A Doctor Confides, “My Primary Doc is a Nurse”

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Last week I interviewed a doctor who told me that his primary care doc is a “physician assistant”  who has been trained to deliver primary care.   He said it casually, dropping the fact into a long conversation.

Dr. David Kauff is an internist at Seattle’s Group Health Cooperative (GHC), an organization that has a fabulous reputation–both among patients and among physicians—for its primary care program.  One reason is that at Group Health, doctors, physicians assistants and nurse practitioners work together in teams. “The success of our model is based on the fact that everyone in this together; we are corralled by a common purpose,” says Kauff, who also serves as GHC’s  Medical  Director for Practice and Leadership. 

I’ll be writing more about Group Health Cooperative in a few days.

 In this post, I would like to focus on the growing role of Nurse Practitioners (NPs) and Physician Assistants (PAs) as clinicians.  NPs are registered nurses who have gone on to earn a master’s or a doctorate. Some specialize in areas such as anesthesiology, pediatrics (pediatric nurses) or Ob-Gyn (certified nurse-midwives). NP’s can run clinics; some run their own practices.     

By contrast, physician assistants (PAs) don’t usually work alone. While physicians may not be on-site, typically doctors oversee their work.  

PAs are formally trained to provide diagnostic, therapeutic, and preventive health care services.  They take medical histories, examine and treat patients, order and interpret laboratory tests and X- rays, and make diagnoses. In many cases, they did not begin their careers as nurses. They may have been  paramedics, respiratory therapists, or emergency care technicians (EMTs) before becoming PAs.  

Currently, 17 states, plus the District of Columbia, let nurse practitioners operate independently.  In 33 states regulations vary. As this map  reveals, in some places NPs are not allowed to prescribe medication. In others, they may have to consult with a physician when treating patients.

It’s worth noting that NPs enjoy greater freedom in the Northwest, the Upper Middle West, and Northern New England (areas that some healthcare reformers refer to as “Canada South” because these states are in the vanguard of reform) as well as in the Southwest, where many NP’s started working in group practices, and they went out and established their own clinics. Nationwide, about 6,000 nurses operate independent primary-care practices.                                               

                                              Why Physicians Object

Today, 14 states are debating whether NPs should be allowed to practice on their own.  Many emphasize the difference in education and years of training. Though in truth, the length of training is not so different. Becoming a primary care doctor requires four years of medical school plus three years of residency. A nurse practitioner  attends nursing school for four years, then spends two to three years in graduate school, depending on whether he or she is getting an M.A. or a Ph.D. (In 2015, all nurse practitioners will be required to earn a Ph.D.) 

Most NPs also have nursing experience. At the University of Michigan, for instance, the average candidate admitted to the NP program has 7 years of hands-on experience as a nurse.  But while the number of years spent training are not so different, as I explain below, traditionally ,the nature of that training has been very different.   

Doctors say that they are worried about patient safety. “I see it as physicians being true to their oath ”  Dr. Adris Hoven, president-elect of the American Medical Association recently told Marketplace Health Care’s Dan Gorenstein.   Hoven insists that doctors are “not threatened” by NPs.  “At the end of the day what they want to do is deliver the best healthcare possible.”  

Dr. John Rowe, a professor of Health Policy and Management at Columbia’s School of Public Health, doesn’t buy the argument.  As he points out, nurse practitioners are already working without primary care doctors: “The fact is this is going on in 16-17 states,” he told Gorenstein, “and there is no evidence that it’s not good for the patient.”  A recent Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation backs him up: “studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar.”

At the same time, Rowe understands why doctors are uncomfortable. “The physicians feel they have something special to offer,” he explains. “And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them.”                                    

When I last wrote about nurse practitioners, back in 2010, one physician/reader (“Sharon M.D.”) was exceptionally candid on this point:

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What the Sequester Means for Health Care, Education and the Exchanges (In-depth Analysis); Will “Looking Stupid” Motivate Legislators to Compromise? Why the GOP Would Rather Cut Defense than Close Loopholes

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Before looking at precisely who will be hurt by of government-wide sequester cuts on health and education, it’s worth considering the possibility—however slim—that legislators still might reach a budget agreement that brings an end to these blind, across-the-board blows to government spending.

Earlier this week Senator Mark Warner told Bloomberg News that he places the odds for a bipartisan debt-reduction deal at better than 50-50.

Why the optimism?  

Warner, who isn’t a political naïf (he served as Virginia’s governor from 2002 to 2006), believes that ultimately law-makers will arrive at a compromise because as he puts it: “looking stupid at some point has got to motivate people.” 

Granted, this is Warner’s first term in the Senate. This could mean that he doesn’t yet understand the ways of Washington. On the other hand, the fact that he’s new to the beltway could mean that he’s still able to think clearly.

As he reminded his Congressional colleagues Wednesday morning: “These cuts were set up to be the stupidest way possible. No rational group of folks would allow them to come to pass.”

Warner is right. NO ONE wanted cuts that Republicans have rightly called “mindless and random.”  That was the point of the Sequester deal forged during a 2011 deficit-reduction agreement. Legislators purposefully chose targets that were so unpopular that everyone assumed that neither party would ever let them occur.  Conservatives wouldn’t countenance slashing military funding by 7.9%, Democrats wouldn’t accept deep cuts to social programs that our most vulnerable citizens need.  They would have to find a compromise. Or, at least, that was the theory.

Instead, Democrats and Republicans deadlocked, and now it seems that they have double-dared themselves into an impossible situation. Sequestration will increase unemployment, weaken the economy, and hurt children, seniors and the military. Even the Border Patrol will take a hit.  More public school teachers will lose their jobs.

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Why We Are Stuck With the Sequester

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A month ago, it was clear that voters would blame Republicans if Congress went ahead with the for the so-called “Sequester”—some $85 billion in automatic government-wide spending cuts.

I thought this meant that Republicans would be forced to back down, call off the Sequester, and accept the fact that if we want to reduce the deficit, we’ll need to raise some taxes while also cutting spending.

I was wrong. The sequester took effect March 1 and Republicans aren’t budging.

The public does, in fact, blame the GOP for the budget stalemate that has led to the sequester:  a recent CNN poll shows that shows that only 38 percent say they have a “favorable view ”of the Republican Party, versus 54 percent who view it unfavorably.

                                  Why Republicans Aren’t Worried

Yet House Republicans are not terribly concerned about what voters think. This is because, back in 2010, they succeeded in re-drawing election district lines in many swing states in a way that creates “safe districts” for Republicans—districts where they have a solid majority. They feel untouchable.  At the same time the new boundaries pack as many Democrats as possible into as few districts is possible.

This is a major reason why Democrats didn’t win a  House majority in 2012, even as their congressional candidates drew about 1.4 million more votes than Republicans nationwide, according to data compiled by Bloomberg News. And, Bloomberg notes, the redistricting “will hinder the Democrats from regaining control of the chamber in 2014.”

District lines are re-drawn once a decade, right after the U.S. census is taken. The last census took place in 2010, and that year Democrats saw massive losses at the polls. As a result, the GOP controlled state government in key states, including Wisconsin, Michigan, Ohio, Indiana, and Pennsylvania. This gave Republicans the power to draw congressional district lines. They seized that chance, aggressively “gerrymandering” so as to protect Republican incumbents while isolating Democrats. The fact Democrats are concentrated in urban areas made their task easier. Nevertheless, creative cartography led to some crazy designs. For instance, Bloomberg points out, “Michigan’s 14th congressional district looks like a jagged letter ’S’ lying on its side.”

 

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Who is Douglas Holtz-Eakin and why is he saying such terrible things about health reform?

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Today, the House Energy and Commerce Committee’s Subcommittee on Health will hold a hearing entitled: Unaffordable: Impact of Obamacare on Americans’ Health Insurance.  (Always nice to know that our elected representatives are keeping an open mind.)

Prominent on the list of witnesses: “Douglas Holtz-Eakin.” Even before reading his testimony, I knew what Holtz-Eakin would say: young, health Americans should brace for “sticker shock.”  Conservatives like Holtz-Eakin tend to stay on script. However stale the rhetoric, they firmly believe that if you repeat a sound-bite often enough, people will believe it.                                     

                                        Who is Douglas Holtz-Eakin?

If you recognize the name, it’s probably because Holtz-Eakin has become a familiar figure in the mainstream media, quoted in the New York Times, writing Op-eds for Reuters and Politico.com, and appearing, not only on Fox Business News, but on CNN and the PBS’ Newshour.

Alternatively, “Holtz-Eakin” may ring a bell because he served as a member of George W. Bush’s Council of Economic Advisers (CEA), and as Director of Bush’s Congressional Budget Office (CBO.)

In a remarkably candid 2011 interview, Holtz Eakin recalled his tour in the Bush administration:

“Going into the summer of 2001, things were getting worse. . . When we first went in and talked to the President, Glenn [Hubbard] and Larry Lindsey said, ‘Mr. President . . . We’re probably not going to run a surplus on budget.  We’re going to run a deficit.”

Bush’s reply: “We’re not going to run a deficit. If you come in here with a deficit, you’re both fired. Go fix it.’”

“We ended up running a budget surplus of one billion dollars,” Holtz-Eakin confided, “driven by gimmicks of remarkable proportions.”
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Expanding Medicaid Is Not Enough–Making Medicaid A Federal Program

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 Note to readers—please read the post below, “Pulse—More Stories from the Heart of Medicine” (which includes “One More Child Left Behind”) before you read this post.

When I read “One More Child Left Behind,”  all I could think of was how much Aaron’s arm must have hurt during the more than 24 hours that he didn’t receive treatment. I also imagined how frightened and bewildered the six-year-old must have been as he heard his mother and grandmother talk, and realized that they couldn’t persuade a doctor to help him.

This story was published in 2009—one year before the Affordable Care Act was passed.  The ACA extends Medicaid to millions. But even under reform legislation, many children like Aaron will not receive care. This is because Medicaid now pays an average of 34% less than Medicare for exactly the same treatment.

Why on earth would we pay doctors and hospital less to care for poor patients than we would pay them to care for the elderly?

Lower Medicaid fees are part of the legacy of racism. (I write about this in Money-Driven Medicine.)  When the Medicare and Medicaid laws were passed in 1965, Southern Congressmen refused to agree to laws that would pay doctors who treated the poor as much as they reimburse physicians who care for older patients.

At the time, relatively few African-Americans living in the South were over 65.  Most died long before they would be eligible for Medicare. Yet many African-Americans were poor, and would qualify for Medicaid. This is what disturbed Southern legislators. They wanted to make sure that healthcare remained segregated.    

Even under Reform, Specialists Who Treat the Poor Will be Under-Paid   

Medicaid rates vary widely by state, but on average, according to the Kaiser Family Foundation, the new program will offer PCP’s a 73 percent raise This should open doors for millions of Medicaid patients. In some states that have been paying the lowest rates, the hike will be much higher. (See this map) The ACA guarantees raising Medicaid reimbursements for primary care for just two years (2013-2014). But I expect this program will be extended, although increases may be modified. Once begun, it will be very hard to justify ending it.

At the same time, specialists who care for Medicaid patients will continue to receive about 1/3 less than when treating seniors.  As a result, even under the ACA a great many Medicaid patients will be hard-pressed to find a specialist willing to see them.
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More Stories from “Pulse—voices from the heart of medicine”

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Every Friday, thousands of readers smile when they see an e-mail from Pulse: voices from the heart of medicine in their in-box. Pulse is a free, online magazine  that publishes riveting, often moving, sometimes controversial, and occasionally hilarious first-person stories and poems about medicine.  (Click on “hilarious” for a story that will astound you, and, if you share my sense of humor, make you laugh. )

All of these tales are true, and the authenticity of the writers’ voices helps explain their power.  Written by patients and doctors, nurses, caregivers, and students, these unblinkingly honest stories and poems bear witness to the suffering that patients endure, and to the compassion of caregivers — as well as their doubts.  

                                        Some of My Favorites

Long-time readers may remember poems and stories from Pulse that I have cross-posted in the past. 

 —  “Useless (But Needed), A Doctor’s Constant Companion”  — one of my favorites

 — “First Do No Harm,”  a story about how we train doctors that drew thoughtful and provocative comments from both doctors and nurses; 

— “Broken”– a controversial story about what happens when a trauma surgeon overrules an obstetrical resident. The question:  should they have tried to save the baby or the mother? Could either be saved?                                       

                A Stairwell Conversation, And a Unique Magazine is Born

Pulse founder Paul Gross, practices family medicine at Montefiore hospital in the Bronx, New York.  He recalls how Pulse was conceived:

 “What would it be like, I wondered, if there were a magazine that told about health care the way it really is? What if patients and health professionals alike got to tell their stories? 

“Around the same time, I had a stairwell conversation with a hospital director of nursing. It stopped me short. ‘For the first time in my long career,’ she said, ‘I’m ashamed to be in this business.’

“To me, this sounded like a cry for help; it sounded like a system in crisis,” Gross adds. “And yet, for the most part, popular magazines and medical journals seemed oblivious.

“It occurred to me that if we found a way to share our stories—the difficult moments along with the glorious ones—perhaps we could jump-start a national conversation about health care. Maybe this exchange could lead us toward a better health system.”
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The Health IT Scandal the NY Times Didn’t Cover

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Below, a guest-post by Michael L. Millenson, president of Health Quality Advisors LLC.  An early, and vocal quality-of-care evangelical, Millenson is the author of the critically acclaimed book, Demanding Medical Excellence: Doctors and Accountability in the Information Age.

As health information technology honchos gather for the annual HIMSS trade show and schmoozefest, it’s a safe bet the industry “scandal” the New York Times placed on page one recently will breed more bored yawns than buzz. The real scandal in health IT involves the customers, not just the vendors, but that’s a topic for quiet conversations journalists can’t cover.

In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in ­– well, actually, poured in not that much money at all when you think about it ­– lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.

Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.

The actual scandal is more complicated and scary.  It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.

That clinical evidence and the way in which the world outside medicine had been transformed by computers did almost nothing to change health care. Computerized medical records were available: before there was “Watson,” the IBM computer helping doctors make decisions, there was “Watson,” the IBM chairman, vainly trying to sell electronic records to doctors as early as 1965. But well into the 21st century, most providers only trusted computers to send out the bills.
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Why Is It That the Truth Never Goes Viral?–A Campaign of Misinformation Unites Conservative Activists and Insurers

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The Post below originally appeared on Healthinsurance.org (mm)

Wild rumors, such as the one claiming Obamacare premiums will start at $20,000 a year for a family of five, are much jucier than the truth.

About a week ago, Investor Daily’s website published a “Fact-Check” post that illustrates how misinformation spreads.

In the post, Jed Graham explains that when the IRS published a final rule about penalties under the Affordable Care Act (ACA), it included a few hypotheticals. For example, the IRS wrote, “The annual national average bronze plan premium for a family of 5 (2 adults, 3 children) is $20,000′ in 2016.”

The $20,000 figure was just an example, Graham explains. “The IRS always uses hypothetical numerical examples in its regulations to illustrate how the rules will work in practice and this was no different.”

Nevertheless, before long, the “conservative news site CNSNews.com began to blare out this shocking headline: ‘IRS: Cheapest Obama Care Plan Will Be $20,000 Per Family.’”

From there, “the ‘fact’ got picked up by countless media outlets and pundits” Graham reports, “most of them on the right,” including:

 •Betsy McCaughey writing for the New York Post;

•Rush Limbaugh;

•Breitbart

•On the left, even Naked Capitalism (a well-researched blog,) reported the news bulletin from CNSNews.com.

This is the problem: Once a faux-fact gets out there, even reporters who have no axe to grind continue to repeat it. If you see the number often enough, you assume it must be true.

How could a reporter tell that $20,000 wasn’t an IRS estimate?

It should have been clear that this was a hypothetical, Graham points out, if you just looked at other hypotheticals in the IRS ruling. “For example: ‘the annual national average bronze plan premium for a family of 4 (1 adult, 3 children) is $18,000.’

“Both examples can’t be true,” he observes, “unless an adult’s premium is $2,000 and a child’s is $5,333.”
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Obama to Boehner: “John, I’m Getting Tired of Hearing You Say That”

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This was President Obama’s reply, during fiscal cliff negotiations, when House Speaker John Boehner declared, for the umpteenth time, that “ The U.S. has a spending problem.” 

I can understand the president’s irritation. How could anyone believe that we have a “spending problem?’

Look around. Consider the state of our bridges, our roads and our crumbling inner city public schools. Are we spending too much on the nation’s infrastructure?

Next, think about unemployment. During this recovery we have lost 750,000 public sector jobs.  Republicans are intent on “starving the beast” (of government) and as a result Washington has not given states the financial support they need continue delivering public services. Across the nation, public school teachers have been laid off in droves, while class sizes increase at unprecedented rates.  Does this sound like government spending run amuck?

One in five American children now lives in poverty. Seventeen million children find themselves in homes where they can’t be sure of getting enough to eat.  (a.k.a. “food-insecure households.”)  At the end of the month, many kids go to bed hungry because the government Food Stamps program (now known as Supplemental Nutrition Assistance Program, or SNAP)  gives families less than $1.50 per person per meal. Are we being overly generous?

During the past two wars, we sent millions of American men and women to Iraq and Afghanistan –many went back for repeated tours. In some cases, their bodies were not  broken–but their minds were.  Now 1.3 million Vets seeking mental health services are told they must wait of 50 days before getting treatment.   A recent government report suggests that 22 Vets die by suicide every day – about 20 percent of all Americans who kill themselves. Are we spending too much on healthcare for Veterans?

Let me suggest that we don’t have a spending problem. We have a revenue problem. Current federal revenue levels are at their lowest levels since the 1950s. 

                      How Anti-Tax Pledges Have Weakened the Nation

In a recent post, Jared Bernstein, a senior fellow at the Center on Budget and Policy Priorities, nailed it: “The tax system doesn’t raise enough revenue.  And that’s not just the recession; it’s also tax policy and anti-tax pledges  . . . The system has become less progressive, with the largest declines in effective tax rates at the top of the income scale.

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Health Wonk Review Posts Investigate

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Nursing Homes, Nurse-Practitioners Developing More  Expertise, Efforts to Block Exchanges, How Patients Respond to Evidence that Some Tests are Unnecessary, and Whether Obamacare “Screws” Young Americans  . . . 

This  time around Peggy Salvatore hosts a Valentine’s Day Edition of  Health Wonk Review –over at Healthcare Talent Transformation . Her round-up of some of the best of recent HealthCare posts includes:

—  A piece on Health Affairs Blog by David Rothman investigating how Americans respond to “evidence that certain medical tests and screenings might be unnecessary, harmful, and not worth the money.”  How do they react to research showing that some drugs are harmful? To find out, you’ll have to read the post.  (You will find the link to this post, and all of the posts discussed below, here )

—  Good news from Louise at Colorado Health Insurance Insider:  A bill that would have repealed the 2011 law that created Colorado’s health insurance exchange/ marketplace, died in committee in a 9-2 vote. “Republicans and Democrats on the Committee on the committee rejected his portrayal of the Exchange– which has already made a lot of progress towards an opening date this fall.”

Louise adds: “Given the progress that Colorado has made over the past two years in creating the state’s marketplace and implementing various other healthcare reforms (both state-based, like maternity coverage and gender-neutral premiums, and ACA-related, including the recent push to expand Medicaid), I would say that Colorado is on track to greatly improve its overall healthcare outcomes.

She also includes a useful map showing the states that have defaulted on setting up Exchanges. As she notes “this doesn’t mean they will get a pass on Obamacare.”  By law, the federal government will set up Exchanges for them.

—  A post by Disease Management Care Blog’s Dr. Jaan Sidorov pointing out that non-physician professionals and lay-persons are managing to achieve a remarkable degree of medical expertise. This is, as Peggy notes, a controversial subject.

— A report that asks “do non-profit nursing homes really provide better care than their for-profit counterparts”?   Over at Healthcare Economist Jason Shafrin analyzes a study that suggests the answer is  “Yes.”   How do they arrive at that conclusion? Again, you’ll  have to read the post.

— A post that takes on “a recent infamous article on Buzzhead ”  claiming  that Obamacare “screws” young Americans.  Over at California Access Health’s Anthony Wright observes:  “there are some obvious and non-obvious reasons why Obamacare is a boon to young adults. “ The non-obvious reasons are worth thinking about.

These are just a few of the treats in this Valentine’s Day Edition.  I recommend that you read the entire Review here.