Do Medicare Beneficiaries Warrant Higher Nurse-Patient Care Coordination Ratios?

In yesterday’s posting on care management nurse-staffing ratios and their associated costs, Peter McMenamin pointed out that a per member per month cost (PMPM) that ranged from $8 to $17 was a reasonable estimation.  What's more, it compared favorably to the monthly management fee in the Comprehensive Primary Care Initiative. 

This is also important for Accountable Care Organizations that are grappling with the amounts that they’ll need to invest in care coordination to achieve the shared savings.  Assuming an ACO becomes accountable for 5,000 beneficiaries, that calculates out to between $480,000 and $1,020,000 per year.

But, asked the Disease Management Care Blog, should there be any differences in care management ratios and costs for Medicare, Medicaid and commercial insurance?  If it’s a commercial ACO, should it estimate $500K, while a Medicare ACO should plan lower ratios and invest $1M?

Peter McMenamin’s thoughts:

A parity between Medicare, commercial, and Medicaid is possible but not exactly plausible.  Thanks to many co-morbidities, Medicare patients have more different docs, more visits, and more drugs.  Unless they are particularly compliant with respect to medications, you’d expect Medicare patients to be more demanding.  Unless they return to a physician so frequently that care coordination is incidental or are hospitalized so much that their care is taken care of, they need considerable care management. If Medicare patients take more time for follow-up, etc. that might explain the difference between $20 PMPM and the somewhat lower PMPM estimates from my calculations.

Good point, of course.  Yet the DMCB is not so sure that there is a correlation between savings and the intensity of care management beyond a certain threshold for any patient of any age.  In addition, while persons with Medicare have greater illness burden, that doesn’t mean the day-to-day management, care plans and shared decision making for conditions like diabetes or heart failure making varies depending on a patient’s age.

Dr. McMenamin and the DMCB will keep their eye out for answers.  More to follow.

A Dose Of Nursing Home Reality

"Hello, Dr. Smith? This patient has a fever..."

Read this New England Journal Perspective by Drs. Ouslander and Berenson on Reducing Unnecessary Hospitalizations of Nursing Home Residents, and it's easy to conclude that the enlightened application of better documentation, quality assurance, payment reform, administrative policies, decision support, guidelines, appropriate downjobbing and delegation of responsibility will keep many sick and feverish nursing home residents away from the unnecessary expense of emergency rooms and hospitals.

Were that it was so simple.  Such is the unreality of many Journal authors inhabiting the oxygen-deprived academisphere.

When residents of nursing homes get sick, they require a significant amount of nursing attention.  Since busy, salaried (and sometimes understaffed) nursing home personnel aren't compensated for the additional work of documenting, monitoring and worrying about that sick patient down the hall, they have every incentive to transfer sick patients elsewhere.  No amount of macroeconomic policy making bells and whistles is likely to change that.

When physicians and other non-physician providers are alerted by the nursing home personnel that a patient is sick, they have been taught that the best approach is to evaluate the patient in person. That takes time and effort.  While they may be compensated for the additional work of a bedside evaluation, it's not enough to make up for the additional work of documenting, monitoring and worrying about that sick patient down the hall.  So, they also have every incentive to agree with the nurse and transfer the patient to a setting where a bedside evaluation is available.  At 2 AM, the answer is to move that bedside to the local emergency room.

Would the bells and whistles that Ouslander and Berensen be enough to keep the nursing homes and the doctors from sending most sick patients to the emergency room?  Based on the simple realities described above, the answer is no.

Nurse Care Managers: The Mortar Holding the Bricks of the Patient Centered Medical Home (PCMH)

It's no secret that the Disease Management Care Blog is an enthusiastic believer in nurse care managers.  In its humble opinion, it makes no difference what "bricks" are used to build a Patient Centered Medical Home, an Accountable Care Organization, a Population Health Management Program or an employer-based care support/wellness initiative, the nurses are the mortar.

Readers can read more on how this specifically works in a DMCB co-authored article titled "The Focus of Case Management Grows" in this on-line version of The Case Management Society of America's (CMSA) Case In Point magazine.

While the manuscript focuses on the PCMH, its lessons can be applied to any corner of primary care:

1. Some patients have higher health care needs, more care gaps and greater risk.  Surveys and analyzing insurance claims and electronic health record data can find them.

2. There are cheap medical  interventions that increase quality and lower costs.  Nurses know about them and, when they're supported by physicians, can champion their use among patients with the most to gain.

3. Most patients want to meaningfully participate in their own care.  This goes to the core of patient centeredness and these nurses know how to harness that energy.

As systems confront the limitations of pay-for-performance, the disappointments of the EHR Kool-Aid, the inertia of Washington-run health care and dwindling budgets, the DMCB is confident that these nurses will finally get the recognition they deserve. What's more, patients will be better off for it.

"Practice At Top Of License" - The Newest Phrase in Dog Whistle Politics

The Disease Management Care Blog remains fascinated - if irritated - by the lingering pestilence of "dog whistle" politics. Readers may recall that this is the use of otherwise innocent sounding rhetoric that conveys deeper meaning that is only "audible" to a tuned-in constituency. So, when the DMCB announces that it supports cinematic art that explores the impermanence of life, the clued-in DMCB spouse quickly discerns this is really all about watching vulgar zombie movies.

One juicy health care dog whistle that's emerging is the phrase "practice at the top of license" as applied to non-physician professionals. To most people, this is interpreted to mean that nurses, pharmacists, optometrists, podiatrists and other health professionals should be able to care for patients at a level commensurate with their training and local State law. Ask an attuned and politically savvy nurse, pharmacist, optometrist or podiatrist what that really means, and you'll get a different answer: this means that they should be able to independently take care of and prescribe treatments for patients without doctor oversight.

Not much seems to be actually written about this (for example), which leads the DMCB to think that only makes it more deniable. It has certainly heard that phrase from many speakers at many conferences on the topic of primary care, access, manpower, patient centered medical homes and accountable care organizations.

This isn't going to be a small issue. Other than the eternally irksome topic of the Medicare sustainable growth rate, there is probably no other issue that is more likely to vex the organized physician groups. For the latest example of this, contrast the Institute of Medicine Report Brief on The Future of Nursing (the phrase here is a similar dog whistle "practice to the full extent of their education and training") with the response of the American College of Physicians: "Physicians and nurses complete training with different levels of knowledge, skills, and abilities that are complementary but not equivalent."

The DMCB appreciates both sides of the issue, which may be suitable for a future post. The important issue here, however, is that the same dog whistle contagion that infected reform ("cover all Americans" really being interpreted as the government option, "provider efficiency" meaning economic credentialing of doctors and the "Patient Bill of Rights" meaning "please forgive us for passing this ugly bill") continues to cheapen what should be an ongoing, open and civil health care debate that brings credit to our Republic.

The next time the DMCB hears the term, it's going to call the speaker out. The topic deserves to be examined in the light of day.

Image from Wikipedia

Advanced Practice Nurses As A Solution to the Crisis in Primary Care

The Disease Management Care Blog welcomes colleague M’Lynda Owens, who is pursuing a PhD in nursing and has extensive experience in the health care industry. She makes an important point: if the market isn’t willing to support primary care and the physicians themselves are walking away from that specialty, why would anyone oppose the expansion of nurses in this field, especially when there is so much science that supports it? Given that point of view, she also offers up some recommendations for health care reform:


This nurse couldn’t help but respond to the provocative comment quoted in the DMCB's recent ‘Selected Quotes’ posting: "When asked about physicians that are reluctant to transform their practices into patient centered medical homes, Gordon Norman offered this astute solution: 'Fine, let the nurses do it.' The silence in the hall was telling."

I've watched the national conversation about health care reform and find the silence surrounding the role of non-physician primary care providers (PCPs) deafening. Advance practice nurses (APRNs) and physician assistants (PAs) have been serving with distinction as PCPs for more than 40 years. Numerous studies (for example here, here, here, here, here and here) have repeatedly demonstrated high clinical quality and patient satisfaction associated with APRNs. In addition to their clinical outcomes, they’re also trained to commit more time talking with and listening to patients during encounters and have an excellent record of patient safety in a wide variety of settings.

APRNs do not want to displace physicians. What they are willing to do is use their training to fill the growing gaps in health care coverage. Physician groups note with alarm that increasing numbers of medical students are not choosing careers in primary care. That may not be necessarily bad. The level of education and skill possessed by specialist physicians for highly acute and complex cases warrants extensive training and should be commensurately rewarded. But someone has to serve in primary care. So if physicians don't want the job, why not let the nurses do it?

As noted above, there is ample science that shows that it doesn't take physician training to manage many of the tasks involved in primary care access, including treating upper respiratory illness, conducting wellness exams, caring for minor trauma, providing institutional care in nursing homes and prisons, following normal pregnancy, treating stable chronic conditions, collaborating with disease management initiatives and addressing the myriad other routine reasons people seek first-contact medical care. In addition, APRNs are paid less than physicians – which helps with cost containment for these types of services. Last but not least, APRNs are willing to serve in rural and economically disadvantaged areas, where reimbursements are low. This is Disease Management 101. Other than the turf battles, why not support letting the nurses practice what they've been trained to do in an evidence-based manner?

To make this happen, the following need to be included right now in health reform:

1. Independent licensure and prescriptive privileges across the 50 States are necessary so that physicians are not statutorily saddled with "supervising" or "collaborating" with APRNs who can competently practice and prescribe medications independently in all but 12 states. An APRN, practicing within her (yes, 95% her) independent licensure, should not be statutorily forced to find a physician willing to take on the oversight of another's practice.

2. Insurers need to reconsider their unwillingness to independently empanel and reimburse APRNs.

3. While the educational roles of pharmaceutical companies are being reexamined, they should drop their reluctance to provide educational support and pharmaceutical samples to APRNs; they are not shadow providers;

4. Pharmacies should honor APRN prescriptions that are not co-signed by a physician.

5. We also need to continue to gather hard data on the safety and efficacy of APRN practice patterns, including their contribution to the care of populations with chronic illness

Why not support the nurses? For the sake of cost containment, access, quality, and disease management, it just makes sense.