Blog Home

Archive for the 'Nurses' Category

The Case For Global Health Diplomacy

April 14th, 2014
by Bill Frist

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

Foreign policy, in general, is a dance—a negotiation of shared goals and identification of conflicts between nations, always with inherent tension. For example, what we want for the government of Afghanistan may not align with their complex political and cultural ideologies.

Read the rest of this entry »

The Health Workforce: A Critical Component Of The Health Care Infrastructure

March 24th, 2014
by Edward Salsberg

Editor’s note: This is the first in a periodic series of Health Affairs Blog posts on health workforce issues by Edward Salsberg. Mr. Salsberg has spent over 30 years studying the health workforce, including nearly 20 years establishing and directing three centers dedicated to workforce data collection, analysis and research. The first center, at the University at Albany, was focused on state health workforce data collection and issues. The second, at the Association of American Medical Colleges, was focused on the physician workforce across the nation. The third, the National Center for Health Workforce Analysis, was authorized by the Affordable Care Act. Mr. Salsberg has now joined the faculty at George Washington University where they are establishing a new Center for Health Workforce Research and Policy.

In the post below, Mr. Salsberg provides an overview of workforce issues. Future posts will discuss more specific health workforce questions and developments.

It could be argued that the health workforce — the people who provide direct patient care, as well as the staff that support caregivers and health care institutions — is the most significant component of the infrastructure of the health care system. Yet as a nation we have invested very little in collecting and analyzing health workforce data or in supporting the necessary research to inform effective public and private decision making. The results of this lack of investment are surpluses and shortages, significant mal-distribution, and less efficient and effective care than would be possible with better intelligence on our workforce needs.

For many health care professions, it takes years to build education and training capacity to increase, supply, or to change curriculum and modify the profession’s skill set. For these professions, we need to not only assess today’s needs but to project our future needs.

What the nation needs is a system to provide data, research findings, and information to thousands of individual stakeholders. This includes individuals considering a health career; colleges, universities and training programs that will educate and prepare them; the health organizations who will employ them; policy makers who need to decide what, if any, programs and policies to support; and the private sector that needs to decide whether to invest in workforce development. The responsibility for assuring an adequate supply and a well prepared health workforce is shared between the public and private sectors at both the national and the state and local level. Regardless of who is making the decisions related to health professions education and training capacity and health professions preparation, accurate and timely data is extremely important to support informed decisions.

Read the rest of this entry »

The Dangers Of Quality Improvement Overload: Insights From The Field

March 7th, 2014

Editor’s note: This post is also co-authored by Ksenia O Gorbenko, Catherine van de Ruit, and Charles Bosk of the University of Pennsylvania.

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients. As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals. We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others. To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change, “you cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change. Front-line providers often bristle at expectations from those they believe have little understanding of the demands of their daily work. Requiring health care providers to improve on all mandated measures at once—in an atmosphere of reduced reimbursements and frequent staff shortages—is a goal that risks burnout, discouragement, and apathy – all signs of initiative fatigue.

Read the rest of this entry »

Examination Of Health Information Technology’s Disappointing Impact Leads Health Affairs 2013 Top-Fifteen List

January 21st, 2014
by Chris Fleming

Years after promises of large gains from health information technology, evidence of the impact of health IT on efficiency and safety remain mixed, Arthur Kellermann and Spencer Jones report in the most-read Health Affairs article of 2013. Achieving health IT’s original promise will require standardized systems that are easier to use and more interoperable, and that provide patients with more control over their health information; providers must re-engineer care systems as well, Kellermann and Jones write. To celebrate the New Year, Health Affairs is making this piece and all the articles on the journal’s 2013 most-read list freely available to all readers for one week.

Second on the 2013 top-fifteen list is a report on 2011 health spending by analysts at the Centers for Medicare and Medicaid Services Office of the Actuary. Every year, Health Affairs publishes a retrospective analysis of National Health Expenditures by the CMS analysts, as well as their health spending projections for the coming decade. In the latest installment in this series, the analysts reported on 2012 health spending in our January 2014 issue and discussed their findings at a Washington DC briefing.

In the third most-read Health Affairs article of 2013, Linda Green and coauthors caution against projecting primary care physician shortages based on simple patient-physician ratios. They argue that increasingly popular strategies — such as the use of teams and nonphysicians, and better information technology and data-sharing — can potentially eliminate projected physician shortages.

The top fifteen articles for 2013 also include studies addressing the impact of states’ opting out of Medicaid expansion, the cost-shifting effects of some workplace wellness programs, and several other topics. The full list appears below. The list is based on online viewing statistics and covers all articles published in 2013.

Read the rest of this entry »

Review Of Accountable Care Organization Landscape Leads 2013 Health Affairs Blog Top Fifteen

January 17th, 2014
by Chris Fleming and Tracy Gnadinger

David Muhlestein’s comprehensive look at the growth of Accountable Care Organizations leads the list of most-read Health Affairs Blog posts for 2013. Muhlestein, Director of Research at Leavitt Partners, followed up this post later in the year with a discussion of why ACO growth was slowing.

Next on the top-fifteen list is a post by Tim Jost on exemptions from the Affordable Care Act’s individual mandate. Several posts in Jost’s extensive “Implementing Health Reform” series made the most-read list. Jost teaches law at Washington and Lee University and is a Health Affairs Contributing Editor.

Number three on our list is a post by Robert York, Kenneth Kaufman, and Mark Grube of Kaufman Hall on what declining inpatient utilization rates tell us about how health care is changing. At number four: an analysis of who will remain uninsured after the Affordable Care Act is implemented by Rachel Nardin, chief of neurology at Cambridge Health Alliance, and coauthors Leah Zallman, Danny McCormick, Steffie Woolhandler, and David Himmelstein,

The full list is below. (You can also review the 2013 most-read list for our sister publication, GrantWatch Blog.)

Read the rest of this entry »

Implementing Health Reform: Looking Ahead After A December Enrollment Jump

December 29th, 2013
by Timothy Jost

Although enrollment for January 1, 2014 began with a whimper in October, 2013, it ended with a bang on December 24, 2013. According to Julie Bataille, Director of CMS’s Office of Communications, had 2 million visits on Monday, December 23, and 880,000 visits on Christmas Eve. The Marketplace call center received more than 250,000 calls on December 23rd and 317,000 calls on the 24th.

After 27,000 enrolled qualified health plans through the federal exchange in October and 110,000 in November, 975,000 enrolled in qualified health plans in December, despite the fact that it was a short month. Enrollment nearly doubled in the last few days of the enrollment period compared to earlier in the month. Hundreds of thousands more have enrolled through the state exchanges as well: about 400,000 in California, more than 188,000 in New York, almost 60,000 in Connecticut. And many more have been signed up for Medicaid.

Some of this heavy traffic is the predicted last minute rush of people who wanted coverage by January 1, 2014, at which time qualified health plan coverage with premium tax credits begins. But it is also due to the fact that the websites are at last up and running. It is now finally possible for consumers to sign up relatively quickly most of the time and to find the coverage they are entitled to. Now the massive planned enrollment efforts that have been on hold for months as the websites struggled can begin. Between now and March 31 we will see a continued surge as American’s uninsured get the coverage long denied them.

Read the rest of this entry »

A Policy Dialogue On Connected Health

December 19th, 2013
by Janet Marchibroda

Editor’s note: In addition to Janet Marchibroda (photo and linked bio above), this post was coauthored by Chris Fleming, Health Affairs Blog Editor.

What is telehealth or “connected health”? What is driving the use of connected health and what are its benefits? To achieve its full potential, what key challenges must be overcome? What are the central policy issues that must be addressed?

These are some of the questions explored by a group of leaders representing providers, payers, research and philanthropic organizations, and technology companies (listed at the end of this post), convened by Health Affairs and the Bipartisan Policy Center (BPC) last month. The session was organized partly to prepare for an upcoming Health Affairs thematic issue on connected health, to which former Senate Majority Leader and BPC Health Project Co-Chair Bill Frist—who chaired the discussion—will contribute.

Read the rest of this entry »

Health Affairs Briefing Reminder And Twitter Hashtag: Redesigning The Health Care Workforce

November 12th, 2013
by Chris Fleming

Amid constant debate over health delivery system reforms, insufficient attention has been given to the needs of the future US health care workforce in light of rapid changes. The November 2013 thematic issue of Health Affairs,”Redesigning The Health Care Workforce,” takes on the issue of how to create the optimal health care workforce for the 21st century.

Please join Health Affairs Founding Editor John Iglehart on Thursday, November 14, at the W Hotel in Washington, DC, for a briefing that features authors from the issue. In addition, Health Affairs is pleased to collaborate with Academic Medicine, the journal of the Association of American Medical Colleges, and its Editor-in-Chief David Sklar to feature several authors from Academic Medicine’s forthcoming thematic issue on training the future health care workforce.

The program will include a keynote address by Princeton Professor Uwe Reinhardt, and remarks by Representatives Allyson Schwartz (D-PA), and Aaron Schock (R-IL).

WHEN:…….Thursday, November 14, 2013
……………..8:30 a.m. – 12:45 p.m.

WHERE:…..W Hotel Washington
……………..515 15th Street NW (Metro Center), Washington, DC


Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_Workforce.

Read the rest of this entry »

New Health Affairs: Issues Facing The Health Care Workforce

November 4th, 2013
by Chris Fleming

The November issue of Health Affairs, released today, discusses how the US health care workforce can respond to the Affordable Care Act’s expanded coverage and new models of care, as well as to an aging population. Some notable studies in the issue are described below, and the issue will be discussed at a Washington DC briefing on Thursday, November 14.

The aging population’s implications for specialty care and primary care.A study by Timothy Dall of IHS Inc. and coauthors forecasts future demand for health care services and providers based on projected demographics and other predictive changes, including the expected effects of expanded health insurance coverage under the Affordable Care Act. The authors project that demand for adult primary care services will grow by roughly 14 percent between 2013 and 2015, and demand for certain specialty care services will grow even faster at a high of 31 percent growth for vascular surgery. Cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent) round out the list of the top five.

Dall and coauthors caution that failure to address the inadequate number and inappropriate mix of specialty care providers will further contribute to long wait times, reduce access to care, and decrease patients’ quality of life.

Diabetes patients in patient-centered medical homes are well served by nonphysicians and physicians alike. In this first study to compare the effectiveness of physician assistants (PA) and nurse practitioners (NP) roles to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher.

Read the rest of this entry »

Health Affairs And Academic Medicine Briefing: Redesigning The Health Care Workforce

October 18th, 2013
by Chris Fleming

Amid constant debate over health delivery system reforms, insufficient attention has been given to the needs of the future US health care workforce in light of rapid changes. The November 2013 thematic issue of Health Affairs,”Redesigning The Health Care Workforce,” takes on the issue of how to create the optimal health care workforce for the 21st century.

Please join Health Affairs Founding Editor John Iglehart on Thursday, November 14, at the W Hotel in Washington, DC, for a briefing that features authors from the issue. In addition, Health Affairs is pleased to collaborate with Academic Medicine, the journal of the Association of American Medical Colleges, and its Editor-in-Chief David Sklar to feature several authors from Academic Medicine’s forthcoming thematic issue on training the future health care workforce.

The program will include a keynote address by Princeton Professor Uwe Reinhardt, and remarks by Representatives Allyson Schwartz (D-PA), and Aaron Schock (R-IL).

WHEN:…….Thursday, November 14, 2013
……………..8:30 a.m. – 12:45 p.m.

WHERE:…..W Hotel Washington
……………..515 15th Street NW (Metro Center), Washington, DC


Read the rest of this entry »

October Health Affairs Issue: Economic Trends And Quality Trade-Offs

October 7th, 2013
by Chris Fleming

Health Affairs’ October issue, released today, evaluates the successes, the costs, and the quality trade-offs of improving physical and mental health in the United States. As Founding Editor John Iglehart says in his October letter, “Medical advances…have extended life expectancy and reduced the prevalence of diseases that stalk modern society. Paradoxically, though, for every success, an equally difficult challenge remains.” Also, with multiple shootings and related incidents fresh in our collective memories, the issue contains a discussion about the cost barriers to mental health care.

Some of the notable articles in the issue are discussed below. The Goldman and Herrera articles will be discussed at a National Press Club briefing tomorrow, Thursday October 10, from 8:30-11:00 AM. The briefing is supported by the Alliance for Aging Research, MetLife Foundation, Aetna Inc., and the National Pharmaceutical Council.

Barriers to Mental Health Care. As American society knows all too well, many people with mental illness fail to seek treatment. Kathleen Rowan and coauthors at the University of Minnesota analyzed data from the Integrated Health Interview Series of working-age adults who were interviewed between 1999 and 2010. They found a significant increase in the percentage of the population classified as having moderate mental health problems, from 3.7 percent in 1999 to 5.1 percent by 2010. There was also a significant increase in the proportion of this group who had public health coverage (from 25.9 percent to 34.8 percent) and a decline in those with private coverage (from 50.2 percent to 39.8 percent.) The authors point out that public insurance typically provides coverage with limited to no out-of-pocket costs and fewer treatment limits than private coverage. Although the authors see the Affordable Care Act as an important opportunity to expand health insurance coverage to people with mental health disorders, they caution that those now eligible to purchase private insurance might still encounter financial hurdles to accessing care.

Read the rest of this entry »

Doctors And The Bully(ing) Pulpit

August 29th, 2013

For busy and opinionated physicians, online comments are both catharsis and a form of self-expression. After all, doctors are in the thick of it. We see how policies affect our patients. We know how politics affect our profession. While traditional editorials require time, editing, and an editor’s decision to publish the piece, online comments provide an easy and instantaneous way for even the most overworked and harried physicians to vent publicly. Seeing one’s opinion stream smoothly from brain to fingertips to computer screen feels good.

It is miraculously simple, but it can be problematic. Amid the stresses of patient care in an increasingly complex health care system, the temptation to unleash anger online can be hard to resist. Making sure our voices resonate with equanimity, with professionalism, with decorum, respect, and tolerance takes work.

In some online discussions, the voices have become ugly.

Read the rest of this entry »

Analysis Of Post-ACA Uninsured Leads Health Affairs Blog June Top Ten

July 11th, 2013
by Chris Fleming

Who will be left uninsured under the Affordable Care Act? That’s the question addressed by Rachel Nardin and coauthors in the most-read Health Affairs Blog post for June.

Next on last month’s top-ten list: Joanne Pohl and coauthors’ look at the relative numbers of physicians and nurse practitioners choosing primary care specialties. The list also features Christine Cassel’s discussion of her priorities as she assumes the leadership of the National Quality Forum, and Robert Berenson’s proposals for improving quality measurement. Additionally, the top ten includes three posts in Tim Jost’s series on implementing the Affordable Care Act, as well as posts on lessons from early ACA Medicaid expansions, the growth of accountable care organizations, and health information technology for the accountable care era.

The full list appears below:

Read the rest of this entry »

Federal Incentives Drove E-Prescribing Increase

July 10th, 2013
by Max Sow

There has been an ongoing debate regarding the efficacy of financial incentives in convincing physicians to move into the digital age, trading in their paper-based systems for electronic health records. Thanks to new research, we can now point toward firm evidence that shows financial ‘carrots’ make a tremendous difference in bringing 21st century modernization to the doctor’s office.

A study published in this month’s edition of Health Affairs shows that the practice of e-prescribing among office-based prescribers including physicians, physician assistants, and prescribing nurse practitioners increased substantially after Congress authorized financial incentives for the practice in 2008. (See Exhibit below.) This is the first research study that analyzes actual prescribing data — from the Surescripts data network, which handles over 90 percent of the nation’s e-prescribing traffic to community pharmacies — to paint a clear picture of how doctors can be motivated to change how they manage information within their practices.

Read the rest of this entry »

New Health Affairs Issue Examines The States And Medicaid Expansion

July 8th, 2013
by Chris Fleming

With nearly half the states planning to expand Medicaid eligibility in 2014, Health AffairsJuly issue includes several articles that reflect, in the words of founding editor John Iglehart, “various cross currents of federalism.”

Medicaid, as seen in this issue, says Iglehart, “is not the uniform national health program envisioned by Democrats, but one that reflects the heterogeneity of the United States and the Republican imperative for decentralized policy making.”

This variety issue also addresses health care workforce concerns, an increase in e-prescribing by providers responding to a federal incentive program, and the lessons for state legislatures when school immunization exemption laws are relaxed.

Selected content in the issue is supported by a grant from Blue Shield of California Foundation.

Noteworthy articles include:

Existing Medicaid Beneficiaries May Be Denied Preventative Care. The Affordable Care Act promotes access to preventive care as outlined by the US Preventive Services Task Force. However, because the law treats new and existing Medicaid beneficiaries differently, the two groups may not be eligible for the same preventive services. A study by Sara Wilensky and Elizabeth Gray of the George Washington University reviewed Medicaid policies across the country between June and November 2012. They found that most states do not offer existing beneficiaries all the services rated “A” and “B” by the US Preventive Services. In contrast, states expanding their Medicaid eligibility must offer these benefits to new participants without cost sharing.

Read the rest of this entry »

The Latest Data On Primary Care Nurse Practitioners And Physicians: Can We Afford To Waste Our Workforce?

June 18th, 2013

If primary care is the foundation of the evolving health care system in this country, and if access to primary care for all is the goal, then nurse practitioners will be increasingly crucial to achieving these aims. Let’s face it, in our current system, there just aren’t enough primary care providers to meet the nation’s need while containing costs and focusing on quality outcomes. With an estimated 30 million more people who will be covered and require access to full primary care based on the Patient Protection Affordable Care Act (ACA) numbers, we will need additional providers functioning to their fullest preparation.

2013 National Resident Matching Program Data

The 2013 National Resident Matching Program (NRMP) released in March is not good news for primary care. Although matching rates were up overall, the primary care numbers are still very low given the national need. According to the American Academy of Family Physicians (AAFP, 2013), only an additional 92 U.S. graduate medical students were matched to primary care specialties compared to a year ago. That translates to 39 more family medicine resident positions filled, 14 more internal medicine positions, 3 more pediatric and 36 pediatric/internal medicine positions filled, compared to 2012. The bottom line is 1,916 U.S. medical school grads were matched to primary care residency programs, with a total of 3,715 primary care matches when international graduates are included (AAFP,2013; NRMP, 2013) .

Primary Care Nurse Practitioner 2012 Graduation Rates

At the same time, the 2012 nurse practitioner (NP) graduation rates announced recently by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties (AACN/NONPF 2013) showed a continued increase in primary care. Primary care NP graduates include those prepared as pediatric, family, adult, gerontological, adult/gerontological, and women’s health NPs. They numbered 11,764 in 2012 compared to 9,708 in 2011, an increase of 18.6 percent or 2,228 NPs.

Read the rest of this entry »

Saving Grady: Reflections On Kate Neuhausen’s Narrative Matters Essay

June 10th, 2013
by Arthur Kellermann

In the past 12 years, several of our nation’s most storied public hospitals have closed, including DC General (2001), New Orleans’s Charity Hospital (2005), and Martin Luther King, Jr. hospital in Los Angeles (2007). When Atlanta’s Grady Memorial Hospital was featured on the front page of The New York Times on Jan 8, 2008, it was widely assumed it would be the next to go. However, at its darkest hour, Grady received help from an unexpected quarter.

In the June issue of Health Affairs, a young physician, Dr. Kate Neuhausen, describes how she and other leaders of a little-known student organization mobilized hundreds of health professions students from around the state of Georgia to join the fight for Grady’s survival. It is difficult to overstate how perilous the hospital’s situation was at the time. Because Grady provides such a disproportionate share of uncompensated care in the state of Georgia, it would have been impossible for metro Atlanta’s hospitals and private health care providers to absorb the sudden loss of more than 900 inpatient beds; the highly specialized trauma, burn and psychiatric services Grady provides; or the displacement of tens of thousands of inpatient days and hundreds of thousands of outpatient visits. The resulting social, medical and financial upheaval would have sent shockwaves throughout the region—the economic engine for the state and a vital financial, commercial and transportation hub for the Southeastern United States.

Fortunately, Atlanta’s business community and philanthropies grasped the gravity of the situation. So did Georgia’s governor, the leaders of Georgia’s General Assembly, the Commissioners of Fulton and DeKalb Counties, the appointed members of the Hospital Authority that ran Grady, the leadership of Emory University and Morehouse School of Medicine (which provides the hospital’s medical staff), Grady’s employees, and its patients. But each group had a different concept of what needed to be done. Urban-rural, partisan and racial politics came into play. Time was running out.

Read the rest of this entry »

New Health Affairs: Medicaid Expansion And Vulnerable Populations

June 3rd, 2013
by Chris Fleming

Health Affairs’ June issue, released today, examines the challenges and benefits for states deciding whether to embrace the law’s Medicaid expansion or opt out. Several studies in the issue also look at population disparities in health care, especially during the recent recession. Selected content in the issue is supported by grants from the New York State Health Foundation and Blue Shield of California Foundation.

Medicaid Opt-out: What Cost to States? Last summer’s US Supreme Court ruling about the Affordable Care Act allows states to decline the law’s Medicaid expansion provision, something fourteen governors have chosen to do. Carter Price and Christine Eibner, both of the RAND Corporation, analyzed how this would affect coverage and spending. They estimate that in these states 3.6 million fewer people would be insured, and federal transfer payments to those states could fall by $8.4 billion. According to the authors, those states will be spending some $1 billion in the short term on uncompensated care. They conclude that in terms of coverage, costs, and federal payments, states and their citizens would fare better by expanding Medicaid coverage.

In a related article, Thomas DeLeire of the University of Wisconsin and coauthors looked at Wisconsin’s four-year-old public insurance program—the BadgerCare Plus Core Plan—for childless adults with incomes of up to 200 percent of the federal poverty level. The authors compared administrative claims data from the first year of the program with the previous year. They found that program participants who were automatically enrolled in the program (and who tended to have very low incomes) showed a 29 percent increase in outpatient visits; a 46 percent increase in emergency department use; and a 59 percent decrease in hospitalizations, including a 46 percent decline for preventable hospitalizations. These results demonstrate that expanding public insurance coverage will increase access to outpatient care and reduce hospitalizations, but the authors caution that unless consumers have sufficient access to primary care, coverage expansions may also increase emergency department visits, shrinking any corresponding cost savings.

Read the rest of this entry »

Where Was The Leadership? The Questions Raised By Jonathan Welch’s Narrative Matters Essay

May 21st, 2013
by S. Allan Adelman and Lewis Morris

Dr. Jonathan Welch’s Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.

While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.

As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated. Those questions, which the leaders in all hospitals should consider, include the following:

Read the rest of this entry »

Practice Redesign Isn’t Going To Erase The Primary Care Shortage

March 28th, 2013
by Jeff Goldsmith

Most experts agree that primary care needs to be re-invented. There are a lot of promising ingredients of practice redesign: better scheduling, electronic medical records with patient portals, redesigned clinician workflow, and work sharing. Linda Green’s intriguing article in the January Health Affairs simulates a strategic combination of these changes and argues if they all happened at once, we would have no primary care physician shortage.

Even if we make much more effective use of clinical time and energy, however, Green’s formula isn’t going to get us far enough fast enough. The baby boom generation of physicians is fast nearing its “sell by” date. In 2010, one quarter of the 242,000 primary care physicians in the US were 56 or older. One in six general internists left their practices in mid-career. Many more hardworking clinicians delayed retirement due to the 2008 financial collapse.

Few manpower specialists have noted the cohort effect likely to manifest itself shortly. A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years. We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks. During this same period, we’ll be adding 3 million new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform. “Train wreck” is the right descriptor of the emerging primary care supply situation.

Read the rest of this entry »

Click here to email us a new post.