Caring for Communities
Providers bring good medicine to small-town America
Visit www.nhsc.hrsa.gov. to learn more about the National Health Service
Corps.
by Diana West
Providers wanted
About 50 million Americans live in areas without access to basic medical
and dental care, according to the National Health Service Corps (NHSC),
which Congress established in 1970 to recruit health care professionals
to medically underserved areas.
To remedy this disparity, the NHSC provides scholarships and forgives
loans to primary care physicians, physician assistants, nurse practitioners,
dentists, certified midwives, mental health professionals and dental hygienists
in exchange for at least two years of work in those settings. About 4,000
recruits work in the field at any given time, logging 4 million to 5 million
patient visits annually. Once their obligation is fulfilled, more than
half opt to stay on or serve in similar areas, says Rick Smith, NHSC's
head of clinician recruitment.
Patrick Armstrong, 52, is a perfect example. Since graduating at age
35 from the University of Iowa's Carver College of Medicine, he has worked
as a physician assistant in rural Montana, beginning at Phillips County
Hospital in Malta (pop. 2,120). "We wanted to raise our family in a small
town," says Armstrong of he and his wife, Kathy, who have three children.
Intermittently, he was the town's only medical provider, giving him
broad experience and long days and weeks on the job. After nine years,
Armstrong moved 90 miles west to Chinook (pop. 1,386), where he works with
a pediatrician and physician assistant at Sweet Medical Center. Once a
month, he travels 150 miles to Glasgow, Mont., to work a long weekend at
Frances Mahon Deaconess Hospital.
"The rewards," Armstrong says, "are the gratitude of patients. They
tell my children, 'Your father saved my life.'"
High-minded mission
A desire to serve low-income, uninsured and underinsured people drew
Margaret Flinter to join the 10-member staff of the Community Health Center
in Middletown, Conn. (pop. 43,167), after graduating in 1980 as a nurse
practitioner from Yale School of Nursing.
"The center had a real sense of drive and passion for creating a community-oriented
primary care center," says Flinter, 56.
That mission has kept Flinter in Middletown through her career as she
helped the center grow from a single location to 12 sites in central and
southeastern Connecticut.
Nurse practitioners perform many of the same functions as a doctor and
are supervised by a physician.
"The challenge is understanding the stress, difficulties and economics
that patients face," she says. "The reward is the satisfaction of having
made a difference in their life and health."
IMPROVING PATIENT CARE
Comparing Costs and Quality of Care at Retail Clinics With That of
Other Medical Settings for 3 Common Illnesses
Ateev Mehrotra, MD; Hangsheng Liu, PhD; John L. Adams, PhD; Margaret
C. Wang, PhD; Judith R. Lave, PhD;N. Marcus Thygeson, MD; Leif I. Solberg,
MD; and Elizabeth A. McGlynn, PhD
1 September 2009 | Volume 151 Issue 5 | Pages 321-328
Background: Retail clinics are an increasingly popular source for medical
care. Concerns have been raised about the effect of these clinics on the
cost, quality, and delivery of preventive care.
Objective: To compare the care received at retail clinics for 3 acute
conditions with that received at other care settings.
Design: Claims data from 2005 and 2006 from the health plan were aggregated
into care episodes (units that included initial and follow-up visits, pharmaceuticals,
and ancillary tests). After 2100 episodes (700 each) were identified in
which otitis media, pharyngitis, and urinary tract infection (UTI) were
treated first in retail clinics, these episodes were matched with other
episodes in which these illnesses were treated first in physician offices,
urgent care centers, or emergency departments.
Setting: Enrollees of a large Minnesota health plan.
Patients: Enrollees who received care for otitis media, pharyngitis,
or UTI.
Measurements: Costs per episode, performance on 14 quality indicators,
and receipt of 7 preventive care services at the initial appointment or
subsequent 3 months.
Results: Overall costs of care for episodes initiated at retail clinics
were substantially lower than those of matched episodes initiated at physician
offices, urgent care centers, and emergency departments ($110 vs. $166,
$156, and $570, respectively; P < 0.001 for each comparison). Prescription
costs were similar in retail clinics, physician offices, and urgent care
centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%,
and 62.6%) and patient's receipt of preventive care (14.5%, 14.2%, and
13.7%) (P > 0.05 vs. retail clinics). In emergency departments, average
prescription costs were higher and aggregate quality scores were significantly
lower than in other settings.
Limitations: A limited number of quality measures and preventive care
services were studied. Despite matching, patients at differentcare sites
might differ in their severity of illness.
Conclusion: Retail clinics provide less costly treatment than physician
offices or urgent care centers for 3 common illnesses, with no apparent
adverse effect on quality of care or delivery of preventive care.
Primary Funding Source: California HealthCare Foundation.
Nurse Practitioners Filling the Void
Listed June 29
By JOANN LOVIGLIO, Associated Press writer
Matt Rourke/The Associated Press Certified nurse midwife Marcia Welsh
performs an abdominal exam on Olga Magana of Oxford, Pa., at the Project
Salud in Kennett Square, Pa., recently. Nurse-managed primary care centers
such as Project Salud have increased to about 250 nationwide today, from
a handful 15 years ago.
KENNETT SQUARE, Pa. Marguerite Harris and her staff of eight provide
prenatal care and child immunizations, write prescriptions, and diagnose
and treat ailments from diabetes to the sniffles. Though it may sound like
a typical doctor's office, no one on staff at Project Salud is a doctor.
The medical center is run by nurse practitioners -registered nurses with
specialized training and advanced degrees whose numbers have risen from
30,000 in 1990 to 115,000 today.
Increasingly, patients are being treated by health care professionals
with N.P. after their name instead of M.D. or D.O. Nurse-managed primary
care centers such as Project Salud have increased to about 250 nationwide
today, from a small handful 15 years ago.
"We've come a long way since the early days, the knockdown drag-outs
with doctors who thought we were overstepping our roles," said Harris,
a nurse practitioner at the Philadelphia-area medical center since 1974.
The change is attributed to factors that include a drop in the number of
doctors choosing primary care as their specialty, a falloff expected to
continue.
According to the American College of Physicians, medical school surveys
showed that from 1998 to 2005, the percentage of third-year residents intending
to pursue careers in general internal medicine dropped from 54 percent
to 20 percent. Many new doctors, saddled with high student loans, are choosing
more lucrative specialties. The supply of general practice physicians is
falling just as the baby boomer population is aging and in greater need
of medical care, and nurse-run medical centers are helping to bridge the
gap.
Nurse practitioners first appeared about 40 years ago in pediatrics,
and quickly expanded into obstetrics and gynecology, family medicine and
adult primary care. They can perform many of the duties of primary care
doctors such as performing physical exams, diagnosing and treating common
health problems, prescribing medications, ordering and interpreting X-rays,
and providing family planning services.
However, some physicians' groups are concerned about the trend. The
American Medical Association is against giving full autonomy to nurse practitioners,
stating as its official policy position that a physician should be supervising
nurse practitioners at all times and in all settings. An AMA spokeswoman
said the association would not provide additional comment on its position.
"There is an element within the physician community that gets a little
antsy. ... They think it's going to take away revenue and business from
them," said Dr. Jan Towers, director of health policy for the American
Academy of Nurse Practitioners. "Really, there's more than enough for everybody."
Some patients say they're more satisfied with the less rushed, more
holistic style of care they receive from nurse practitioners. "It got to
the point where my doctor was in such a hurry, he wouldn't even look me
in the face," said Diane Gass, a North Philadelphia resident who has been
a patient at her neighborhood nurse-run health center since it opened about
a decade ago. Gass, 61, said her nurse practitioner took four hours during
the first visit taking her medical history and getting to know her.
"For years the doctor was treating me for ulcers, but I was in such
pain," she recalled. "The nurse kept asking me questions about the pain
and about my medical history, and we got to the bottom of what was really
going on: I had a gallstone." One outpatient procedure later, Gass' gallstone
and her chronic pain were gone for good.
A 2000 study in the Journal of the American Medical Association concluded
that patients who receive primary care from nurse practitioners fare just
as well as those treated by doctors and report similar levels of satisfaction
with their care.
Nurse practitioners also have steadily been gaining greater acceptance
by insurers and in most states. In about half of the states, nurse practitioners
who frequently have lower fees for office visits than doctors are now recognized
by insurance carriers as primary care physicians. In all but seven states,
they can practice either independently or with remote collaboration with
doctors. In all states except Georgia, they have some level of independent
authority to prescribe medications; some states do prohibit nurse practitioners
from prescribing narcotics.
"One of the statistics that stands out is that we (nurse practitioners)
see our patients twice as often as similar practices of physicians," said
Tine Hansen-Turton, executive director of the National Nursing Centers
Consortium, a Philadelphia-based industry group. "Doing primary care well
is the foundation for saving health care dollars -working on improving
health early instead of, for example, paying for coronary surgery and bypasses
later."
On the Net:
American Academy of Nurse Practitioners: www.aanp.org
American Medical Association: www.ama-assn.org
National Nursing Centers Consortium: www.nncc.us
Date of Publication: June 26, 2006 on Page A12, SouthCoast Today
CASH Practice
I am going to try and give what I have seen being done in a generalized
view, and if anyone wants specifics, we can talk about it later. There
are some similarities, as well as legal issues, many of which are similar
to what the Minute Clinics, etc., are already doing, although this is not
a comparison to them or anyone like them, in other words, accept this as
a disclaimer.
We do an average of $ 5-6,000/day in cash, and we do accept several
insurance companies as well. We also dispense the basics for the cash pay
pt., so we are very careful about any drug rep issues, which can be negative
in keeping up on current situations and samples. The population I am dealing
with is primarily Mexican Hispanic, and many are “undocumented”, which
is just an FYI.
We use a standard fee for a provider visit, and do not charge for the
first follow up for medical versus surgical visit. If the procedure is
a surgical one, there is a set fee for that procedure, which will include
the follow ups. This does change when we have to give extra injectables,
such as multiple Rocephin shots over several days, as well as extended
wound care.
But, the medical aspects works such as this:
Pt comes in for whatever problems and tells us they are going to be
a self pay, regardless of whether they have insurance, (will address this
below). They then fill in the basic intake information and standard forms.
The only extra piece of paper given is that, if they choose to pay in cash,
they sign that they will be given a receipt, and that they understand they
can submit it for reimbursement, but they understand they can not receive
reimbursement greater than what they paid. This is kept on file, and is
a known practice by all the insurers, and this document is available for
confirmation, and agreed to be released if requested. They are then categorized
as any cash pay pt would be, and a record is opened for them.
We then see them and do whatever details are necessary to make a diagnosis,
but, do not get involved in any prices, which are left to the MA, in our
case. If a test is performed in the office, such as a U/A dip, accuchek,
PG test, and similar, it is an additional cost. If the pt needs labs, U/S
or medications, the MA will give them the prices before they check out.
For dispensing, we have meds for all age groups, and do not carry any
narcotics, although we do have dexa, tordol, benadryl and the like. For
meds, (which are primarily generics), we have a large storage area, and
we buy in bulk, and then count out the normal dose for each med. We label
the same type of bottle as any pharmacy, and, since we are buying in bulk,
the actual prices come out to less than many of the same meds I would get
via my health insurance, but, when you are buying in the thousands, it
really cuts prices down.
Two primary reasons for the dispensing, although we do make something
on each med, but, it probably is either near the actual cost, (labor, materials
and whatever other costs would normally be associated if all this were
considered), although the volume is what makes it to break even or slightly
over costs. Primary reasons are that the pt probably could not afford the
price the pharmacy would charge, as well as many probably would not get
the script filled if not supplied. We can only do this for those that are
listed as cash pay, and they usually can not get reimbursed for what we
dispense. We NEVER dispense to those listed as insurance, except for the
injectables, and even that can be fine lined, so, if it is only available
in multidose vials, we do offer it there, and if they have insurance, we
will write a script, and they can bring the drug for us to inject, in which
in a few cases, only the charge on their second visit will be an injection
fee, paid on their initial visit.
Whether cash pay or insurance, they are treated the same when it comes
to care, (I know that is what it should be, but some places pressure to
do extra testing or over prescribing), and this can be quickly addressed
by auditing several charts at random and seeing if the continuity of care
is there. It will help the staff, as well as satisfy anyone that questions
levels of care. For the cash pay patients that have chronic conditions,
they can come back each month and their scripts are refilled and a notation
is made in their record, and a bill sheet is completed. If they have insurance,
we usually write refills, and, except for an uncountable few, there are
definite divisions to keep the cash and insurance issues totally separate.
We even go so far as use a different labs for those pts that pay cash
versus the ones that are insurance. The one exception to this is when we
do PAPs, HIV I and II, and some C & S that we are about to put on antibiotics.
So, each day we get two separate stacks of results, one coming from the
lab we have drawn or sent specimens to, and the others are from companies
such as Quest or LabCorp. Whatever is drawn within the facility is logged
in a separate journal, and the lab orders for outside are calculated by
taking one of the preprinted numbers from the lab slip and putting on the
visit sheet for that day.
If a pt needs fasting labs, they are usually told what their costs will
be, and they usually come back the next morning, and the outgoing lab order
has been paid for in advance, but, again it is less than they would pay
at the full lab rate. The usual labs are the same for either group, including
CBC, Diff, Plt, CMP, Lipids, possibly, depending on history, they also
have TSH, Hep Screen, and various STDs, HemA1c, and the like. The ones
done in house are billed to us. We do not have many STATs because if they
are that unstable, they usually are sent to the ED for a more thorough
work up. Depending on their status, as well as level of care given they
may or may not be charged.
We act as both a PCP facility, as well as do some types of basic Urgent
Care. Certain charges remain the same no matter what time it takes, such
as nail removals, wound care, IUDs, and similar procedures. The only time
that charges are not fixed are when they come to us and we know it will
be an extended time of care, such as recently we had a multiple gun shot
victim, who was discharged from the hospital, and by default we became
his PCP. The person was offered the option of being seen in an institutional
setting, which probably would have been little to no cost, or he would
need to see us daily for wound care and was given a set price, no matter
what the time spent.
We do try to offer the best care we can, and also try to utilize “community”
agencies whenever possible. Our cash charges are significantly less than
we would bill any insurance, but not what we would actually get reimbursed.
For the cash paying pt, which we rarely get any complaints about the costs,
they are sometimes paying $ 500.00 or more in cash. This would be similar
to the new pt that needs a full H&P, baseline lab work, and medications,
as well as any other in house testing. Figure this is probably a one time
charge, maybe yearly, and compare that to insurance costs, deductibles
and co-pays, and it really is very reasonable.
What pts are not allowed to do is switch from insurance to self pay
and back as they feel it suits them. If they tell us they have insurance,
it is verbified, and they are treated like any other covered person with
co pays or deductibles, etc. If they lose their insurance, they can still
come to us on a cash pay basis. All payments are given at the end of each
visit. If a test or medication is to be done another day, they have the
choice of paying at that visit, or when they come in for the next time.
We accept cash, debit or credit cards. For long term pts, we do offer a
few a payment plan.
Pts rarely balk at the charges and cash payments, and the front desk
people try to give estimated costs before further treatments or tests are
done. Admittedly, we do discount some tests or meds in the cost for the
total visit. I have even given free meds for children when the parents
only can pay for one, and they both need care. We may lose for the moment,
but, gain in the long term, in trust and knowing we have provided care
that was necessary, but otherwise not affordable.
We do keep the care and cost factors separate, for the cash pay pt.
We see the pt, write down what needs to be tested, dispensed, etc., and
hand the bill sheet to one of our nursing people. The recommended meds,
tests. or similar pt care sheet is also documented in the chart, the CPT
codes are left in the financial section of the chart, but what that is
the only document of the financial encounter, the charges are not . Unless
there really are further questions, as providers we do not get further
involved. If it is something our nursing personnel feel is really needed,
we may be asked to talk to the pt, but, we still try to avoid knowing the
actual charge, so we can remain as neutral as possible. This way, at least
for me, I can still provide the best care I can, and I do not get involved
in the payments or charges, unless I know beforehand there really may be
a serious problem, and I may ask to have the price cut, but not in front
of the pt, and only with a good reason.
The only advantage, or disadvantage that I personally have is that my
background, before my NP, and even nursing degree, my background was in
health care administration, so I am very familiar with coding, health care
accounting, and auditing. The only other experience I also can bring is
that I have done audits for private insurance companies, as well as State
and Federal Agencies, including “fraud”. I try to use this to make sure
things are 1000 times above board so no one falls into a problem.
Just like when we write for lab tests, or scripts, we usually do not
know if they are actually carried through, whether cash or insurance, until
we find that we are missing something, or the pt shows up for a visit and
we review previous notes. We do not see MVA or workman’s comp, but we do
school PEs, Sports PEs, DOT and similar physicals, all of which are a cash
price, unless it is part of a “wellness” visit, and we are a part of the
Vaccines for Children. So, if it is a wellness visit under insurance, the
only charge will be an “administration” fee, as allowed under contract
and law. If they are a “Medicaid” pt, besides their co-pay of $ 1-2.00,
there are no other charges.
I realize this is somewhat lengthy, (but I am known for that), and without
overreading, I hope that I have covered the basics. I can state that the
clinic does an average in excess of $ 4-5,000, cash pay, on the average
day, and our population does not seem to balk at the fees.
If I can answer any specific questions, please do not hesitate to ask.
I hope this helps. Marty mfnp@cox.net
www.gcd.com HR Law/Labor & Employment
April 2006
Pay Differentials Between Physician Assistants and
Nurse
Practitioners May Violate the Equal Pay Act
By: Charles A. Freeman and Laura Y. Taylor
On March 17, 2006, the U.S. Court of Appeals for the 6th Circuit in
Beck-Wilson et al v Principi held that
seventeen female Nurse Practitioner plaintiffs could proceed to trial
on their claim that their Veterans
Administration hospital employer violated the Equal Pay Act by paying
them less than their Physician
Assistant co-workers. The decision of the Court serves as an alert
to all employers to carefully examine
the gender mix and pay differentials between job categories that perform
similar duties and to take
appropriate corrective action where required to avoid potential Equal
Pay Act violations.
Facts of the Case
Nurse Practitioners (NPs) and Physician Assistants (PAs) working at
the Cleveland, Ohio Veterans Affairs
Medical Center (VAMC) were paid according to congressionally determined
pay scales under two
different statutory frameworks. The Nurse Pay Act of 1990 ensured that
the Veterans Administration (VA)
pay nurses competitively in each local market. However PAs were paid
according to the General Schedule (GS) pay scale.
NPs and PAs received regular step increases within their pay grades
and cost of living adjustments
as authorized by Congress. In addition, the applicable statutes empowered
the VA to increase the basic pay
of health care personnel, if necessary, to (1) provide competitive
pay, (2) achieve adequate staffing or
(3) recruit personnel with specialized skills. Pursuant to that statutory
authority, the Cleveland VAMC in
1990 adopted a special pay scale for PAs in response to difficulties
encountered in recruiting entry level PAs.
Although the education and certification processes for NP and PA positions
differed, they performed
similar work at VAMC, and worked side-by-side performing the same functions
and using the same
skills. When a position was available, the hospital would advertise
it as a middle level practitioner
position to be filled either by an NP or a PA. 95% of the NPs employed
at the Cleveland VAMC were
female while 85% of the PAs employed at that facility were male.
In 1999, plaintiff Laura Beck-Wilson learned that the PAs were earning
more money for performing the
same duties as she did as an NP. When her requests for an appropriate
pay adjustment were denied, she
and a group of NPs filed suit alleging violations of the EPA.
Decision of the Court
The appellate court held that the plaintiffs had established a prima
facie case of an EPA violation, and
that the case should proceed to trial. In order to establish a prima
facie case, plaintiffs had to show that
the employer paid different wages to employees of opposite sexes for
equal work on jobs requiring
substantially equal skill, effort and responsibility and which are
performed under similar working
conditions. Whether a job is substantially equal for EPA compliance
purposes is resolved by an overall
comparison of the work that is actually performed.
In the Beck-Wilson case, the court found the plaintiffs had met their
prima facie case burden by
demonstrating the fungibility of the two jobs which the hospital officials
had conceded existed. In that
regard, the Court rejected the hospital’s defense that the equal pay
claim should fail because the plaintiffs
had not established complete gender diversity between the two positions;
e.g., 5% of the NPs were male and
15% of the PAs were female. The court held that complete diversity
between the plaintiffs and their
comparatives was not required to establish a prima facie case. The
plaintiffs’ prima facie case was further
supported by statistical evidence that the predominately male PAs were
paid more than the
predominantly female NPs for performing substantially equal work. On
an individual
comparison basis, each of the plaintiffs was able to identify a specific
opposite gender counterpart with an
annual wage disparity ranging from $600 to over $10,000.
Under the EPA an employer can rebut a plaintiffs’ prima facie case by
establishing one of the affirmative
defenses; e.g. that the alleged discriminatory pay differential was
based on a system of (1) seniority,
(2) merit, (3) measuring earnings by quantity or quality of production
or (4) any other factor other than sex.
The appellate court, however, rejected the VAMC’s claims that the pay
differentials arose
because of government mandated programs or because the VAMC did not
have the authority to place the NPs
on an increased special pay scale to eliminate the differential. Instead,
the appellate court found ample
evidence of numerous NP resignations thereby raising a genuine issue
of fact as to whether the VA could
have exercised its authority to increase the NPs’ pay in response to
a recruitment and retention problem just as
it had done in 1990 for the PAs.
The Implications for Health Care Employers Although licensing and certification
requirements
for PAs and NPs vary among the states, the basic clinical tasks performed
by both groups do not differ
widely in most primary care settings. With the growing reliance upon
physician assistants and nurse
practitioners to deliver quality health care services on an economic
and affordable basis, the manner in which
these members of the health care delivery system team are compensated
will continue to be a matter of
concern.
The Beck-Wilson decision illustrates the proposition that differences
in written job descriptions
alone will not suffice to successfully defend an EPA violation claim,
nor will compensation surveys suffice
to defend an EPA violation if, in fact, the employees in both job classifications
perform similar work under
similar working conditions. Substantial equality will be determined
by an overall comparison of the work
actually performed and, where the duties of the different job classifications
are viewed and treated as
"fungible", the potential for an EPA violation exists.
As the court noted in the Beck-Wilson case, complete gender diversity
between the two classifications is not
required to establish a prima facie case and it is no defense to an
EPA claim that there is some
representation of the opposite sex in each of the two affected classifications.
Accordingly, the Beck-Wilson decision strongly suggests that health
care employers carefully examine
the duties performed by both PAs and NPs along with the comparative
pay scales under which they are
compensated. In addition, employers should examine their hiring practices.
It is not uncommon for health
care employers to advertise positions as available to PAs or NPs. However,
this practice places employers
at risk of EPA claims by indicating that the same functions may be
performed by either class of employee.
It is not entirely clear where the line is drawn for gender distinctions
between job categories. In Beck-
Wilson, NPs were 95% female and PAs were 85% male; however, there is
no defined, numerical
threshold for EPA violations. Therefore, employers must consider many
factors, including job duties,
working conditions, pay differentials, and gender disparities, to determine
whether they are in
compliance with the EPA. Further, employers must keep in mind that
the gender composition of job
categories is subject to change and should be monitored on an ongoing
basis. Where there is a
gender disparity between employment positions, significant pay differentials
will need to be clearly
supported by legitimate business and labor market conditions to successfully
defend a potential EPA claim.
Clearly, the risk of EPA violations is not unique to the PA and NP positions.
Any job classifications that
are paid disparate wages for performing the same job functions will
be subject to a lawsuit if the positions
are marked by gender disparity. For example, in certain facilities,
RNs and LPNs, as well as
anesthetists and anesthesiologists, may perform the same job duties.
In the health care industry, which has
hundreds of different job classifications, it is important to analyze
job duties and responsibilities, working
conditions, hiring practices, and pay scales to avoid challenges under
the EPA.
If you have any questions about your obligations under the EPA or Title
VII, please feel free to contact any Labor & Employment attorney at
Gardner Carton
source: http://www.gcd.com
What
Is a Legal Nurse Consultant?
permission granted
Vickie L. Milazzo, RN, MSN, JD
founder and president of Vickie Milazzo Institute
Inc. Top 10 Entrepreneur Vickie L. Milazzo, RN, MSN, JD
is the founder and president of Vickie Milazzo Institute.
She is credited by The New York Times with creating the
legal
nurse consulting profession in 1982.
She is the recipient of the Nursing Excellence Award
for Advancing the Profession and the Stevie Award
(business's Oscar) as Mentor of the Year. Vickie has
revolutionized the careers of thousands of RNs.
A legal nurse consultant is a registered nurse who uses existing expertise
as a healthcare professional plus specialized training to consult on medical-related
cases at fees of $100-$150/hour. Few attorneys know how to read medical
records or understand the terminology and subtleties of healthcare issues
to achieve the best results for their clients. A legal nurse consultant
bridges that gap in the attorney's knowledge. While the attorney is the
expert on legal issues, the legal nurse consultant is the expert on nursing,
the healthcare system and its inner workings.
According to the Houston Chronicle, "Of the approximately 900,000* attorneys
in practice today, 25 percent deal with medical malpractice and personal
injury cases." These attorneys rely on specially trained legal nurse consultants
to help them win their cases.
Who are Legal Nurse Consultants?
Legal nurse consultants live all over the U.S., rural or urban. Legal
nurse consultants have consulted on cases as simple as a neck injury caused
by an auto accident, as high-profile as the Rodney King case and as groundbreaking
as Fen-Phen, Vioxx, silicone implants and toxic mold litigation.
Additionally, legal nurse consultants provide healthcare expertise for
insurance companies, utilization review firms, government agencies, private
corporations and hospitals both as staff members and consultants. The legal
nurse consulting profession allows nurses many options for establishing
a satisfying and profitable part-time or full-time consulting career.
What services do Legal Nurse Consultants Provide?
Legal nurse consultant services include assisting with discovery; conducting
research; reviewing medical records; identifying standards of care; preparing
reports and summaries on the extent of injury or illness; and locating
expert witnesses. Although most legal nurse consultants work behind the
scenes, they may also serve as expert witnesses. The legal nurse consultant
acts as a specialized member of the litigation team whose professional
contributions are often critical to achieving a fair and just outcome for
all parties.
Types of Clients Who Need Legal Nurse Consultants
1. Attorneys (plaintiff and defense)
2. Insurance companies
3. Healthcare facilities
4. Other legal nurse consultants and medical-legal consultants (plaintiff
and defense)
5. Government agencies
6. Private corporations (e.g., for developing corporate strategies
for quality assurance, risk identification and management, evaluation and
control of loss exposure)
* According to the American Bar Association Market Research Department,
in 2005 there are 1,104,766 attorneys in the U.S.
The Certified Legal Nurse Consultant Is the Key to
Understanding the Medical Issues
For the Adams case, Scott tapped both her 19 years of nursing experience
and her extensive training as a Certified Legal Nurse Consultant. "I developed
a detailed chronology of the case and explained all the medical procedures
in lay terms," she says. "My services included indexing the records and
explaining the difference between second and third degree burns. I also
pulled out every recorded instance of Adam's pain and suffering and prepared
a chart listing all the pain medications, sedatives, etc., she took."
Walker explains the value of Scott's Certified Legal Nurse Consultant
services. "I had no idea what was being done to the plaintiff because much
of it was in medical shorthand. Sharon indexed the records so we could
find what we were looking for. Then on a daily basis she summarized Adams'
condition, treatments, surgeries, medications and outcome." This detailed
summary made it easier for Walker to answer defense interrogatories and
to decide which witnesses to call.
"We were most concerned about Adams' pain and suffering," he continues.
"We needed a handle on that. Sharon put all the procedures and surgeries
into words we could understand. For example, debridement is just a medical
term to me. Sharon explained that meant scrubbing off the dead skin. When
you see how often they did that, you understand how much my client suffered."
Scott's next step was to make the actual amount of painkiller Adams
received real for people. Walker explains, "Sharon tallied all the dosages
for the first six weeks of treatment, then concluded by saying my client
had received enough medicine to relieve the pain of 850 heart attacks or
1,700-3,400 hours of labor. That vivid picture of what Adams went through
gave us an advantage over the defense attorney when we started talking
about damages."
Although the case was pending in federal court, local rules required
Walker and the defense to attempt a good-faith settlement. "Both sides
chose mediation," he says, "and we settled in about a day. Sharon's summary
made the damages so evident, we never had to discuss them. This made for
a cleaner conference focused on the liability issues."
The result was a $14,000,000 settlement, at that time (2000) one of
the largest out-of-court settlements ever reached for a personal injury
case in Virginia. "One reason we got this settlement," Walker acknowledges,
"was the understanding of the medical records Sharon gave us." An indirect
result of this case was that the vehicle in which Adams nearly died has
been redesigned to move the gas tank and its opening to the back.
Certified Legal Nurse Consultant Serves as Plaintiff
Attorney's Watchdog to Keep Defense Honest
When an attorney takes on a medical-related lawsuit, the attorney is
confronted with enormous volumes of medical records crammed with esoteric
terminology, inexplicable shorthand and indecipherable handwriting. Yet
his client's (plaintiff or defense) future depends on the attorney understanding
those records and using them to support the case effectively. That's why
a Certified Legal Nurse Consultant’s service is the healthiest thing that
will ever happen to an attorney's practice.
One of the largest personal injury firms in the Pacific Northwest, Stritmatter
Kessler Whelan Withey Coluccio (SKWWC), also uses Certified Legal Nurse
Consultants. "Certified Legal Nurse Consultants are very professional and
thorough," says SKWWC partner Michael E. Withey. "They're keenly appreciative
of our clients' needs. I recommend them highly."
This Seattle-based firm has a nationwide practice limited to cases involving
catastrophic injury and wrongful death. Their noteworthy victories include
the Exxon Valdez oil-spill litigation and the record-breaking $15,000,000
wrongful death verdict against then-Philippine ruler Ferdinand Marcos and
his wife Imelda.
In 1998, a notable personal injury case came Withey's way. Jeremy Lohr
was injured in a chemical plant explosion in Moses Lake, Washington. The
accident, in which two other workers died, was the subject of an "I Survived"
article in Reader's Digest1.
According to the Washington State Department of Labor and Industries
L&I News, "A six-inch high-pressure pipe burst and workers were exposed
to a toxic mix of silicon tetrachloride and trichlorosilane. An estimated
35,000 pounds of material was released."2 Jani Gilbert, Washington State
Department of Ecology, reports that both silicon tetrachloride and trichlorosilane
can form hydrochloric acid when they come in contact with water vapor in
the air. The release created about 14 tons of highly corrosive hydrochloric
acid, which can burn human skin and lung tissues.3 Lohr collapsed while
pulling another fallen worker to safety, according to the Reader's Digest
account. The man Lohr was trying to rescue died of his injuries.
The Certified Legal Nurse Consultant Frees the Attorney
to Focus on the Legal Issues
"Lohr sustained significant lung injuries," Withey says. "He requires
constant antibiotic treatment and inhalants to aid his breathing. He will
eventually need a lung transplant. He also sustained scarring of his corneas
and suffered a loss of vision necessitating corneal transplants."
These kinds of injuries leave both physical and emotional scars requiring
long-term rehabilitation. The defense hired medical experts in various
disciplines to examine Lohr and evaluate the extent of his injuries and
need for rehabilitation. Withey, in turn, hired Sue Burnham, RNC, CLNC
to be present with Lohr during the defense medical examinations (DMEs).
"I accompanied Jeremy to four defense medical examinations," Burnham
reports, "including psychiatric interviews by a doctor known to be very
pro-defense, and appointments with a vocational rehabilitation specialist,
a retinal specialist and an exercise physiologist. My role was to keep
these doctors hired by the defense honest."
"Sue provided us with tapes and a status report regarding each exam,"
Withey adds. "Her presence let the defense know someone was there who knew
how these exams should be handled and who could take care of the client
in case anything inappropriate took place. This was very helpful, because
it allowed me to focus on trial preparation instead of personally attending
the examinations with Lohr." The case settled out of court in Lohr's favor
for an undisclosed amount.
Certified Legal Nurse Consultants Save Attorneys Time
and Money
I have a small office," Walker says. "I can't read 4,000 pages of medical
records. Having the services of someone like Sharon allows me to take on
complex cases that I could not handle otherwise."
Scott's status as an independent Certified Legal Nurse Consultant in
private practice is an advantage for Walker. "I trust her judgment and
her opinions more than I would a nurse working in my own office. An independent
consultant doesn't have an ax to grind with you. If you get a case of questionable
merit, Sharon will tell you not to pursue it."
Another benefit of working with a Certified Legal Nurse Consultant is
cost savings. "You can lose a lot of money on cases with complex medical
issues if you're not on firm ground," says Walker. "My out-of-pocket expenses
on the Adams case were around $240,000. Sharon can quickly and economically
identify whether you have a case, and she can cut down on your staff time
going through medical records. If you're in a small or medium-sized firm
and you need help indexing records or understanding complex medical issues,
a Certified Legal Nurse Consultant is indispensable.”
Certified Legal Nurse Consultant Uncovers the Significant
Extent of the Injuries
Phillips continues,
"Dale's expertise as a Certified Legal Nurse Consultant enabled her
to help me sort out all the nursing, physician and home health issues and
present a clear case. I could understand the injuries, procedures and prognosis,
and see where the physicians were negligent. Dale also assisted in identifying
additional records I needed to obtain for a more complete review of the
case."
"Ted had significant nerve damage," Barnes reports. "You could tell
that by watching him try to smile. A nerve conduction study should have
been ordered to confirm this observation."
"The doctor assumed the condition would resolve itself," Phillips adds,
"but he should have ordered the study to guide the boy's treatment. Dale's
knowledge of medical testing is so extensive that she suggested we order
the study to document the existence and extent of nerve damage and to help
demonstrate Ted's suffering. We could do that with subjective evidence,
but the objective evidence provided by the nerve conduction study was more
persuasive, and we wouldn't have had that without Dale."
Barnes' legal nurse consultant services are essential in Phillips' type
of practice. "Most of my clients are children who have been bitten in the
face and disfigured," he explains. "The parents may downplay their child's
suffering to encourage the child through this horrible event and to allay
their own guilt. In addition, because 75% of attacking dogs belong to a
family member or friend, parents don't want to hurt the defendant in the
case. The doctor may also optimistically downplay the severity of the injuries
because he believes he can handle the problem. Under these circumstances,
I may never learn the devastating effect on a child without an experienced,
word-by-word examination of the medical record for clues such as bed-wetting,
hives, stuttering, muteness, violent behavior or other signs of post-traumatic
stress. Dale picks up on these clues, sometimes by talking to the plaintiff,
but usually just from examining the record."
Likewise, some injuries can appear more significant than they really
are. Phillips states, "A medical term may suggest something awful to me,
but Dale knows enough to tell me the finding is not significant."
In Ted's case, "Dale realized the injury was more extensive than we
originally thought. She saw that the doctors were focusing on one issue,
but they were neglecting other serious problems. We had the opportunity
to correct the situation and get the child the help he needed. The patient
received better medical treatment because of what Dale observed."
Phillips notes several additional benefits of using Dale's legal nurse
consultant services on all his cases:
1. "My case is stronger and cleaner, and my presentation is more efficient
and effective because of Dale's great summary of the medical information."
2. "From the outset the full nature and extent of the injury is on
the table, enabling us to put our best foot forward with the insurance
company."
3. "My demand letter appears more objective because it's backed by
a medical person, and frankly, Dale is more objective because she has so
much experience."
The total settlement in Ted's case came to more than $6,000,000, including
costs of past and future medical care. As in other cases, the cost of Dale's
legal nurse consultant services was rightly passed through to the client.
"It's not like she's a secretary or paralegal," Phillips notes. "She's
an outside professional who provides additional expertise and an invaluable
medical perspective on the case."
He concludes, "Attorneys have neither the time nor the experience nor
the medical knowledge to thoroughly review the records. We can't rely on
the treating physician. If he doesn't know us, he may not be open with
us. I think every attorney needs a Certified Legal Nurse Consultant like
Dale, someone medically trained, on his team."
* Name has been changed.
Inc. Top 10 Entrepreneur Vickie L. Milazzo, RN, MSN, JD is the founder
and president of Vickie Milazzo Institute. She is credited by The New York
Times with creating the legal nurse
consulting profession in 1982. She is the recipient of the Nursing
Excellence Award for Advancing the Profession and the Stevie Award (business's
Oscar) as Mentor of the Year. Vickie has revolutionized the careers of
thousands of RNs.
She is the author of Inside
Every Woman: Using the 10 Strengths You Didn't Know You Had to Get the
Career and Life You Want Now, from John Wiley & Sons, Inc. Order
this top 5 Amazon.com bestseller now.
Reprinting and republishing of this article is granted only with the
above credit included. Permission to reprint or republish does not waive
any copyright or other rights. Copyright © 2006 Vickie Milazzo Institute,
a division of Medical-Legal Consulting Institute, Inc., Houston, Texas.
All Rights Reserved.
Nurse
Practitioners: Transforming Healthcare in America
By Elisa Juarez
As the
need for nurse practitioners becomes more and more evident, so does the
value of their approach to healthcare. Not only are they filling
gaps in patient care, they are transforming the practice of medicine in
ways that will benefit patients and communities for years to come.
Over time, the
roles of nurses have expanded, and the number of nurses pursuing advanced
degrees has tripled. Nurse practitioners can be found in hospital
settings such as obstetrics, neo-natal ICU, and other critical care units.
They also practice in out-patient settings as varied as pediatrics, mental
health, women’s health, geriatrics, college campuses, and family practice.
Managed
care, high physician malpractice rates, and increasing patient populations
have put a large burden on physicians, making it almost impossible to meet
the needs of their patients. In addition, many people have decreased access
to healthcare because they are under-insured or have no health insurance
at all. NPs are filling the void in the healthcare system. They provide
most of the same primary care services that physicians do, including basic
health screenings, routine physicals, immunizations, and health education.
They also diagnose and treat illness, order and interpret lab tests and
x-rays, and arrange consultations with specialists when indicated.
According
to the National League for Nursing, nurse practitioners and clinical nurse
specialists have been found to reduce costs and improve access to primary
health care to the poor in urban and rural areas. “Estimates of increases
in the productivity of physician practices that include nurse practitioners
range from 20 to 90 percent.”* The American health care system has
emphasized curative, institutional and dependence oriented service at very
high costs. Patients are not well served by this approach, and nurses
can do a lot to change it. “As relationships with patients grow,
patients use fewer institutional services and only then, those that are
really needed.”*
So why
choose a nurse practitioner as your primary care provider? NPs are known
for spending time with their patients, and for using a holistic approach.
They are also strong advocates of patient education and soliciting input
from their patients when designing each individual’s plan of care. Patients
who actively partner with their PCP have been shown to be more compliant
with their plan of care. Research has also shown that patients who use
an NP as their PCP have fewer emergency room visits, shorter hospital stays,
and often lower medication costs.
In this
age of rising healthcare costs, NPs are making a difference in keeping
those costs down. They serve in rural areas and county clinics, bringing
top-notch care to underserved populations. The above facts make it abundantly
clear that nurse practitioners are meeting many needs and providing an
invaluable service. As they continue to gain recognition and support
in the medical community, they are carving their own niche and transforming
health care in America.
*National League for Nursing Position Statement,
1999
Elisa Juarez is President of MasterQuest Recruiting
& Consulting in Arlington, TX. Her firm specializes in RNs, NPs,
and Nurse Managers. www.mquestrecruit.com
Marilyn G. Brown, RN, FNP, ARNP, is an experienced
nurse and NP that is currently practicing in the CCU of a Dallas hospital.
She also works part-time with Physicians Geriatrics Services in Dallas,
TX.
Finding
Your Niche in the NP Market
By Elisa Juarez & Ingrid Hinojosa
Nurse Practitioners
have become a trusted and needed presence in the healthcare field and in
communities across the country. Finding your niche in the market
can be challenging and exciting, and it is the key to long-term personal
satisfaction and professional development.
One of the first
steps in finding your niche is to identify and understand your strengths,
needs, and interests. In addition to identifying your strengths,
it is beneficial to know and understand your weaknesses, since these can
be turned into strengths. Awareness is the key, and the first step
toward success. There are many books, classes, and other tools available
to assist with this process, including career assessment tools and coaching
which are offered by many career consultants. Here is a valuable
truth for you to hold on to: It is not what you do, but who you are
that makes the difference. What you do and how you do it are important,
but finding your niche is more about who you are, and what you have to
give.
The next step
is to ask yourself the following questions:
1. What type of clientele do I
want to work with?
2. What do I want to be doing?
3. What do I value most in a work
environment?
4. What are my objectives (short-term
and long-term)?
5. How hard am I willing to work?
6. Do I want to have my own practice?
Thirdly, become
familiar with the many benefits NPs offer to doctors, patients, and communities
and present them to potential employers. These include the following:
Nurse Practitioners…
1) take a load off doctors, allowing
them more time for critical and complicated cases
2) allow for a higher volume of
patients
3) are more accessible to patients
than the doctor
4) can spend time with patients
and use an educational approach to health and wellness
5) have prescriptive authority
in most states
6) offer cost-effective care
Perhaps your process
is guided by a desire to serve where there is the greatest need, which
would be in medically underserved areas. If you are also interested
in having your own practice, you can do a needs assessment to find one
of these areas. You will also need to find a supervising physician
and get your own Medicaid and Medicare numbers. Going the entrepreneurial
route requires marketing, commitment, and hard work. Business knowledge,
including marketing and management, are as important as medical training.
A career assessment would be especially valuable if you are considering
this option, since it reveals your interpersonal style and skills, management
style, career interests and needs, and the types of positions that would
be the best fit for you. Since going this route involves greater
risk than working for someone else, it would be wise to do an in-depth
assessment of the requirements, challenges, and benefits, along with your
personal career assessment.
Another recommendation
in finding your niche is to become aware of legislative issues that pertain
to nurse practitioners and the people they serve. Getting involved
in a professional association and other NP organizations is an excellent
way to stay on top of the issues and collaborate with other NPs to make
a difference in the industry. This is an exciting time for NPs to
be involved, as they are carving out their niche and increasing public
awareness in the healthcare market. Take the time to read articles,
talk to other nursing professionals, and become an expert in your field.
As you find and develop your own niche, you will also be adding to the
strength and credibility of nurse practitioners throughout the industry.
Elisa Juarez is President of MasterQuest Recruiting
& Consulting, Arlington, TX. Her firm specializes in healthcare,
particularly physicians and nurse practitioners. They offer career
assessment and coaching services, as well as search and placement services.
For more information, please visit www.mquestrecruit.com, or contact Elisa
at elisa@mquestrecruit.com, (817)561-4933.
Ingrid Hinojosa, RN, MSN, FNP-C, is owner of
Integrated Family Healthcare in Grand Prairie, TX, and is in the process
of opening additional clinics in underserved areas. She has many
years experience in rural medicine in south Texas, and once served as an
investigator for the Texas State Board of Medical Examiners. She
is a certified Childbirth Educator, and still puts in hours as an RN on
the Med-Surg floor of an area hospital.
www.intergratedfamilyhealthcare.com
(972)262-4700
Practitioners fill doctor void
Nurses answer call in state, U.S.
Jodie Snyder
The Arizona Republic
Jan. 21, 2006 12:00 AM
Here's a typical day for Erich Widemark:
Treat depression in several patients. Prescribe
allergy treatments for others. Give injections to help with carpal tunnel.
Remove a mole.
Widemark is no doctor. He's a nurse practitioner,
a member of a profession increasingly being looked at to ease crowded waiting
rooms and hospital units.
Nurse practitioners are registered nurses with
advanced training. In Arizona and other states, they can treat patients,
order tests, interpret X-rays and write prescriptions. Unlike physician
assistants, they can work independently or with a doctor.
The number of active nurse practitioners in Arizona
has increased 44 percent since 2000, according to the state board of nursing.
As a group, nurse practitioners are working to
become more visible and get more respect from physicians and insurers.
Although nurse practitioners can specialize in
fields such as cardiology or psychiatry, most, like Widemark, are in family
practice.
"With the concerns about there being a physician
shortage, nurse practitioners can be the answer to providing quality care,"
said Patt Rehn, executive director of the Arizona Nurses Association.
Roger Hughes, executive director of St. Luke's
Health Initiatives, a health care policy research institute, said that
fewer doctors are signing up to be primary-care providers and that leaves
a void that nurse practitioners and physician assistants can fill.
"The bottom line with nurse practitioners is that
this is all being driven by economics and professional choices," Hughes
said.
It's believed that all but 15 percent of primary-care
visits can be handled by nurse practitioners or physician assistants, Hughes
said.
Increasingly, savvy doctors are setting up family
practices that rely on a couple of nurse practitioners, rather than another
physician, to provide care. By doing that, doctors can reduce their overhead
yet see more patients, Hughes said.
Growing field
Nurse practitioners quickly point out that they
are not simply "physician extenders": Their nursing background allows them
to bring a different attitude to patient care.
More nurses are going into the field. Nationwide,
about 106,000 nurse practitioners are on the job, with about 6,000 jobs
added each year, according to the American Academy of Nurse Practitioners.
On average, the annual salary for a nurse practitioner
is $73,620, and their malpractice insurance costs are considerably less
than those of doctors.
At Arizona State University, about 160 students
are in its nurse-practitioner program at the College of Nursing.
Bernadette Mazurek Melnyk, the college's dean
and a nurse practitioner herself, wants to double the number of students
in the next three to four years.
Many nurses become nurse practitioners because
they want to continue their education but don't want to be managers, said
Melnyk, who hopes to see patients herself every couple of weeks.
"For many of us, it's very difficult not to have
that interaction," she said.
That was the case of Denise Link, a nurse practitioner
who also is an ASU professor. In the 1970s, when the idea of nurse practitioners
was starting, she chose the profession because she wanted to learn more.
Even though she now is a professor at ASU, she still regularly sees patients
at the university's family health center.
When she started out, Link was commonly mistaken
for a physician.
"Everyone was always telling me that I acted like
a doctor," she said.
That still happens to Widemark.
"It's something I am very clear about," he said.
"I tell my patients that I am not a doctor, but then they tell me that
I'm their doctor."
Doctor-nurse conflicts
The relationship between doctors and nurse practitioners
can be thorny at times.
Debra Bergstrom, who has been a nurse practitioner
for 10 years, said that she decided to open her own practice rather than
work for doctors because she felt they didn't see her as a peer.
"I was tired of being treated like a second-class
citizen," she said.
The Arizona Medical Association, the state's largest
organization of physicians, believes that nurse practitioners should not
be in solo practice, like Bergstrom, because they lack the training to
handle problems they may encounter with patients. The association believes
that nurse practitioners can be helpful when working under the supervision
of a physician, said Andrea Smiley, the association's spokeswoman.
Smiley said she didn't know of any specific cases
where a nurse practitioner working unsupervised caused patient harm.
Smiley said increasing the number of nurse practitioners
isn't the answer to a shortage of primary-care providers. Increasing the
number of nurse practitioners is a moot point unless physicians are there
to supervise them, she said.
"It's kind of like a chicken-and-egg issue," she
said.
Nationally, about 4 percent of nurse practitioners
are in private practice, according to the American Academy of Nurse Practitioners.
Insurers pay less
Insurers frequently also don't recognize the
importance of nurse practitioners, Bergstrom said. They don't pay her as
much for the same service as they do for physicians. For example, Blue
Cross and Blue Shield of Arizona pays her 60 percent of what Medicare pays.
Medicare is the standard for physician reimbursement.
"We were told that's how it is," she said, "take
it or leave it."
Blue Cross and Blue Shield of Arizona bases its
reimbursement partially on the level of training and education of health
care providers. The insurer doesn't discuss specifics about how much it
pays, according to Regena Frieden, company spokeswoman.
Other insurers will not credential nurse practitioners,
which means insurers won't pay them at all for their services, Widemark
said.
For Link and other nurse practitioners, it's difficult
to see the distinction, especially when waiting rooms are full of people
to be seen.
"It's not just a shortage of physicians," she
said. "It's actually a shortage of primary-care providers: nurse practitioners,
physician assistants and doctors. There are high demands on providers of
all kinds of health care.
"It's really time for us to think outside the
box."
source: http://www.azcentral.com/business/articles/0121nursepract21.html
Walk-in
clinics help to cure US healthcare ills
By Christopher Bowe in New York
Published: December 6 2007 02:00 | Last updated:
December 6 2007 02:00
Walk-in retail health clinics have moved from
oddity to near ubiquity in just two years in the US. They provide nurse
practitioners, who treat minor illness, perform examinations and offer
preventive medicine such as vaccines for about $50.
Take Care, acquired this year by the drugstore
group Walgreens, estimates it will open one clinic a day and have more
than 400 by this time next year. The industry is expected to reach 5,000
-10,000 retail clinics in the next few years.
"Patient demand could warrant significantly more
than 5,000-10,000 clinics. What will limit it is the availability of nurse
practitioners," says Peter Miller, chief executive of Take Care.
The explosion of walk-in clinics is one of several
significant moves to reform US healthcare by business and other groups
outside the traditional medical industry.
They range from clinics in retail stores to internet
social networking for doctors, retailers' rethinking pricing policies for
prescription drugs, widening support for cost-effectiveness studies of
medicines, and financial service industry help for hospitals.
These seemingly unrelated examples could change
the system at some of its weakest points. They are tackling problems including
inexpensive access to basic healthcare for everyone, transparency in medical
information, and personal accountability for one's own health.
Walk-in clinics have been set up in some of the
largest drugstore and retail groups, including Wal-Mart, Target, CVS and
RiteAid.
Their business model seeks to offer basic healthcare
for patients, whether insured or uninsured.
They treat minor illnesses at low cost, and could
help to head off higher costs with preventive medicine while leaving physicians
time for complex cases.
In addition, they generate a computer patient
record for each visit, which could help to spur wider adoption of electronic
health records.
"We are serving as a critical entry point for
patients," says Mr Miller. "In many cases, there are patients that haven't
been in the healthcare system in years."
Since it opened two years ago, the established
medical community's concern in one of Take Care's first markets of Kansas
City has shifted. In some months 10-15 per cent of its patients are referrals
from doctors.
Clinics see potential to expand services, including
helping with obesity and patient health and wellbeing, "transforming how
healthcare is practised today", says Mr Miller.
Doctors are not to be left behind. Sermo, the
internet networking site for doctors, has emerged to give physicians a
network to discuss their medical cases or problems, find new information
such as drug data, operate their business better, or post personal information.
Sermo has up to 40,000 US physician members, recently
adding 2,000 each week. Dr Daniel Palestrant, founder and chief executive,
says: "It could be indispensable. But it also does what we want to do -
and that's help fix healthcare."
Healthcare costs have also attracted new reform
efforts. Wal-Mart, the world's largest retailer, launched a $4 plan for
30 days' supply of commonly used generic drugs. It has targeted $10bn (€7bn,
£5bn) of savings by squeezing out pricing anomalies and making generic
drugs pricing more transparent.
Efforts to get evidence to judge whether medical
treatments are cost-effective were boosted last month by government researchers.
Peter Orszag and Philip Ellis, of the Congressional
Budget Office, argued in the New England Journal of Medicine that healthcare
costs and quality could be helped by "generating more information about
the relative effectiveness of medical treatments and enhancing the incentives
for providers to supply and consumers to demand, effective care".
Some estimates, they wrote, say that less than
half of all medical care "is supported by firm evidence of effectiveness".
Finally, hospitals have seen their bad debt continue
to soar as uninsured patients or those with less insurance fail to pay
large bills.
As people are required to take on more costs,
this debt has created a vicious cycle that is destabilising US healthcare,
experts say.
McKinsey & Co says financial institutions
have expertise either being used or implemented in the future that could
help the healthcare payment system, with "electronic payment processing
capabilities that the sector needs".
US healthcare is changing and adapting with these
new ideas, either paving the way for potential federal policy reforms,
or in lieu of their absence.
Tuesday, January 15, 2008
By STEVE DOYLE
Times Staff Writer steve.doyle@htimes.com
Nurses urge lawmakers to ease regulations
Some local nurse practitioners say they have a prescription to help
Alabama's medically underserved areas.
On Monday night, about 100 nurse practitioners packed Huntsville's swanky
Heritage Club to press for changes in how the state regulates their profession.
Alabama's nurse practitioner rules are among the nation's strictest, limiting
their ability to write prescriptions and requiring them to be paired with
a collaborating physician.
A proposed bill drafted by the Nurse Practitioners Alliance of Alabama
would relax those rules and make it easier for trained nurse practitioners
to work in poor, rural counties where medical care is scarce, said Cindy
Cooke, the group's state president.
"Our biggest goal is to increase access to health care," said Cooke,
a nurse practitioner at Fox Army Health Center on Redstone Arsenal. "We
want to attract quality people from those underserved areas, train them
and send them back home."
Cooke said Alabama's 1,400 nurse practitioners, who at minimum have
a master's degree in nursing, could improve the state's dreadful ranking
in health care access studies. One recent report placed Alabama behind
the 49 other states and the District of Columbia at ensuring timely medical
care for residents, she said.
Lawmakers are listening.
State Sen. Parker Griffith, D-Huntsville, is considering co-sponsoring
the nurse practitioner bill. A bipartisan collection of state House members
- Republicans Mike Ball, Mac McCutcheon and Howard Sanderford, and Democrat
Butch Taylor - also showed up at the Heritage Club to listen.
The legislative session begins Feb. 5.
A retired cancer specialist, Griffith said nurse practitioners are qualified
to treat most illnesses and could make a huge difference in rural counties
that lack primary care doctors and obstetricians. He said he would like
to see rural clinics run by nurse practitioners spring up across Alabama,
linked by Internet to medical schools and teaching hospitals so the nurse
can quickly get advice from specialists if needed.
"The health care system needs improvement, and this does that," Griffith
said Monday. "It's not magic; it's just getting people who are trained
into areas that other health care providers will not go."
Nurse practitioners will always work closely with doctors, Cooke said,
but they shouldn't be required by the state to have a formal, collaborative
agreement. The 10-year-old rule means the nurses have to get their collaborating
doctor to sign off on everything from mammograms to sports physicals, she
said.
Drugs are another sore subject: Nurse practitioners in Alabama cannot
write prescriptions for any potentially addictive medication, including
cough medicine with codeine.
"It's very restrictive," Cooke said. "We need to be able to write that
in order to adequately take care of our patients."
Alabama, Florida and Missouri are the only states that do not allow
nurse practitioners to write prescriptions for narcotic medicines, she
said.
The current rules have caused problems for at least two local nonprofit
agencies: the Community Free Clinic and HEALS clinics for low-income students.
Free Clinic Director Shotsie Platt said she'd love nothing more than
to have nurse practitioners working alongside volunteer doctors at the
clinic on Franklin Street. But with no physician willing to give the OK,
the idea has been stuck in neutral for eight years. When the doctors get
swamped, some patients will continue to have to be turned away, Platt said.
HEALS Executive Director Tracey Wright said her group had to close its
clinic at New Hope Elementary last fall after the clinic's nurse practitioner
lost her collaborating physician.
"We still see those children," Wright said Monday, "but they have to
come into town" for treatment at another HEALS clinic.
? 2008?The Huntsville Times
Upbeat diagnosis for clinics
Specialists in other states reject qualms about CVS units
By Stephen Smith, Globe Staff ?|? January 22, 2008
ROCKY HILL, Conn. - The future of medicine in Massachusetts can be found
along an unremarkable patch of suburbia south of Hartford, inside a CVS
pharmacy where Sheree Albino sat hunched and pale on a recent Sunday morning.
Her sinuses were killing her. She wanted relief. And she didn't have
time to wait.
"So I came here," Albino, 52, said, her voice rasping like sandpaper.
She'd just left the drugstore's MinuteClinic, a sliver of a medical office
next to the photo processing counter and not far from the chew toys for
dogs. "It's quick and easy. They should have done this a long time ago."
With CVS planning to open dozens of medical clinics in Massachusetts,
Mayor Thomas M. Menino of Boston and other critics have warned of inferior
care driven by an unquenchable profit motive. He and others predicted that
in the name of convenience, patients would sacrifice an ongoing relationship
with a doctor.
But interviews with a dozen independent researchers, insurers, and regulators
in other states painted a far more positive portrait. Increasing evidence,
they said, suggests that when patients are treated for sore throats and
other minor illnesses at retail clinics, the care may actually be as good
as - if not better than - in more traditional doctor offices. That is testament,
in large measure, to an approach akin to a chef faithfully following a
cookbook. Nurse-practitioners in the clinics use a computer-generated template
that, for example, will not allow them to prescribe an antibiotic unless
they first make sure the patient has no allergies to the drug.
"Frankly, from our perspective, there's a lot of good stuff in the MinuteClinic
model," said Dr. Marcus Thygeson, vice president of HealthPartners, a major
Minnesota medical plan whose patients have made 20,000 visits to the retail
clinics in the past four years. "We like the convenience and ready access."
No state has more experience with retail clinics than Minnesota, the
birthplace nearly eight years ago of MinuteClinic, which still dominates
the field even as competitors crowd in. An independent, nonprofit coalition
of doctors, insurers, consumers, and employers called MN Community Measurement
annually rates health clinics' and doctors' practices statewide.
"Lo and behold," said Jim Chase, executive director of MN Community
Measurement, "the MinuteClinic actually did very well."
The most recent report card from the group, based on data from 2006,
awarded MinuteClinic the highest marks in Minnesota for treating children
2 to 18 years old for sore throats, giving it a score of 99 percent. The
lowest grade: 26 percent for a doctors' group.
The high score reflects that nurse-practitioners were careful not to
prescribe antibiotics for sore throats caused by viruses because the drugs
are useless against viral infections. Incorrect use of antibiotics can
spawn dangerous germs that are resistant to medication.
"This is not a prescription mill," said Michael Howe, the former Arby's
chief executive who now leads MinuteClinic, which has 475 outlets, up from
466 just a week ago. The CVS subsidiary has never been sued for malpractice,
executives said.
The clinics, which do not require appointments and stay open on evenings
and weekends, treat a limited number of ailments: minor illnesses such
as ear infections, poison ivy, and bronchitis. In its name and advertising
slogan ("You're sick, we're quick!"), the chain trumpets a promise of speed
and efficiency.
And much like a fast-food restaurant, they list set prices for medical
care. In Connecticut, it's $59 for pink eye treatment, $69 for strep throat.
The nurse-practitioners in the stores are supposed to refer patients
to primary care doctors, urgent care centers, or emergency rooms if a patient's
medical condition falls outside the MinuteClinics' scope of care.
Mary Kate Scott, a California consultant who has extensively studied
in-store clinics, said that by restricting the services they provide, "it's
actually very easy to hit an extraordinarily high quality rate.
"Because you do the same thing again and again, you get extremely good
at it," she said.
Retail clinics are proliferating across the nation, with a report by
Scott estimating that between January 2006 and September 2007, the number
grew eightfold. The expansion is being driven by twin epidemics: the aging
of baby boomers and the declining number of primary care physicians.
And Massachusetts has emerged as a potentially lucrative market because
the push for universal health insurance means that previously uninsured
patients who skipped visits in the past are now likelier to seek out treatment.
It's hoped by sending patients with simple problems to in-store clinics,
doctors and emergency rooms will have more time for cases that demand their
expertise.
"Having their time available to do the complex work or to work with
patients with chronic conditions really depends on us figuring out how
to create a system that allows the easier stuff to get done as easily and
cheaply as we can," said Margaret Laws, of the California HealthCare Foundation,
which commissioned Scott's report.
"Retail clinics may be that - or may not," she said.
Concerns persist about the wisdom of offering episodic medical care
inside retail outlets. Matthew C. Katz, executive director of the Connecticut
State Medical Society, said members have expressed "grave concern about
the continuum of care" for patients who go to store-based clinics.
Specifically, he said, doctors are worried that they're not always alerted
when their patients are seen at retail clinics, which in turn creates a
risk that tests will be duplicated or extra doses of the same medication
might be prescribed. CVS executives said patients are asked if they have
a primary care physician and a record of their clinic visit is sent to
the physician if the patient permits it.
Some physicians are embracing the arrival of retail clinics. Claire
Nadeau, a nurse-practitioner who manages the 16 MinuteClinics in Connecticut,
said a physician who practices near the Rocky Hill CVS urges patients on
his after-hours phone recording to consider going to the pharmacy for night
and weekend treatment.
That is exactly what Sheree Albino did. "This was a Sunday," she said.
"You can put a call into your doctor, and they have somebody get back to
you. At a MinuteClinic, you might get relief a little bit sooner."
Colorado Nurses' purview
may expand
By ED SEALOVER
February 3, 2008 - 12:44AM
DENVER - In Ordway — population 1,250, 53 miles east of Pueblo — family
nurse practitioner Karen Tomky is the area’s medical community.
Legally, however, Tomky can’t authorize a handicapped parking permit,
she can’t OK a do-not-resuscitate form and she can’t sign off on a high
school sports physical, even if she did the examination.
In big cities, the rising cost of insurance policies and the declining
number of businesses offering health coverage generate the most concern.
Small towns have a different problem. In some places, such as northwest
Colorado or the San Luis Valley, the nearest doctor can be hours away and
the care other medical professionals can give is limited.
Even before the General Assembly begins dealing with the issues of how
to insure 792,000 more Coloradans and bring down insurance costs, legislators
are tackling a largely overlooked topic that could mean a lot to rural
residents.
A trio of bills that has passed from the House into the Senate would
expand the authority of advanced practice nurses to handle some duties
that now require doctors.
“They’re well-educated, they have lots of experience, they’re out on
the front lines and they’re taking care of our people,” said Rep. Ellen
Roberts, a Durango Republican who sponsored one of the bills.
Steve ErkenBrack, a member of the governor-appointed Blue Ribbon Commission
on Health Care Reform, said some counties have no doctors. In other places,
like southwest Colorado, few or none of the limited number of physicians
takes Medicaid, leaving the poor without doctors.
Most doctors today go into highly profitable specialty areas, leaving
a shortage of primary and family-care doctors. Only one-third of American
doctors are in primary care, and only 17 percent of Colorado medical school
graduates go into family care.
“If we were to wave a magic wand and cover everyone in Colorado with
some kind of coverage, we don’t have enough primary physicians to treat
them,” commission Chairman Bill Lindsay said.
There are about 3,000 advanced practice nurses in the state, however,
and many of them specialize in treating rural patients. These nurses with
specialized education — such as midwives, pediatric nurse practitioners
or nurse anesthetists — examine patients and offer some treatments, but
there is a limit to what they can do.
Tomky, for example, signed a handicapped parking permit request for
a patient four years ago but then got a note from the Department of Motor
Vehicles stating only doctors could sign such an application. Something
similar happened when she inked a donot-resuscitate agreement for a patient
a few years back.
Roberts’ House Bill 1061 would allow advanced practice nurses to certify
a patient’s health status, authorize continuation of treatment and give
directives for end-of-life care.
Two bills by Rep. Sara Gagliardi, an Arvada Democrat and licensed nurse,
would make it easier for advanced practice nurses to get reimbursed like
physicians for the work they do. House Bill 1060 expands the reimbursement
requirements of insurance providers and House Bill 1094 authorizes payment
to such nurses for services to Medicaid clients.
Ensuring that advanced practice nurses can receive Medicaid money should
expand the health care options for poor and disabled Coloradans in areas
where few doctors accept Medicaid and Medicare patients, advocates say.
Expanded responsibilities could also help the patients who advanced
practice nurses already see. Because doctors alone are allowed to sign
some documents now, there can be delays in getting medical equipment or
medications to some patients, said Tay Kapanos of the Colorado Society
for Advanced Practice Nurses.
Even if the bills pass, some things still will require a doctor’s involvement,
such as determinations that patients can no longer give consent to treatment,
declarations of a terminal illness and signings of death certificates.
ACCESS
Giving nurses more authority would help make up for doctor shortages
in rural Colorado, proponents say.
Ontario to expand role
of physician assistants to ease wait times
March 17, 2008 at 1:32 am · Filed under Poitical, Social, Uncategorized
http://www.thestar.com/living/Health/article/345869
Mar 13, 2008 07:27 PM
Keith Leslie
THE CANADIAN PRESS
Ontario residents hoping to avoid long waits at hospital emergency rooms
could soon find themselves being treated by an unfamiliar type of health-care
professional: the physician assistant.
Health Minister George Smitherman said Thursday that physician assistants
have played a long-standing role in the Canadian Armed Forces and in the
United States, and he sees opportunities for them in the provincial health-care
system.
Smitherman said the province is reviewing the data from a one-year pilot
project at six Ontario emergency rooms which deployed physician assistants
in teams with nurse practitioners, and he is already liking what it sees.
“We’ve seen anecdotally … it does seem like where the nurse practitioners
and physician assistants have been deployed together, that has been an
effective model,” he said.
“We would … offer to Ontarians this as one more example of how we can
utilize the skill set of health-care professionals to make sure that their
access to health care is timely, effective and gives them a good degree
of patient satisfaction.”
Smitherman said it’s “a little bit early” to determine the exact role
physician assistants would play in Ontario’s health-care system. He said
there are other two-year pilot projects underway to evaluate the role of
physician assistants in other areas of hospitals in addition to emergency
departments and community health centres.
“We know that there are lots and lots of places where human resources
are in such scarce supply that we have to be really smart and use our health-care
professionals to their broadest scope of practice,” Smitherman said.
“We think it’s also an exciting opportunity to lure some Canadians back
home to be practising as physician assistants.”
Conservative health critic Elizabeth Witmer said she supports increased
roles for both nurse practitioners and physician assistants, and believes
they would also be a big help in long-term care facilities.
“People who have them in their hospitals have told me they do appreciate
(PAs), and it has made a difference,” Witmer said in an interview.
“Whatever we can do to make sure that people have access to health care,
we need to do.”
However, Witmer said more than one million Ontarians are still without
a family doctor, and she warned that an increased role for physician assistants
won’t solve that problem, especially when there aren’t many trained PAs
in Canada.
So far, Manitoba is the only province in Canada to have legislation
governing the roles and responsibilities of physician assistants.
The Ontario Medical Association said physician assistants will have
the education and skills to deal with daily health-care needs as well as
medical emergencies.
They will carry out their duties under the supervision of a physician,
and their duties will vary depending on the doctor’s area of practice.
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