a physician. But preferring a NP/PA – or “not having a preference” between a NP/PA and a physician – is a big deal; it insinuates that, for certain ailments, the public views a NP/PA as just as effective a clinician. That has significant repercussions for how care is delivered, particularly for young people and underserved populations.
The researchers conducted a survey that focused on three different scenarios to judge patient preferences: a straight-up comparison of preference for physicians vs. NPs/PAs; a scenario where a patient could see a NP/PA today vs. a physician tomorrow for a minor ailment; and a scenario where a patient could see a NP/PA today vs. a physician in three days for a minor ailment. Continue reading…
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.
The Passenger Pigeon. The Dodo bird. The primary care clinic nurse. All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.
Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs. “There are no ‘nurses'” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”
Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms. True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.
This columnist looked for medical literature on the topic. He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape. If he’s wrong, he wants to hear from his readers.
If true, what are the implications?
“The more you learn, the more you realize you don’t know.”
You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.
The implication of this for the practice of medicine is that a little knowledge can be very dangerous.
What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.
I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)
The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it, it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.
Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing.
Six years ago, my husband saved my life.
I had a severe allergic reaction to a medicine in the hospital in the middle of the night; he ran for the nurse. As for me, despite being a doctor myself, I couldn’t even breathe, let alone call for help. And so, even before and certainly since, I advise my patients not to be alone in the hospital if they can help it. I don’t even think anyone should be alone for office visits. There is too much opportunity to misunderstand the doctor, forget to ask the right questions, or misremember the answers.
National organizations like the American Cancer Society give the same advice: when possible, bring a friend.
As a patient safety researcher and an advocate for high quality healthcare, however, I find giving this advice distasteful. Is a permanent sidekick really the best we can do to keep patients safe? What about those who are already vulnerable because they don’t have such a superhero in their lives, or that superhero just has to punch in at some inflexible job?
Let’s take another look at the circumstances that ended up with my husband shouting, panic-stricken, in the hallway. The medicine I was given is known to cause severe allergic reactions. It is so well-established, in fact, that the standard protocol for giving this medication is to give a small test dose first. It was the test dose that nearly did me in. The hospital followed standard procedure by giving me the test dose. But they chose to do it at midnight, when the hospital is staffed by a skeleton crew, even though the medicine wasn’t urgent. Strike one for safety.Continue reading…
The Accountable Primary Care Model: New Hope for Medicare and Primary Care
Primary care has long been something of an outcast in the medical profession — and despite convincing outcomes and a validated assessment tool, checkered reimbursement has brought the Institute of Medicine’s Primary Care Model to the brink of demise.
But the accountable care movement, and some Medicare Advantage plans in particular, have breathed new life into primary care and offered new hope for the struggling Medicare system. At St. Louis-based Essence Healthcare, a 4.5-star Medicare Advantage plan, network primary care physicians’ deep experience in providing accountable care has spawned innovations that advance primary care and make progress toward the “Triple Aim Plus One” (outlined in C9 below). Their success is the result of five years of active practice transformation and continuous improvement in a risk-bearing environment.
The best practice experience from these front-line physicians can be summarized in the Accountable Delivery System Institute’s Accountable Primary Care Model. This model embraces the four pillars outlined in the Institute of Medicine/Starfield model and expands them for Nine C’s of Accountable Primary Care Delivery. They are:
C1: First contact means that care is initially sought from the Primary Care Physician/Clinician (PCP) when new health or medical needs arise. In a nationally representative sample of more than 20,000 episodes of care, when these events began with PCP visits, as distinguished from some other source of care in the system, costs were 53% lower. This cost differential persisted after controlling for ER visits, health status, socio-demographics, and other relevant variables.
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.
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.
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.
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.