Tuesday, January 6, 2015

Do No Harm? It May Be Hard to Avoid With Health Law’s Medicare Cuts - NYTimes.com

The Affordable Care Act made changes to government payments for Medicareservices that are expected to save tens to hundreds of billions of dollars per year. This sounds like a good thing — and it very well may be — but only if those spending cuts don't cause harm. Research suggests they just might.

As any business would, hospitals often respond to reduced revenue by cutting costs. They especially tend to cut back on staff, according to a number of researchers.

Reductions in Medicare payments to hospitals between 1996 and 2009 were nearly entirely offset by cuts to operating expenses, and predominantly to personnel, Chapin White and Vivian Wu reported in Health Services Research in 2013. In other work, also published in Health Services Research, Ms. Wu and Yu-Chu Shen found that hospitals responded to lower Medicare payments in part by reducing staff and length of stays.

On the other hand, a study by health economists from Northwestern University's Kellogg School of Management found that hospitals responded to the market collapse in 2008, which reduced revenue through depressed returns on investments, not by cutting staff but by trimming back in other specific areas, including advanced medical records and less profitable services like those for substance use treatment or those provided in trauma centers.

Such cuts by hospitals may harm quality of care. For example, recent work suggests that cutting length of stays increases mortality for heart attack patients and those with pneumoniaOther work, published recently in the journal Medical Care, suggests that an 11.5 percent decrease in nursing staff per 1,000 inpatient days (a standardized measure of staffing levels) could increase adverse events — such as deaths, infections and surgical complications — by 1.2 percent. In their study, Drs. Wu and Shen found higher heart attack mortality rates in hospitals that had experienced larger Medicare payment cuts and had cut spending, "particularly among registered nurses," in response. For each 1 percent payment cut, heart attack mortality was 0.4 percent higher.

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Monday, January 5, 2015

Doctor, Shut Up and Listen - NYTimes.com

Betsy came to Dr. Martin for a second — or rather, a sixth — opinion. Over a year, she had seen five other physicians for a "rapid heartbeat" and "feeling stressed." After extensive testing, she had finally been referred for psychological counseling for an anxiety disorder.

The careful history Dr. Martin took revealed that Betsy was taking an over-the-counter weight loss product that contained ephedrine. (I have changed their names for privacy's sake.) When she stopped taking the remedy, her symptoms also stopped. Asked why she hadn't mentioned this information before, she said she'd "never been asked." Until then, her providers would sooner order tests than take the time to talk with her about the problem.

Betsy's case was fortunate; poor communication often has much worse consequences. A review of reports by the Joint Commission, a nonprofit that provides accreditation to health care organizations, found that communication failure (rather than a provider's lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes in hospitals. 

A doctor's ability to explain, listen and empathize has a profound impact on a patient's care. Yet, as one survey found, two out of every three patients are discharged from the hospital without even knowing their diagnosis. Another study discovered that in over 60 percent of cases, patients misunderstood directions after a visit to their doctor's office. And on average, physicians wait just 18 seconds before interrupting patients' narratives of their symptoms. Evidently, we have a long way to go.

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Sunday, January 4, 2015

NYTimes: When Prisoners Are Patients

It's an odd thing, to take care of someone who is chained to a bed, guarded 24/7 by bored corrections officers idling away time with TV and card games, who cannot receive visitors or even phone calls. But it happens when prison inmates are sick enough that they need care that only a hospital can provide.
As a nurse caring for such patients, the first rule I learned — or figured out, because no one said it aloud — was not to ask what the prisoner had done to land him (they were all men) in jail. Better not to know that he is a serial murderer, a vicious rapist. It was easier for me to think of the prisoners as people, just like the rest of our patients, rather than to condemn, because condemnation and compassion are tough impulses to reconcile.

I cared for one prisoner over several weeks, and I got to know him in a vague "don't ask, don't tell" way. He had an above-the-knee amputation and could walk only with an artificial lower limb, which we kept propped against the wall whenever he lay down. His other leg, the whole one, was handcuffed to the bed. He was very sick from cancer and chemotherapy. It seemed absurd.

"He's a nice guy," I told a corrections officer one day after the prisoner and I had talked.
"No he's not," the officer replied, fixing me with a level look that suggested he knew things about the prisoner that I didn't.

The guard's intimation about the prisoner's troubling past didn't change how I treated him, or even how I felt about him. But it did make me wonder if I should be more wary around him. The violent prisoner who feigns illness to break out of a hospital, killing staff members as he goes, is a recurring plot element on TV crime shows (and actually happened, in 2006, when a prisoner receiving care at a hospital in Blacksburg, Va., killed a guard and a police officer in an unsuccessful escape attempt). Was the one-legged prisoner just waiting for his moment? I have no idea. He was discharged and was readmitted several times, eventually dying in the hospital unvisited and, except for some of us nurses, unmourned.

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