Author: Stephen Moberg

Increasing coordination and integration of care, as well as decreasing fragmentation, are several ways to help eliminate unnecessary hospital readmissions. But how does this look practically speaking?

It is all too common that physicians are forced to readmit their patients because the alternative, sending them home to an inadequate environment with little social support, would cause their condition to deteriorate further.

Researchers from two universities in New York have developed a program where medical professionals and social workers collaborate on patient’s discharge, home planning and observation post-discharge. This may be a credible solution to help decrease costs from unnecessary hospital readmissions due to improved communication and quality care.

After a patient is discharged from the hospital, a social worker will call to set up a home visit to determine how they feel, if they are taking their medications properly and if they are experiencing any uncomfortable side effects, assess the healthiness of their living environment and more. Another key factor, I can’t help from mentioning, is that the social worker emphasizes the importance of following up with their primary care provider.

This study took into account 100 patients living independently, but who were at high risk for hospital readmission. After the two-year study concluded, the data revealed that having a social worker involved cut hospital readmissions by half.

“A social worker can create savings equal to his own salary and benefits just by preventing seven readmissions a year – and the patient’s quality of life is improved significantly in the process,” says Dr. Shawn Bertowitz, the medical director of the study.

It seems to me that including other skilled individuals, like social workers, in the delivery of healthcare for patients is essential. It may be a good indicator that Affordable Care Organizations (ACO) will decrease hospital admissions effectively as team coordination is further developed.

The last 50 years have made the biggest impact on where our healthcare system stands today. In our previous blog post, we covered the history of healthcare from the late 1880s to the mid-1900s.

Brief history of healthcare continued…

• 1965: President Lyndon Johnson moved a bill through Congress that created Medicare and Medicaid. The government expanded proposed legislation to include physician services for the aged.

• Early 1990s: Unsuccessful attempt to overhaul the U.S. Healthcare system. Hillary Clinton guided a project aimed to convince Congress to move towards a universal health insurance system.

• 2008: The rise of support in the universal health insurance bill. Barack Obama, Hillary Clinton and John Edwards, three of the most successful Democratic presidential primary challengers, agree to support a universal health insurance bill.

• Early 2009: President Barack Obama asked Congress to develop a universal health insurance proposal. “My plan begins by covering every American. If you already have health insurance, the only thing that will change for you under this plan is that the amount of money you will spend on premiums will be less,” Obama said. “If you are one of 45 million Americans who don’t have health insurance, you will after this plan becomes a law.”

• Late 2009: Final version of ACA – H.R. 3590 – debated by Senate. The final vote was 60-39 to give final approval to the bill.

• Early 2010: Congress sent President Barack Obama an ACA “fixer bill” – H.R. 4872. This bill makes several changes to the H.R. 3590 bill, including changes to health-related financing and revenues. It also modifies higher education assistance provisions. The two bills (H.R. 3590 and H.R. 4872) combined are referred to as the ACA.

• Early 2012: U.S. Supreme Court heard oral arguments on legal challenges to ACA. One of the challenges was concerning a provision to the ACA that would require most individuals to own health coverage or else pay a penalty. Another challenge concerns the individual mandate provision.

• Late 2012: President Barack Obama’s re-election confirmed that the ACA will remain a law.

• Today: Government producing materials to help public understand the law. Federal agencies, state regulatory agencies and other various groups have been developing rule-making notices, white papers, regulations and more to help the public interpret regulations, procedures, forms, processes and programs needed to implement the law.

We aim to give our readers the facts. We hope that this information has been helpful and will encourage you to make decisions and form opinions, about our healthcare system, based on facts and not political rhetoric.

The White House has decided to delay the ACA’s employer-coverage mandate, for businesses with 51 employees or more, by one year and does not think it’s a big deal. Over 90% of businesses with 51 or more employees already do offer health insurance. Basically, employers have an additional year to comply with the regulations of the ACA.

Businesses are relieved because they have been experiencing trouble setting up the proper technology and infrastructure to comply with the new law, in such a short period of time.

However, it is important to note that while businesses have been granted a year-long grace period, the individual mandate remains unchanged.

Employees, whose companies are affected by the recent delay, can obtain subsidized coverage through the individual insurance exchange in the meantime.

If an individual does not purchase insurance for 2014, they will be fined and that amount will escalate fairly rapidly over the next three years.

That’s the big news for today concerning the ACA. Let’s take a brief look at some of the major events that have occurred over the past 100 years between the government and healthcare.

• 1880s: Germany’s Universal Health Insurance Program influenced United States policy makers. On January 1, 1891, the U.S. implemented a sickness-related income protection program that paid for people to obtain healthcare through local “clubs”. Sick insurance was not compulsory at this point.

 C.D. Babcock, Secretary of the Insurance Economy Society argued that sickness insurance programs did not reduce poverty, mortality, or duration of sickness. Medical practices, where these programs were already implemented, were experiencing a demoralized system.

• Late 1800s/Early 1900s: Reformers were interested in improving social conditions of the working class. President Theodore Roosevelt and progressive groups campaigned for compulsory health insurance.

• 1920: James Lynch of the New York State Industrial Commission proposed a “universal health insurance” program that would pay for medical and maternity care. His proposal included that worker’s would pay half the cost of their health insurance, while their employers would pay the other half.

• 1930s-1940s: Call to bolster national preventive care programs and support state and local health departments. President Franklin Roosevelt was not interested in a large federal health insurance program.

• 1946: President Truman argued that the U.S. needed a prepaid health insurance system for the entire population. The country was already using taxpayer money to provide free medical care for low income or no income families.

“This is not socialized medicine,” Truman said. “Everyone who carries fire insurance knows how the law of averages is made to work so as to spread the risk, and to benefit the insured who actually suffers the loss. If instead of the costs of sickness being paid only by those who get sick, all the people—sick and well—were required to pay premiums into an insurance fund, the pool of funds thus created would enable all who do fall sick to be adequately served without overburdening anyone.”

Tomorrow we will bring you up to speed on where our healthcare system stands presently. Please check back!

Click here to continue reading about our government’s involvement in healthcare.

Reality dictates that there is a definite difference between physicians and nurse practitioners, due to their levels of education. As a whole, I think everyone would agree that we value a physician’s extensive education. However, if the physician is not accessible when the patient is sick or needs medical assistance, that education is meaningless.

In order for physicians to have a legitimate argument that keeps nurse practitioners from seeing patients independently, they have to become more easily accessible to patients. To paralyze our competition, so we don’t have to change, is really not what we nor the culture needs.

As primary care physicians, our challenge is to improve primary care by making it more robust and built around access to physicians. Furthermore, in order to achieve the quality of care that our culture deserves, we will need to include nurse practitioners.

A physician and nurse practitioner’s training is meant to complement one another. Nurse practitioners are trained to manage preventive care, straight-forward acute illnesses and previously diagnosed chronic conditions. Physicians are trained to manage all of these, as well as patients with complex problems, multiple diagnoses and complex acute problems. This difference is exactly why the playing field should not be leveled.

I battled with this very concept when I was practicing medicine. I saw patients that had experienced heart attacks and heart failures, all the time. I had to come to grips with the fact that I was not a cardiologist.

My residency training lasted for three years. Typically a cardiologist’s residency training lasts for 5-7 years. While I treat patients with heart problems frequently, I had to acknowledge that this doesn’t make me a cardiologist. It’s not ridiculous for a heart patient to prefer to see a cardiologist over me because of their more extensive and heart-specific training.

Along this same thinking, nurse practitioners cannot expect to be considered equal to a physician when their education and training is much less. However, I do not say this to undermine nurse practitioners.

According to the American Academy of Family Physicians, nurse practitioners spend between 5 and 7 years completing 5,350 clinical hours of study, whereas physicians spend 11 years completing 21,700 clinical hours of study.

To say that they are equal would be completely disregarding our education system, which is built upon the fact that the more educated a person is in their profession, the more qualified they are to do that profession.

Most of the time, nurse practitioners may give the same diagnosis and/or treatment plan as physicians. The problem lies with those remaining patients that may be more complicated and require different medical insight than the nurse practitioner has been trained to handle.

While the difference in education and training between a physician and a nurse practitioner is dramatic, it should not be the main point of focus. Physicians need to be discovering ways to solve their shortage crisis in order for accessibility to be improved.

There are two things our culture demands of healthcare – access and comprehensive care if needed. Currently, emergency rooms and primary care offices alike have been struggling to meet these demands, but often come up short. Emergency rooms provide around the clock access to patients, however they lack continuity; emergency room physicians make the most appropriate decision for patients based off the short amount of time they have been in the exam room. On the other hand, primary care offices are backlogged, but physicians have a long-standing relationship with their patients and are able to provide better quality care based on this relationship.

Several years ago, one of my patients, Daniel, came into the office for an infected hand. It was pretty bad off and in one sense I wanted to immediately hospitalize him.

Daniel was 60 years old and had been hanging drywall for much of his adult life. He didn’t have insurance and worked very hard to make a living.

I hesitated to hospitalize him because I knew he would easily walk away with a bill for $15,000-20,000.

After evaluating his hand and his situation, I recommended that he come into the office every day for the next 3-4 days. In order to have any chance of healing the infection, it had to be closely monitored, elevated continuously and treated with antibiotics.

It wasn’t an easy task, but I knew he could handle it. Daniel was motivated to stick to my medical recommendations because he knew I didn’t want him to have to pay an unnecessary bill from being hospitalized. I felt confident in my recommendations because he would return to the office.

This is exactly why hospitalization has become such a hot topic. Since primary care physicians are hard to reach, patients default to the emergency room. Emergency room physicians do not know the patient; therefore, if there is any question, the patient will be admitted for monitoring.

Our culture desperately needs primary care offices to extend operating hours, during the week, and offer weekend hours, in order to pull patients out of the emergency rooms. It is completely reasonable to expect primary care offices to be available 7 days a week and up to 12 hours per day on any given week day, as a minimum. This can be accomplished without overworking the support staff.

Some may argue to make emergency rooms more capable of being used for primary care. This is absolutely the wrong answer for our culture. The key is to re-establish primary care as the central hub of healthcare and redefine emergency rooms as a place for patients to receive emergent care.

Several days had passed and Daniel’s hand was almost completely healed; the decision to treat him outside of the hospital, though time consuming, literally saved him thousands of dollars.

If I had sent him to the emergency room or if Daniel had gone to the emergency room without seeing his primary care doctor first, there would have been no other choice than to be hospitalized. This is something that happens all day long in primary care.