Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

The Changing Landscape of Health Care Jobs in the United States

IMG_2285Attention all new nursing grads and other health care job-seekers: Today in the NYT there is a fascinating interactive feature “How the Recession Reshaped the Economy, in 255 Charts” by Alicia Parlapiano and Jeremy Ashkenas. It helps illustrate where the health care jobs are in our country, what the average salaries are within different sectors of the health care system, and what the trends are in terms of growth (or decline) of the different sectors.

Using data from the U.S. Bureau of Labor Statistics, the authors illustrate in easy-to-read charts how the number of jobs have changed for a particular industry over the past decade. These data are only available for private industries, so for health care, public health jobs are (unfortunately) not included. The only middle-wage private industries that did not lose jobs during the recession were those within health care.

One of the charts is titled The Medical Economy and here is what stands out to me:

  • Health care industries that were relatively unaffected by the recession and that have shown steady growth include home health care services, outpatient care centers (both general outpatient care and ones specific to mental health), and physician’s offices.
  • Health screening programs (including blood and organ banks) have recovered and grown.
  • Psychiatric and substance abuse hospitals have recovered and grown.
  • General medical-surgical hospitals remained relatively unaffected by the recession but appear to be mostly flat in terms of growth.
  • Specialty hospitals (excluding psychiatric and substance abuse) have recovered and grown, but they have shown a substantial decline in jobs since March 2012 (with a small blip back up over the past few months). I would imagine these changes for specialty care hospitals are correlated with the roll-out of ACA, especially changes to Medicare reimbursement for hospital care.

Take home lesson for people in the job-search mode within health care: Follow the money and look for jobs in the economically healthier parts of the U.S. health care system. Don’t rely on hospitals as the only places for job-searching.

Take home lesson for those of us in the role of nursing (or other health care professions) education: These ‘hard’ economic data provide even more good reasons to recruit and prepare students for work in primary care, community-based, non-acute care settings.

Corporate Employee Wellness Wants You

Uncle Sam I Want You - Poster Illustration
(Photo credit: DonkeyHotey)

At least it seems to want me. A corporate/university wellness program is stirring to life at the University of Washington: Whole U. An unfortunate title since a simple Google search of the name brings up numerous spa and ‘body aesthetics’ businesses offering laser treatments and ‘body composition improvement’ (aka: “We’ll take fat from your butt and inject it into your face”).

We already have a university employee wellness program (of sorts) called UWellness (a much better name than Whole U). The stated purpose of UWellness is “balancing the emotional, intellectual, occupational, social, and physical components of health.” Makes sense, except for the intellectual part. Did they just throw that in because we’re a university and should be doing scholarly and intellectual pursuits? What the heck is intellectual health? Avoidance of all writing by French philosophers?

UWellness currently offers the following wellness services: 1) free annual flu shots, 2) referrals to Weight Watchers for weight loss, 3) links to a student-run group promoting bicycle and walking safety (including selling low-cost bike helmets), and 4) free annual ‘routine mammography’ for all women ages 40 and above at an on-campus mobile mammography van (a mammobile?). The first three offerings make sense to me and would earn an A or B according to the U.S. Preventive Services Task Force (USPSTF), an independent panel of non-federal experts in prevention and evidence-based medicine. However, the mammography offering surprised me since the USPSTF changed their breast cancer screening guidelines in 2009 to recommend biennial routine mammography for women aged 50-75 only (biennial screening for women ages 40-50 is optional/not routinely recommended). UWellness contracts with Seattle Cancer Care Alliance to provide the mobile mammography services, so I suppose they are stubbornly following the old guidelines (that the equally stubborn American Cancer Society still follows). There are, of course, intriguing political and economic self-interest issues there that I won’t touch on here…

The Whole U program is a “holistic employee engagement initiative which emphasizes community building, appreciation of the diverse lifestyles and interests of our faculty and staff and participation in programs that promote healthy lifestyles. Establishes a point system that encourages participation through prizes and engages a network of program ambassadors within departments to serve as key communicators in helping direct employees to the Whole U.” Sounds more than a bit Orwellian to me.

Penn State faculty recently staged a successful protest over the roll-out of their  university/corporate wellness program Take Care of Your Healththat required faculty and staff to fill out a questionnaire asking about workplace stress, marital problems and women’s pregnancy plans–or pay a $100 a month penalty. (Good NYT article on it here.) A recent RAND Corporation report Workplace Wellness Programs Study found that half of all U.S. employers offer some sort of employee wellness program, many of which include individual health risk assessments and the use of incentives for participation. The most popular employee wellness programs include support programs for weight loss and smoking cessation. Rigorous cost-benefit analyses of these employee wellness programs are lacking, but the RAND researchers estimate the programs should be cost neutral within five years of implementation.

Starting in January 2014 the ACA allows employers to offer incentives of up to 30% of health coverage costs to employees who participate in the wellness programs, including completion of the health risk assessments (and biometric assessments like body-fat percentage measurements, blood pressure readings, and blood glucose measurements). So get ready to be queried at work on your health behaviors, to have your candy vending machines taken away, and to have your waist and hips measured by ‘program ambassadors.’

Meanwhile, my version of corporate/university employee wellness includes avoidance of French philosophers. I’ve also bought a bouncy exercise ball to use as a desk chair–mainly because someone stole my corporate-issued office chair. And it may come in handy to fend off the Whole U program ambassadors when they come knocking on my door.

Becoming A Nurse: Nurse Writer Panel Discussion

You are all invited/open to the public:

Becoming a Nurse

Nurse Writer Panel Discussion and Reading

Thursday April 18th 6-8:30pm

Suzzallo Library Smith Room

6-6:30 Light Refreshments

6:30-8:30 Panel Discussion, Reading, and Book Signing

I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse

Edited by Lee Gutkind

In Truth Press. Pub. Date: April 2, 2013

This collection of true narratives captures the dynamism and diversity of nurses, who provide the vital first line of patient care. Here, nurses remember their first “sticks,” first births, and first deaths, and reflect on what gets them through long demanding shifts, and keeps them in the profession. The stories reveal many voices from nurses at different stages of their careers: One nurse-in training longs to be trusted with more “important” procedures, while another questions her ability to care for nursing home residents. An efficient young emergency room nurse finds his life and career irrevocably changed by a car accident. A nurse practitioner wonders whether she has violated professional boundaries in her care for a homeless man with AIDS, and a home care case manager is the sole attendee at a funeral for one of her patients. What connects these stories is the passion and strength of the writers, who struggle against burnout and bureaucracy to serve their patients with skill, empathy, and strength.

Panel will include an interview with Theresa Brown who writes for the NYT Well Blog. Participants include Josephine Ensign, DrPH, Associate Professor, Department of Psychosocial and Community Health, whose essay Next of Kin appears in the anthology.

This project was supported, in part, by an award from 4Culture  4culture_color

University of Washington Health Science Library   logo-hsl-admin-color-printer

Superstorm, Super Nurses, Super Inequality

New York City (Manhattan) from Ganrty Park aft...
New York City (Manhattan) from Ganrty Park after Hurricane Sandy (Photo credit: TenSafeFrogs)

Living in the Pacific Northwest with the return of our perpetual grey days and rain, I do not hear the same level of weather complaints as I usually do. In the wake (literal/multiple meanings) of the devastation of Superstorm Sandy on the East Coast, most people here are grateful for our relatively benign weather.

On Monday, when the storm was hitting Virginia, I called to check in on my elderly father, who is now mostly homebound in hospice. High winds and local flooding were affecting his town in Central Virginia, but he had two nurses with him when I called. One was the visiting home hospice nurse who was checking his health status and making sure he had his medications. The other was his caregiver, a retired Emergency Department nurse. She is a no-nonsense person who walks with a cane and has been known to wave it my father’s way when he forgets to take his medicines. Clearly my father was in capable hands. I could get on with my job of grading student papers. I know firsthand what an important role home nurses play in the daily lives of elderly people and their families. And especially so in times of natural disaster.

I was pleased to see the NYT article “Enduring the storm for homebound patients” by John Leland (11-1-12). He highlights the essential work of the 5,000 nurses, aides, and social workers through the NYC Visiting Nurse Service who have been out providing services to patients around the city during the storm. He quotes nurse Allison Chisholm as saying, “…it’s something you have to do as a nurse. (…) I don’t see this as being a hero. I have a conscience. I have to sleep at night.” Mr. Leland quotes an elderly male patient exclaiming how he can’t get over the nursing service. His home nurse seems to have climbed fourteen floors in the dark to change the dressings on his leg wounds. And this patient adds that he can see how expensive the home nursing care must be. (Presumably covered by Medicare). But Mr. Leland follows with a quote from another elderly patient (a non-retired social work professor) who says, “This service saves a fortune because we don’t have to be in hospitals. They don’t pay these people enough.”

Indeed, that was something that was bugging me about the coverage of Sandy that I have been receiving: not enough attention to the consequences of extreme economic inequities being played out. (The residents of lower Manhattan being referred to as “The Dark People” for one thing.) I am sure that altruism and duty have been major motivators for the visiting nurses, aides and social workers who have provided essential services to people across the socio-economic spectrum. But they—and especially the home health aides who make minimum wage or just above—depend on the income from their jobs to feed, house, and clothe themselves and their families. They simply cannot afford the luxury of taking the day off.

David Rohde wrote an article on this for The Atlantic. In “The hideous inequality exposed by Hurricane Sandy” (10-31-12) he points out that income inequality in Manhattan rivals parts of Sub-Saharan Africa, and only Sierra Leon and Namibia have higher income gaps. I have walked the length of Manhattan many times, but until now had not realized how all of the major public hospitals are located in low-lying, flood-prone, power-outage areas.  The Manhattan skyline was forever changed with 9-11; the Manhattan skyline of light/dark, haves/have nots is perhaps forever burned into our national psyche. Now, to do something about it.

Moral Distress: Call for Stories

Moraldistress is the psychological disequilibrium when a person believes he or

Moral Compass
Moral Compass (Photo credit: psd)

she knows the right course of action to take but cannot carry out that action because of an obstacle, such as institutional constraints or lack of power. (source: Arizona Bioethics Network). Moral distress has been studied in nurses—mainly acute care nurses—since the 1980s. Although imperfectly defined and measured, moral distress appears to be strongly related to professional burnout and patient safety issues in a variety of health care professionals including doctors. (see NYT article “When Doctors and Nurses Can’t Do the Right Thing” Pauline Chen, 2-5-09).

A 2010 symposium focused on moral distress was held at the University of Victoria on Vancouver Island. As reported recently by Bernadette Pauly and her colleagues in the journal Healthcare Ethics Committee Forum (2012, issue 24) interventions targeting moral distress have focused on individual coping skills of nurses and other providers. (I’ve mainly seen interventions such as deep breathing, meditation and journaling.) Most research has focused on acute care nurses and has reinforced the notion of “nurse as victim” in the hierarchical hospital system. Pauly and colleagues called for greater attention to structural issues involved with moral distress, including the ethical climate of the hospital administration. In addition, they questioned the current emphasis in nursing education on teaching ethical frameworks instead of specific guidance and skills in how to navigate increasingly complex ethical terrain in everyday practice. They also recommended interprofessional education—bringing together nursing, medical and other health professions students for this sort of ethics education.

The journal Narrative Inquiry in Bioethicshas a call for stories about moral distress from nurses and other health care clinicians. It would be great to see submissions from nurses working in schools, public health, home health, community-based clinics, and occupational health sites, as well as from acute care settings. This is your chance to contribute to a forum that could contribute to some positive structural changes in our health care system—and not just more deep breathing and meditation trainings.

Here’s the information: Narrative Inquiry in Bioethics Call for Stories

Narrative Symposium: The Many Faces of Moral Distress Among Clinicians

Edited by Cynda Hylton Rushton, PhD, RN, F.A.A.N. and Renee Boss, MD, MHS

Narrative Inquiry in Bioethics will publish an issue devoted to personal stories from clinicians regarding situations that cause moral distress and how they have responded to them. Moral distress arises when professionals find that they are unable to act in accordance with their moral convictions. The focus of this inquiry is on the personal and professional short- and long-term impact of moral distress and the ways that clinicians respond to and make meaning from that distress. Appropriate contributors might include nurses, physicians, social workers, nursing assistants, clinical ethicists, occupational and physical therapists, and professionals in training. We want true, personal stories in a form that is easy to read.

In writing your story, you might want to think about:

·         Which specific clinical situations give rise to moral distress? Why?

  • How do you experience moral distress—physically, psychologically, socially or spiritually?
  • How do you deal with moral distress? In past distressing situations

o   Did you take actions that allowed you to uphold your deepest values?

o   What conditions within yourself, the people involved, and the external environment allowed you to do this?

o   How did you made sense of the situation?

  • What have been the short or long term consequences?

o   Have you ever been professionally disciplined for acting upon your moral conviction?

o   How has moral distress affected your job performance or your commitment to your job?

o   What has been left undone or been the residual impact?

o   How have your own values evolved as a result of moral distress?

  • How would you change the system (e.g., policies, hierarchies, processes) to alleviate moral distress within your position? Do you think it can be alleviated, or is it inevitable?

You do not need to address all of these questions—write on the issues that you think are most important to share with others. You do not need to be a writer, just tell your story in your own words. We plan to publish 12 stories (800 – 2000 words) on this topic. Additional stories may be published as online-only supplemental material. We also publish two to four commentary articles that discuss the stories in the journal.

If you are interested in submitting a story, we ask you first to submit a 300-word proposal—a short 
description of the story you want to tell. Please include a statement about what type of clinician you are and what kind of environment you work in (no institutional names are needed). Inquiries or proposals should be sent to the editorial office via email: narrativebioethics@gmail.com. We will give preference to story proposals received by Oct 31st. For more information about the journal Narrative Inquiry in Bioethics, the guidelines for authors, and privacy policies, visit our webpage with Johns Hopkins University Press at: http://www.press.jhu.edu/journals/narrative_inquiry_in_bioethics/guidelines.html

 

Bedside Nursing

British nurse in nurses' station.
British nurse in nurses’ station. (Photo credit: Wikipedia)

Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.

Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.

Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.

Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.

Then there is the fact that hospital-based jobs for nurses are rapidly disappearing as hospital administrators reduce their nursing staff, and as more hospitals merge or close altogether. Some experts claim that one-third of all hospitals in the US will close by 2020 (see David Houle and Jonathan Fleece’s post on KevinMD. 3-15-12)

Bedside nursing is probably a term that needs to be, well, put to sleep.