Paging Doctor Nurse!

Nurse and Lawyer’s dad sent on an article about the IOM report on the future of nursing. It was also discussed on Talk of the Nation this week. The report talks a lot about education for nurses and how advanced-practice nurses can help address the shortage of health care providers expected to worsen when new health care laws take effect.

Lawyer: Well, Nurse may be on track to be one of those nurses with doctorate degrees that the report says we need! So that’s one way to work for change. Get your boots on the ground.

Nurse: The education issue is huge. And divisive. While I agree that more education is good, and it seems reasonable to move towards a standard of a bachelor’s degree for entry-level nursing, it’s also true that some of the best nurses I know have associates’ degrees.

The article talked briefly about the idea of post-graduate clinical residencies for nurses– and I think that is  a very exciting idea. This is already widely practiced in a very haphazard way by hospitals who have various residencies, preceptorships, and externships for new graduate nurses, but there is no standardized way to do it and a nurse can be lisenced without any experience outside of school. Clinical skills and experience are largely obtained in your first nursing job.

Lawyer: Interestingly and mildly tangentially, that is also true of lawyers — though some (and an increasing number of) law schools have clinical programs where students work on real cases under faculty supervision, it’s still standard practice for newbies to have no practical experience. This (along with the student debt problem) accounts for some of the phenomenon of new graduates going so often into big law firm jobs, rather than working for smaller organizations that could really use the help — big firms have the resources to provide the training that isn’t required as part of the degree.

Nurse: Finally, the standard of education varries greatly. Some places are really pushing for NP’s to require doctorates rather than just masters’ degrees. The DNP degree has been created for this purpose, although a PhD in nursing also exists with a more academic/research focus.
Nurses with advanced degrees tend to be in somewhat different roles than ADN or BSN nurses– they are often educators, or specialists, or managers, serving as resources. They may teach, or do research, or direct nurse-led programs. They may work in primary care or alongside physicians in prescribing and treating. Some (but not many!) work in policy areas.

Lawyer: The Penn program mentioned in the NYT article seems to be getting at caring for people in a way that reduces demand for services. A kind of preventive care that kicks in only after a major incident — preventing relapse, rather than preventing disease to begin with — but still a step in the right direction.  At the risk of getting all econ here, with a shortage of this magnitude, we’ve got to increase supply AND cut demand. It seems to me that nurses could be useful in cutting demand.

Nurse: I agree. readmissions is a huge problem that can be addressed with good follow-up care, and nurses are a great way to do that. Not only will it lessen the burden on the system, but it is good for patients and good for health. This might be one of those situations that needs a very well-designed and executed study to prove that it saves money, since it involves laying out cash upfront. It’s a different way of thinking and those are sometimes hard to sell.

Lawyer: How do we effect change at the cultural level? (If I knew the answer to that. . . jeez.)

Nurse: It’s too bad that there’s so much infighting within the health care professions. Who doesn’t want nurses in expanded roles? What? Physicians? I call shenanigans.

Lawyer:  We need to pay nurses more. There, I said it. Not just to attract more nurses (though that would probably happen), but also because people will then take them more seriously as professionals and be more willing to entrust them with major tasks. (cf. NYT’s discussion of kindergarden teachers a few months ago.)

Nurse: Good point. I have had many people as me, if I’m considering getting my doctorate in nursing, why I don’t just go to medical school since it’s 4 years anyway, and I’d get paid a lot more. And it’s true, I would. My answer is that even nurses practicing in primary care have a different philosophy of care, in general, than physicians do.  But why that pay gap? For education and training, perhaps? Doesn’t hold much water when the nurse is doctorate-prepared. (Another reason to standardize residency programs for nurses– gets rid of that excuse entirely!).

Lawyer: We just need to keep fighting the idea that nurses are inherently less smart, useful, skilled, etc., than are doctors. (I’ll save my feminism rant for another day, but, yeah.) Just because many doctors have significantly more training than many nurses doesn’t mean that it has to stay that way.

Is there a role for law here? The Patient Protection Act is certainly a major force here, and a force for good, but it’s also creating a lot of issues that we need to solve. There are all the traditional answers to what law can do here — malpractice reform to cut costs, various iterations of who pays for which government programs — but could there be something else?

Nurse: Look at nurse practice act– these are different state by state, and the scope of practice varries from state to state. Some states require NP’s to work under physician supervision, some have prescriptive authority, some can function totally independently. Why does it need to be fragmented this way?

Lawyer: California’s is available here: (scroll down to Chapter 6: Nursing). Lots and lots of rules. This is one of those things that really has to be regulated by state law — it’s one of those types of things that seems like a state issue, not a federal issue. (That’s highly technical, I know.) There is an organization that promulgates “Uniform Law” — they very carefully draft laws that make sense to have agreement on and then try to persuade states to adopt them — but they have a really hard time getting enough states to adopt things to make them worthwhile. Still, this seems like the sort of topic where that kind of unity would be useful. (There is a Uniform Healthcare Decisions Act, and a Uniform Healthcare Information.

Health Reform Update Quickie

Most of the talk these days is about financial reform, ethics, and oil, but that healthcare bill is percolating through. NYT recently took a look at how Texas feels about it. In brief, they hate it because it costs too much.

Nurse: So. What gets me is that a lot of objections seem to be from “small government” types, whose general attitude is that the markets handle things in the best way on their own without interference. and when we’re talking about healthcare, there are a few problems with this– including that it’s clearly not working. costs are through the roof, outcomes aren’t improving, safety is a constant issue, and the system rewards choosing billable procedures over best practices.

Lawyer: And maybe, if people were shopping for healthcare services themselves, the market might take care of it. But they aren’t shopping for medical services — insurance companies are. And many of them aren’t shopping for insurance companies — their employers are. So the people setting the criteria are not the people using the services, and the people using the services end up having very little choice — hence, no market forces making it work.

Nurse: I seem to recall a Gawande essay in the new yorker about the town with the highest per capita health care costs being in texas?  I would argue that healthcare is a basic human right and that the government should be protecting it as they do life, liberty, and property– but this is more controversial.

Lawyer: I mean, none of our great old documents say we have a right to healthcare. But how about the right to life? And how about international human rights agreements? I will quickly be out of my depth if we start talking about international law, but let me leave it at this: among developed countries, we’d be doing pretty badly even if everyone did exactly what this new law says.

Nurse: To the argument that providing insurance to all the uninsured is way too expensive, I say that’s short-sighted. Ask any health care professional: chronic diseases that are poorly controlled are both extremely common and extremely expensive. When these patients are uninsured, they are treated in crisis only, and the cost of this care is out of control when compared to ongoing primary care– which typically, people do not seek without insurance.

Lawyer: Exactly. People are looking at the price tag and comparing it to zero, not comparing it to the alternatives. It’s like having a job where you absolutely need a car to get to it, and looking at a used Honda and saying “that costs too much,” when the other choice is a brand new BMW. You have to buy one — so comparison shop. Don’t just let your jaw drop at one price in isolation.

Sure, lots of things I believe in are genuinely open to the criticism that the government shouldn’t be spending money on that. The problem is, the government is going to pay for all this stuff anyway, and they’ll pay less, and people will be healthier, if we make the outlay.

Next time someone tries to argue otherwise, I will ask them if they want to repeal EMTALA. (That’s the law that requires emergency rooms to treat anyone who shows up needing treatment.) If you’re in an accident and you don’t have (a) your checkbook or (b) your insurance card with you, would you like the hospital to just leave you bleeding in the hallway until you prove you can pay?

Otherwise, emergency rooms will treat people who need it. And without insurance for preventive care, more people will need it.

I have a feeling we’re preaching to the choir here. Can I get an amen?

No Good Options Here. . .

Recently, a public dialysis clinic at Grady Hospital in Atlanta has been forced, for budget reasons, to close. This means they have to discontinue care to the patients they’ve been seeing. Most are eligible for medicaid/medicare, but they have a good number who are undocumented immigrants, and these people can’t get care from the state. They can’t pay for it themselves. And they can’t get it in their home countries. The hospital is giving them some options — but it doesn’t seem to be helping.

NYT has a short series on it.

The patients have been trying (unsuccessfully) to get into court, on the grounds that they are being illegally abandoned by their healthcare providers.

Lawyer: We had a discussion about it at the law school — mostly as an immigration law issue — which really got me thinking. It raises some impossible questions. Such as: If the hospital is being forced to cut its budget, is there any “right” way?

Nurse: It looks to me, although there aren’t a lot of details, that they are trying very hard to make a “right” way. Offering transitional services and assistance returning home seem to me like pretty hefty measure to help. Cutting the budget, closing the clinic, and offering nothing and little notice does seem wrong, but at this point, that’s not what is happening.

Lawyer: Patients are continuing to pursue a lawsuit (which has twice been dismissed — that dismissal is now being appealed to the State Supreme Court) against the hospital, claiming that they are being abandoned. It does indeed look like the hospital has done a lot to try to ease the transition — giving them a period of time and funding to seek treatment elsewhere, offering to fly them home, paying for private dialysis for a transitional period — I’m wondering what else they could actually do, if they cannot provide care indefinitely.

Nurse: I agree. I don’t think this could really constitute abandonment. These patients are receiving a service now which can no longer be offered, but there’s been a very generous allowance of time, money, and resources (although the article doesn’t provide specifics, and we all know that there are lots of forces which work against the success of poor undocumented immigrants).

Lawyer: And if we require them to provide care indefinitely one they’ve started, aren’t we creating an incentive to refuse to begin treatment?

Nurse: Yes! That’s really not feasible. I mean, can we say that a medical doctor must continue to see patients as long as he is physically able? No, we cannot– he can retire, he can move, he can change his practice model. . .just as we can’t force a publically funded clinic to operate without funds.

Lawyer: In the health debate going on now ( still going on… jeeeeez) no plan provides coverage or subsidy for undocumented immigrants. One proposal allows them to buy unsubsidized coverage in the exchange. Others don’t. Should they?

Nurse: Sigh. This is one of those very sticky things. We know they are here, and they are very expensive when they utilize our healthcare system through charity hospitals and ER’s (EMTALA much?). I think there is indeed a duty to treat– and neither that duty, nor the people in question, is going to dissapear. So yes, we should allow them to buy coverage. Doing so does not give them anything for free and it doesn’t charge our taxpayers– in fact, it has the potential to save us all money because hospitals like Grady won’t have to pick up the slack with taxpayer funding.

Lawyer: Oh, Nurse. I love it when you say things like “EMTALA.”

The practical issue, of course, is that if we refuse routine care, patients end up in emergency care which costs more. But if we have a reputation for providing free routine care, more people will come to use it, and it will become less feasible. Catch-22.

Nurse: True, true. But perhaps there needs to be another category– routine care that isn’t free, but rather affordable and accessible. This is a big thing to think about and it’s not easy to fix. I think there’s room to explore more options. I know that any payment at all is out of reach for some of these people at this point. . . and there are a lot of interconnected issues that  cause that, too. I don’t know how far we can make it on this problem without addressing immigration on another level.

Lawyer: Another thing that came up in our discussion was that the legal issues and ethical issues are really in tension here. Legally, it really doesn’t look like the Grady patients are being abandoned.

But ethically, the healthcare professionals in that setting might be in a bit of a bind — basically, the law doesn’t protect what is, or at least feels like, a duty that they have. The code of ethics in healthcare is not law. Which occasionally gets people into a real tight spot. (Recall our whisleblowing nurse!)

Nurse: I agree that there is definitely frequently a tension there, but in a case like this, I’m not sure that all the patients are holding up their end of the bargain. We as healthcare professionals do care for and advocate for our patients, but they need to participate in their care and meet is in the middle to the extent they can. We can provide you support and care for your lung disease, and we can give you counseling, referrals, and medications, but we cannot follow you around and stop you from smoking each cigarette. Likewise, we can help you to set up a new plan when we can no longer care for you, but we cannot literally make you do anything about it. Now, we do not have all the details, and certainly, some of the patients in this story don’t have the resources (including literacy, perhaps?) to really navigate the system well enough to find other arrangements, or there aren’t great options, as some have stated. But the article also says that many patients never really investigated alternate arrangements and plan on taking advantage of the generosity of our system in providing emergent care. I don’t think the latter group really can be considered abandoned  at all. As for the others, it’s murky.

Lawyer: Finally, if you DO somehow get the outcome that a hospital like Grady is required to continue care indefinitely for existing patients (to close, they simply stop accepting new patients), we have created a serious conflict of interest for the hospital — they have NO incentive to keep their patients alive. The sooner their patients die, the sooner they are off the hook. (Don’t mean to suggest that individual practitioners would feel this way — but the hospital as an institution, in its allocation of resources.)

Nurse: Ugh. As the article pointed out, dialysis can cost 50,000 dollars per year, easily. Patients on dialysis can live this way for years and years and years. I don’t see how that could really be a workable solution.

A final question: the article mentions a contract between Fresenius, the dialysis provider, and Grady, which operates the clinic. Fresenius seems to feel that their contract is to provide, and be reimbursed for, services for one year. I don’t know what the contract contains, but in that case, the employees of Fresenius may feel an additional obligation to continue giving care.

Lawyer: Though their legal position is much simpler. They have a contract, with defined terms and defined end date. Though it doesn’t really look like the hospital has a legal obligation here, there is at least an argument that they do, where the contract provider really has no possible liability. Aaaand we’re back to our tension between ethical duty and legal obligation. I’m getting dizzy!

We’ll keep an eye on this. . .

Here it is. Obamarama.

Lawyer: I went through the transcript with a highlighter to mark places where he actually said something concrete. I got to page 3 before I found anything.

Nurse: Overall, I think he’s doing a good job with this– it’s actually politically quite a tightrope between being too vague and making concrete promises that have to be shifted in some way later, and this always bites you in the ass. That said, it’s kind of disapointing to see how safe the approach is. While I recognize that it is largely impossible to enact sweeping dramatic change in a democracy which is beholden to so many interested parties, I wish it wasn’t. There are so many roots of the problems we have with healthcare delivery that are not addressed in this proposal– in a way, we are treating symptoms instead of making smart lifestyle choices. But I suppose that’s inevitable. Sigh.

Here are the substantive points he made, one by one:

1. We’d better build on what we have, rather than trying to build a whole new system.
Lawyer: Agree!

Nurse: Reluctantly agree out of pragmatism, not true belief.

2. This plan has three basic goals.
a. More security and stability for people who have insurance
b. Insurance for people who don’t have it
c. Slow the growth of health care costs

Lawyer: He doesn’t say much about how (c) is going to happen…

Nurse: And indeed, a lot of the most promising ways to do that are not possible in what amounts to a conservative (in the true sense of the word) reform effort.

3. Insurance regulation:
a.companies can’t deny coverage for preexisting conditions or drop/water down coverage when you get sick.
b. No arbitrary limits on how much coverage you get
c. Limits on out-of-pocket charges
d. Routine check-ups and preventive care must be covered

Lawyer: I mean, yeah.

Nurse: Right, this should be obvious. It’s not, but it should be. Even if this was the only thing that changed, we’d be better off.

4. Rather than out-right legislating what insurance companies must do, we will make these above reforms requirements for joining the health insurance exchange. Companies will want to join it so that they can compete for new customers. The exchange will give customers bargaining leverage.

Lawyer: I think this is a sound approach. Better to make people want to do things your way than to try to force them. Anyway, it worked with the whole drinking age thing. As long as it actually works. And insurance companies do actually participate. And follow the rules. Anybody know how this is actually going to function?

Nurse: It’s a tasty carrot. Mmm. carrots.

5. Tax credits for individuals and small businesses who can’t afford insurance, based on need.

6. Immediate low-cost, minimal coverage for the currently uninsured.

Lawyer: Um… details?

Nurse: Provided by? And covering. . .? People who can’t pay are still given care, but they are generally bankrupted by it. Maybe we are just getting around that.

7. People will be required to carry basic health insurance (just like auto insurance.) Businesses required to at least chip in. (Hardship waivers.)

Nurse: This at least makes sense, if we are going in a insurance-based model (See my previous post for a little discussion on that).

8. (wait for it…) Yes, there will be a public option available as part of the insurance exchange. (As one of many options.) CBO estimates that fewer than 5% of Americans would choose this option. The option will be self-sufficient, relying on the premiums it collects.

Lawyer: Wow, that low estimate makes me super-nervous.

Nurse: I think this is an essential part of the plan, not just in what it will actually do, but in the message it says. I do worry that it won’t truly be self-sufficient because people who elect it may have reasons not to buy private insurance or may find it too expensive. Depends on how the rest of that regultion reform plays out.

Lawyer: That’s too bad. Because people seem to be saying that it’s going down the crapper.

9. This will be paid for by cutting wasteful spending we already have, rather than expanding the deficit. If the projected savings don’t happen, we’ll cut spending, rather than adding to the deficit. Medicare trust will not pay for it.

Lawyer: Sounds good in theory. But I have a feeling that substantial savings will take a long time. I mean, longer than four years. Because our spending is really wasteful, yes, but we can’t just snap our fingers and quit doing that.

Nurse: And this is one place where we really need a cultural shift to fix it. A cultural shift involving how physicians and patients conceive of thorough care, and how malpractice suits are both perceived and actually used. Which leads into the next issue.

10. We’ll have some sort of panel to reduce defensive medicine. HHS is going to handle it. (vague, fuzzy, proclomations.)

Lawyer: I want to hear more about this! Ring ring, hello, Kathleen? Can we talk?

Nurse: Again, this is a deeply rooted cultural issue, in a way. I think we need some good evidence-based practice here– which means we need some research.

Lawyer: cf. Stimulus Bill.

Nurse: I have heard vaguely about studies which show that high-tech intervention can actually be harmful rather than helpful– as in using electronic fetal monitoring, which has been shown to cause unnecessary c-sections with no better outcomes, yet it’s become a standard of practice. HHS, can you work on this angle??

11. Poor Teddy Kennedy! This was his dying wish!  Also, as he said, this is a moral issue, not just a policy issue.

Lawyer: Aww. Shot to the heart.

Nurse: Ok. Cool.

12. People thought we were socialists back when we invented social security and medicare, too, but can’t we all agree now that we need those things and they were a good idea?

Lawyer: JEEZ, thanks Obama, I’ve been trying to tell people that for a while now.

Nurse: well, what’s wrong with socialists? And another thing: he talks about requiring insurance to cover preventive care, but I think we could make huge progress by going a step further and offering incentives for preventive care. Maybe that would just be smart business for an insurance company, I don’t know– but i think it would help!

Lawyer: Mmm,  more carrots. Carrot cake. I have to go…


NurseA recent article in the Atlantic, by David Goldhill, discussed health insurance reform from an angle we haven’t heard a lot of: why do we expect all of our healthcare expenses to be paid for by insurance? Everything from a checkup to our daily prescriptions to our accidents to our catastrophic illness is, in most people’s minds, the provenance of insurance. This, he argues, has the effect of making the insurance companies, rather than the patients, the customers, and it throws the whole free-market dynamic off entirely. He proposes mandatory health savings accounts as another path. Now, there a problems there, too, and I don’t agree with many of his points, but he raises an interesting question. If we own a car, we are required to have car insurance– but that doesn’t cover new tires, oil changes, and the like. It covers accidents, liability, theft, and damages we might not be able to afford without it. Same with insurance on our homes, our lives, our possessions. . . but not our health. Of course, we’ve been in this system for so  long that most of us could not pay out of pocket for the majority of our health expenses, but the author argues, and correctly, I believe, that the cost of health care as billed to insurance companies and the cost of health care as incurred by providers and facilities is astronomical, and much of that cost is due to administrative nonsense and lack of decent competition and incentives to perform. Interesting, no?

We WILL talk about the Obama speech.

But not right now. Torts starts in 10 minutes and I didn’t even get to watch the speech yet, let alone think about it, due to that phenomenon about which I’d been warned, but had not really yet understood: the first year of law school.

But one of my professors was nice enough to reschedule my only Friday class this week, which means my 3-day weekend starts in… an hour and twenty-five minutes. So watch for it.

In the mean time, I’m going to go follow the example set by our upstanding members of congress and heckle my professor during lecture. We’ll see how that goes over. Professor Engstrom, if you happen to read this: I don’t actually think you were lying in class.

R.I.P. Ted Kennedy

Full disclosure: here at nurse’s house, we have always been big fans of Ted Kennedy. Mr. nurse has jokingly (i think?) talked of getting Kennedy’s face tatooed on his bicep. We’re both former residents of, and lovers of, the bay state. Ok. moving on.

Healthcare has lost a great advocate in Ted Kennedy, long-time MA senator who just died of brain cancer.  Even those who dislike him cannot help but admire and respect him. How better to honor his legacy than to set aside some of the ridiculous posturing of healthcare reform (screaming at town halls? death panels?) and attempt to craft an improvement to our system in a selfless way, personal interestes be damned?

Kennedy was a major force between HIPPA, SCHIP, the ADA, Medicare’s 2003 prescription drug law, and MA’s health reform.

As Kennedy himself said in 1978, “One of the most shameful things about modern America is that in our unbelievably rich land, the quality of health care available to many of our people is unbelievably poor, and the cost is unbelievably high.” (Text of the speech here). He pushed for national health insurance– and this was over thirty years ago. It’s shocking how relevant his speech remains today.

I hope we can find a way to rally and do Kennedy proud. He was a deal-maker and a compromiser with an incredible sense of service. Let’s all be grownups and do him proud.

Lies, damn lies…

An old friend of lawyer’s from her research days has put together a very cool project that takes user-submitted healthcare experiences and pits them head-to-head, one at a time, to compare experiences (costs, wait-times) between universal health care options  (mostly in Canada) and the various situations people (mostly in the US) are in these days.

We like it because one side doesn’t always win, but the collection of anecdotes paint a very clear picture that, as the project’s author, Becca T., points out, gets at something statistics can’t.

Take a look. Maybe even submit a story of your own. But clear your schedule first — it’s addicting.

let’s talk about death!

Not to preach to the choir, but let’s talk about this ridiculous coinage, “death panels.” almost brilliant– who’s in favor of death panels? the problem is, whatever a death panel is, it was never part of the Obama health proposal.

the proposal was to allow doctors to be compensated for time that they spend counseling patients on end-of-life options. there is not, and never was, any type of “panel” involved. so we can dismiss that part. and the death? well, yes, there is death. and there always will be. but discussing options for how to manage it is NOT the same thing as denying care to old people, or allowing people who might get well to die instead.
indulge me a minute– i am not a critically ill person, and i haven’t had a very close family member deteriorate and die in front of me. but i have seen, very much up close and personal, a lot of patients and families go through this. sometimes, patients or their families have made their wishes very clear all along– do everything, including ventilators, IV nutrition, and shot-in-the-dark risky surgeries, for a glimmer of home. that is a choice, and there is no proposal on the table that will eliminate it. I have also seen families whose clearly stated wishes were to withhold aggressive treatment  in the care of terminal illness. This is also a choice, and a difficult one, but often a good one. What’s really at stake here, though, are the people who have not ever stated clear wishes, or perhaps even considered them. These are people who would benefit from a thorough, honest conversation with a medical professional. They need to know that sometimes people put on ventilators never get off, that they may be sedated but still in pain, that they can get pressure sores despite excellent care, that they may have tubes in their rectum and bladder and nose and throat, keeping them alive. Not to talk them out of it, but to make sure that they know what could happen. I have seen a 90 year old person elect to have aggressive surgery only to die in the ICU after 30 minutes of CPR. I have seen an end-stage cancer patient die in a messy, chaotic hospital room in a flurry of strangers while his loved ones waited outside.
we need to create a culture that doesn’t judge people one way or the other for the decisions they make– and we need a culture that encoruages them to make decisions.