Several weeks ago, the New York Times ran an article detailing a program started by Medicare to hire “mystery shoppers to call the offices of primary care physicians to see if they were talking new patients or patients, how long waits are, and how they respond to patients who have private insurance or patients with public insurance like “Medicaid.” Physicians, not surprisingly, have responded with outrage, and CMS quickly abandoned the program.http://www.nytimes.com/2011/06/27/health/policy/27docs.html?pagewanted=all
The program was started to help tfigure out how to deal with the primary care physician shortage and to make sure that the 30 million new patients covered by the soon to be implemented (hopefully) PPACA (Patient Protection and Affordable Care Act), which depends on primary care, will actually be able to find a primary care physician in a country with a notorious shortage of people going into primary care.
I have no problem with the government trying to collect data about physician willingness or ability to take new patients or on whether they discriminate against people on Medicare or Medicaid. Since the government — and that means us the taxpayers — are a huge funder of graduate medical education, I’ve always wondered why we’ve allowed physicians of any sort to refuse to accept patients with public rather than private insurance. But all of this begs the fundamental question. If we want more primary care physicians, why don’t we just get over it and pay their medical school tuition, with the obligation that they will have to pay back the cost of their education if they don’t remain in primary care for a significant number of years (and I don’t mean two years in the military or working on an Indian reservation, both of which are certainly worthy endeavors but hardly pay back the investment we, the taxpayers, have made in them.
Consider the math — which I would like to actually check on. The average graduating doc, has $100,000 or more in medical school debt.http://www.studentdoc.com/medical-school-loans.html. So if the government shelled out $100,000 for their education, this would be like giving them a $100,000, compounded with interest over a period of years, or wisely invested (even today) the return on this investment would be significant. If education for PCPs was free or at very low cost, maybe that would go a ways to ending the catastrophic shortage of primary care doctors.
The patient was a 70-year-old woman who’d been struggling with two different types of cancers for at least eight years. For most of them, she’d been on dialysis, first every three days, and by the time I met her, every other day. Her husband had been taking excellent care of her through this long ordeal. By the time we met, a few months before she died, it was clear that she was in the very last stages of her illness. Anyone who looked at her could see that this was a dying woman and that she had very little time left. A reasonable and compassionate physician would have suggested that she be admitted to hospice care to make her comfortable and give her better quality of life during her last days. Unfortunately, it does not seem that she had this kind of physician. Instead, a cardiologist had recommended open heart surgery to fix her heart problems and her husband, who apparently was in a let’s do everything we can mode to the bitter end, agreed. Although the woman told friends she was ready to go, she did not go peacefully. This frail woman whose kidneys had already failed, whose heart was failing and who could barely make it across the room was subjected to an operation she should never have had, and that no physician in his or her right mind should have ever recommended or agreed to perform. And what happened. She spent most of her last days on earth in an ICU, tethered to a ventilator until she finally was allowed to die.
When I heard the story of this woman’s final days, I was horrified but sadly not shocked. These stories abound. I hear them all the time. I have seen physicians examine patients like this and recommend aggressive, invasive, highly toxic procedures that the patient will never survive. It’s a though they are so focused on the patients’ failing organs that they simply can’t see the people in whom those organs reside. Sometimes the physician wants to know what’s up, to definitively determine what’s going on. (The patient is dying, you feel like saying, that’s what’s going on). Sometimes they claim they are responding to pressure from a family member in denial. Sometimes the doctor can’t let go, or feels like the patient’s death is somehow something that’s happening to the doctor rather than the patient (the interpretation is that the doctor has failed, not that we all have to die sometime). Our cultural obsession with miracle cures and last ditch efforts complicates matters. So does our definition of the role of the doctor as curer rather than healer. And, finally, the way doctors and hospitals are paid makes matters much worse. Doctors are not paid to help patients deal with death when it’s inevitable, they are paid to use the hammer, which as the saying go, turns the patient into a nail, pounded deeper and deeper into the wood of torturous medical treatments even when everyone really knows how futile they really are. Each operation a physician performs is more thousands of dollars in the bank. Each patient who doesn’t survive the operation, but also spends their last days in an ICU is more money accruing to a hospital. Hospitals don’t get rich on hospice but they do get rich — or at least get by — on unnecessary operations that end like this one, with days spent on a hospital ward. Because of the payment system and its perverse incentives good doctors and good hospitals do bad things to good people who also don’t understand their options and are not helped to do so. And of course, endings like this are what are driving health care costs through the roof. To be tortured to death, Medicare –not to mention the patient’s family and any other supplemental insurers she had– spent hundreds of thousands. And for what?
As I listened to the story of this woman’s end — after hearing countless others like it — I have come to the conclusion that in the current environment hospitals and doctors seem unable to stop themselves from delivering torturous treatments to dying patients. In spite of every effort to encourage patients to use hospice care — on the part of hospice practitioners, not Medicare or insurance companies — hospice remains poorly understood and vastly underutilized. This woman was put on hospice three days before she died, rather than three months or years. (I know, hospice only lasts for six months, but people can go into and out of hospice if they survive longer). Anytime anyone mentions the idea of paying doctors to have serious and systematic conversations with patients about end of life care, Republicans cry “death panels.” Apparently torturing people to death is just fine with them, but allowing people to die in comfort and with dignity is not. So I have a proposal. Since Republicans adore helping the rich get richer why not just pay doctors not to do the unnecessary operation. After all, we pay farmers not to plant their fields, why not pay doctors not to perform operations that will torture patients to death. I am not quite sure how all this could work out, but I have a few ideas. The oncologist or other physician sends a patient to another specialist to figure out just how bad things are and the specialist would like to recommend this or that procedure, operation, whatever. It is clear that the patient has hardly any chance of surviving. So a panel of experts makes that determination, tells the physician they will get paid not to do the operation, and someone other than the physician steps in and explains how the patient can be made comfortable during their last days. Maybe, some of the money going to the physician could be used to finance excellent end of life care. Instead of a finders’ fee it would be like an ender’s fee. The patient would be spared a horrible death, the doc would get the money, and the system would save a ton because the doctor’s fee is only a tiny portion of the incredible costs that result from these kinds of failed treatments. Like I said, its the health care version of current agricultural policy, where we pay farmers to save the integrity of their land. In this case, we’re saving the patient from a terrible death and saving money at the same time.
Of course, I know this will never happen and shouldn’t. But what should is not only hospice care but effective primary care. When I hear a story like this what I want to know is where was this woman’s primary care doctor? Sadly, I can guess at the answer. He or she had probably been sidelined years ago when the woman went to an oncologist who became the de facto PCP. Although she had what was clearly going to be a terminal illness (two of them in fact), the PCP probably had little contact with the patient. The oncologist and myriad specialists — in this case nephrologists, cardiologists, and who knows who else — took over. Without an effective primary care system –not to mention palliative care system–she was at the mercy of the let’s do everything folks without a countervailing perspective and voice. Indeed her ending was practically pre-determined. I am, of course, outraged by this ending. It should never have happened. In many other countries, ones with sane health care systems, she would probably have had a much better ending. There is no reason why patients cannot have such endings here. So maybe my idea isn’t so crazy after all. Maybe its only the logical conclusion of the path we have taken in a system in which health care is just part of a system designed for profit not patient care.
This was posted on the Boston Globe Blog. Thought people might be interested.
All over the world, the month of May is set aside for a celebration of nurses. But this May, the news for nurses is not what Florence Nightingale would have wished it to be. It’s not just that nurses have had to struggle to maintain safe staffing ratios at hospitals like Tufts New England Medical Center in Boston and Saint Vincent’s in Worceter. The bad news comes in yet another study – this time from Britain but funded by the US National Institute of Aging – documenting the impact of long work schedules on the human brain. The study, entitled Change in Sleep Duration and Cognitive Function: Findings from the Whitehall II Study, which appeared in the May issue of the research Journal Sleep, should make all nurses reconsider their commitment to the twelve plus hour day.
For centuries, workers have struggled to cut the hours they work each day. In Europe,and the United Kingdom most nurses work a 37 hour week. In this country and in Canada, nurses increasingly work twelve hour shifts, usually back to back, sometimes for up to four or five days in a row. And very few nurses get out of the hospital after only 12 hours. Studies have documented that nurses routinely work 13 or more hours – and that’s without either voluntary or mandatory overtime. Add a commute to the RN work schedule, plus duties at home, and nurses simply don’t get enough sleep. Nurse researcher Ann Rogers has reported that “when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week.” .http://www.protectmasspatients.org/docs/Rogers.pdf
Researchers Alison Trinkoff and Jeanne Geiger Brown, at the University of Maryland School of Nursing have documented that nurses who work 12 plus hour shifts aren’t getting enough sleep. Many nurses, these researchers report work such long shifts that they simply don’t get the “opportunity to sleep” the seven or eight hours adults require for their health and well-being. In a study of nurses’ sleep habits, Geiger- Brown found that 58% averaged only 5.5 hours of sleep. When they work three or four 12 plus hour days, they are also unable to easily reestablish a “consistent sleep schedule.”
When the voluntary abandonment of the opportunity to sleep is compounded with overtime – either mandatory or voluntary – things become even more complicated for nurses and patients. Sleep studies document that errors go up. But the impact of lack of sleep isn’t only on patients. It’s on nurses themselves.
Nurses who work such long hours have more back, neck and shoulder injuries, http://www.ncbi.nlm.nih.gov/pubmed/12539799, suffer from more depression and are also at risk for other health problems. A 2007 study has documented that lack of adequate sleep puts people at twice the risk for cardiovascular problems and early death. http://www.reuters.com/article/2007/09/24/us-sleep-death-idUSL2462796020070924
And now we have this new study that tells us that people who don’t get enough sleep suffer from greater brain aging. If you don’t get your seven or eight hours, you can suffer as much as a four to seven year increase in age. Even before this study came out, Geiger Brown and her colleagues asked the question, “Is It Time to Pull the Plug on 12-Hour Shifts?” http://journals.lww.com/jonajournal/Abstract/2010/03000/
My reccomendation? Before the month is over RNs, should take a visit to an exhibit at the American Textile History Museum in Lowell, Massachusetts. The museum is a monument to American fabrics and to the workers whose sometimes backbreaking labor produced them. One glass case exhibits a letter written to a mill official in 1867 and signed by dozens of mill workers. It reads as follows:
“To the treasurer of the Appleton Corporation. We, the undersigned operatives in your employ, believing that 11 hours a day is inimical to our best moral & physical interests, would most earnestly request you to reduce the term of labor from 11 to 10 hours per day & your petitioners as in duty bound will ever pray.”[i] When you read this and combine it with all the documentary evidence, the answer to Geiger-Brown’s question ought to be “YES”!!!
This is an op-ed I did for Nurses’ Week that ran in newspapers across the country. Perhaps some of you have seen it. I’d love to hear your experiences about getting jobs as new grads, or even veteran nurses.
Nursing shortages? They’re supposed to be yesterday’s news. In a bad economy, nurses whose husbands or wives have lost their jobs are hanging on to theirs’, with retirement savings wiped out, nurses are delaying their own. According to American hospitals, all this means that we have plenty of nurses at the bedside. Remember those alarms bells that rang at the turn of the new century, warning of catastrophic nursing shortages? Well, they’ve all have been turned off. Maybe we will short a couple hundred thousand RNs by 2020, but for now –not to worry.
As we celebrate this year’s Nurses’ Week, we should ignore those convenient bromides and begin to worry – big time.
First of all, the nursing shortage that has been declared a thing of the past is very much present in hospitals today. To cut their budgets, most hospitals are not hiring enough nurses to adequately care for the kind of intensely sick patients that fill hospital beds today. These are patients who are receiving invasive procedures and toxic treatment – patients who need intense monitoring by nurses. They may not be getting the attention they need because nurses are assigned so many patients — – say six or eight on day shift or nine or maybe even more at night rather than four or five. Even though hospitals may record no RN vacancies, at these kind of staffing levels, patients are still experiencing a shortage of necessary nursing care.
What’s more, hospital hiring policies are plugging the pipelines that produce new expert nurses. To put it simply, very few hospitals are hiring newly minted RNs today. New graduates from nursing schools all over the country are reporting difficulty finding jobs. Nurse managers tell me their hospitals just aren’t hiring new grads. “I’m only allowed to hire experienced nurses, which I am having a hard time finding. I can’t hire any new nurses,” a nurse manager at a teaching hospital complained.
This, of course, creates a patient care catch- 22. If hospitals won’t hire new graduates, the new grads can’t get experience. If they can’t get experience, then whom will hospitals hire when experienced nurses leave their positions? And since the average age of the RN is 47, a lot of RNs will be retiring in a few years, no matter how bad the economy is.
To make matters worse, nurse managers tell me that hospitals are not expeditiously filling positions left vacant when an RN quits or retires. As one nurse manager at a major hospital in the Northeast told me, “They won’t allow us to fill a position once we know someone is leaving. We can only fill it when they’ve left. Then it can take up to a year to go through the search and paper work to get someone in that position. So we’re working short for an entire year.”
For working nurses all this will sound terribly familiar. And just as happened during the 1990s, these practices are bound to produce another catastrophic nursing shortage in only a few years. The fundamental problem is that politicians, policy makers and health care administrators don’t seem to understand that it takes years – at least eight to ten –to produce an expert nurse. Hospitals seem to think you can turn on the spigot and get hot and cold running nurses. Then, when your budget gets tight, you can turn it off and, when its convenient, turn it on again. That’s the kind of magical thinking that got us into trouble in the 1990s. Unless hospitals are forced to change their ways, as baby boomers like myself get older and sicker, there may not be anyone there to answer the buzzer.
This piece I just did just came out in the Boston Globe Web edition. Read it, but instead of weeping, people should be writing to the President and to Senators to support Berwick’s candidacy.
Given the broader Republican attacks on Medicare and Medicaid, the confirmation of the administrator for the Centers for Medicare and Medicaid Services (CMS) may not seem like a big deal. But as the Senate decides between two candidates — Dr. Donald Berwick, President Obama’s recess appointment for the post, and Marilyn B. Tavenner, the current CMS deputy administrator — the stakes are quite high. At issue is how the most important government health care programs will be run and how closely its administrator will be tied to the very health care companies CMS regulates.
The professional histories of Berwick and Tavenner could not be more different. Berwick is a Harvard trained pediatrician and co-founder of the Cambridge-based Institute for Healthcare Improvement, the nation’s premiere patient safety and quality improvement organization. Although the institute tends to promote its agenda among the hospital industry’s top leaders, it has focused on teamwork in health care and nursing initiatives like the Transforming Care at the Bedside project. It has also helped the hospital industry implement “best practice” initiatives that help protect patients from harm. At CMS, Berwick has backed programs that link hospital pay to patient satisfaction, streamlined operations to reduce bureaucratic hassles, and argued that physicians should have discussions with patients about end-of-life care.
Berwick has wide support from the American Medical Association, as well as from many in the hospital industry and corporate America. But, from the perspective of Tea Party Republicans, other conservatives, and some Democrats, he has several fatal flaws. Berwick has acknowledged that all health care systems ration care and has argued for transparency and accountability as we decide what we can afford. When working for greater global patient safety, he has argued that we need to learn from other health care systems, like the United Kingdom’s. Indeed, he’s even expressed these views in print, in (Heaven help us!) foreign medical journals like the British Medical Journal. To some, this constitutes proof positive that the relatively mainstream pediatrician favors “death panels” for the old and infirm and major cuts in services for the rest of us.
In July of 2010, President Obama used a recess appointment to place Berwick at the head of the CMS. With this appointment, the president seemed to recognize that the health care law he’d promoted — the Patient Protection and Affordable Care Act — promised Americans more than access to health insurance. Now the president and some Congressional Democrats seem about to buckle under conservative pressure by abandoning Berwick and supporting Tavenner, a nurse who has spent 25 years working for Health Care Corporation of America and the nation’s largest for-profit hospital system. Ordinarily I’d rejoice at the idea of seeing an RN at the helm of CMS. But this particular RN has worked for a for-profit hospital system that, as research studies report, spends 11 percent less on patient care — mostly by stinting on nursing care.
While Tavenner worked for HCA, the company was busily enhancing its profit margin by defrauding the Medicare, Medicaid, and TRICARE systems. Terry Leap’s new book, “Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What To Do About It,” details HCA’s sorry history. In 2000, for example, HCA paid fines of $840 million for improperly billing the government and in 2003 HCA had to fork over another $631 million.
Although Tavenner may not have been personally involved in these scandals, it hardly seems wise to put her in charge of the government system her company helped defraud. The job of CMS administrator is to protect patient safety and quality, something that federal officials with close ties to the industries they are supposedly regulating and monitoring seem to have a hard time doing.
The fact that Berwick’s candidacy is now in jeopardy has prompted an Internet and letter writing campaign that includes some of the most prominent patient safety advocates and organizations in the country, including physicians and patient safety gurus Lucian Leape and Robert Wachter.
As legislators judge the qualifications of candidates for one of the top health care jobs in the country, they shouldn’t be sifting through medical journals to find out of context comments about health care systems in other countries. They should instead be asking what candidates for this high office have done to assure patient safety and quality services right here at home. In any contest between Tavenner and Berwick, Berwick’s decades long record of initiating some of the most important patient safety campaigns in the country should make him the clear winner. If someone with Berwick’s record and stature cannot win the nomination, perhaps we should simply just take the two P’s — patient and protection — out of the PPACA.