By Diana J. Mason, PhD, RN, FAAN. The “death panel” rhetoric that arose during the debates about health care reform is an example of what’s wrong with the conversations about health policy in this country. The sound bite was fear-mongering at its best–or worst, depending upon your view. The phrase was based upon the fabrication that the health care reform law, if passed, would authorize a government panel to decide which Medicare recipients should live and which should die. Nothing could be farther from the truth.

The proposed legislation included the authorization of payments to physicians for conversations about advance directives and end-of-life preferences on a periodic basis, even among Medicare beneficiaries who were healthy. The “death panel” rhetoric created such a firestorm among average citizens that it stopped public conversations about informed choices about planning for how one prefers to die.

In October of this year, the American Academy of Nursing sponsored a public forum entitled “Critical Conversations on Advanced Care Planning and Decision Making: Models That Work” at the Kaiser Family Foundation with the intent of restarting a public conversation about these important issues. The event was co-sponsored by the Archstone Foundation, California Healthcare Foundation, Jonas Center for Nursing Excellence, Rita and Alex Hillman Foundation, and the John A. Hartford Foundation. All of these foundations know that we cannot improve care at the end of life until we have more thoughtful conversations about how to educate the public, health care professionals, and payers about best practices in this realm.

One of the panelists, Amy Berman, RN, Senior Program Officer for the John A. Hartford Foundation, has been sharing her story about being diagnosed with incurable breast cancer and her decision to forego aggressive treatment that may or may not prolong her life but would certainly have made this first year since diagnosis one of coping with major surgery and the adverse effects of chemotherapy and radiation therapy. She announced at the forum that she was about to celebrate her first year post-diagnosis anniversary and that it had been the best year of her life. For Amy, her treatment choices have been about how she wants to life the rest of her life, not just how she wants to die. (more…)

By Diana J. Mason, PhD, RN. I was quite distressed to read in this morning’s news that the Obama Administration had reversed the new Medicare regulation that would pay for periodic conversations between physicians and patients about preferences for end-of-life care.  According to today’s New York Times, Speaker John Boehner said that  “the provision could be a step ‘down a treacherous path toward government-encouraged euthanasia.’”

Sara Palin started this rhetorical myth when she declared efforts to incorporate paying for such conversations under Medicare in the House health care reform bill (not included in the final law) as creating “death panels”. This lie is undermining advances that advocates for better end-of-life care have worked on over the past decades. While the Times article quotes an unnamed White House official as saying that this reversal will not preclude these conversations happening anyway, the reality is that conversations about the treatments one wants and doesn’t want at the end of life take time. If this time isn’t paid for, the conversations will not take place or will not be as thoughtful as they ought to be.

In 2010, the American Academy of Nursing convened a task force to develop a policy brief on end-of-life conversations (PDF) to counter the distortions of the “death panel” rhetoric. One of the recommendations is paying for these conversations — not just for physicians, but for nurses and social workers who may be the providers who patients and family members seek out to discuss these difficult issues.

Palin’s political rhetoric has co-opted reasoned discussions of policies to support better end of life care. I have talked with leaders of national consumer organizations, health-related organizations (including insurers), and foundations that are reluctant to engage in public discussions of end-of-life decision making because of how politicized the issue has become. Now the Administration runs in fear, too.  Those of us who know the evidence supporting better and more frequent conversations about end-of-life preferences, those of us who have seen people die a horrible death that is prolonged from unnecessary and agonizing medical interventions that are assaultive, those of us who have been part of someone’s experience of dying according to their own values and preferences and who know that dying can be as journalist Robert Lipsyte once described as “the richest of experiences” in his book In the Country of Illness — all who know how difficult, yet crucial end-of-life conversations are must not fear publicly challenging the myth of death panels. We need to point out that the real “death panels” are what occurs now when health care providers make the end-of-life decisions for someone who has not had the opportunity to explore and write down their preferences. Silence means that the death panels win.

By Diana J. Mason. The Institute of Medicine’s (IOM) report on the Future of Nursing released on October 5^th at the National Press Club was developed by an interdisciplinary committee after public hearings around the country and an exhaustive review of the literature on various related themes, such as the evidence on the outcomes of nursing care. Physicians Harvey Fineberg (President of the IOM) and Risa Lavizzo-Mourey (President of the Robert Wood Johnson Foundation) spoke to the importance of the report for improving health and health care in the United States. Risa specifically pointed out that the report was not so much about nursing as it was about how to transform health care. Additionally, committee member and physician Jack Rowe (former head of Aetna) spoke eloquently to the importance of ending interprofessional turf battles by focusing on what patients need.

Organized medicine continues to be stuck on protecting its view of its turf. In a statement issued after the IOM report was released, the American Medical Association (AMA) claimed that only physicians can lead health care teams because they are more educated than nurses. They claim it’s a matter of quality and safety, but they are ignoring the evidence to the contrary that is laid out in the IOM report. To better understand the origins of this turf battle, read Chapter 3 of the IOM report and look at the work of legal scholar Barbara Safriet.

What the AMA doesn’t seem to understand is that the future of health care requires skills that other health care providers have. Especially in primary care, clinicians need to emphasize health promotion, chronic care management, and care coordination. Physicians are highly trained diagnosticians of disease and surgeons, but this is a narrow skill set for primary care. The ideal is to have primary care physicians who can provide that expertise when needed but be on teams that may be headed by them, nurse practitioners, nurse midwives, social workers, or others. For example, for people with chronic mental illness who have developed important relationships with mental health practices, the social worker may be the best person to head the team.

Nurse-managed health centers have demonstrated that nurses can lead primary care centers that are health or medical homes using interprofessional teams that include physicians. We know that nurse practitioners can do 90% of what primary care physicians do with comparable outcomes, plus the health promotion and care coordination.

If we all can keep our eye on the real aim defined by Jack Rowe—focusing on what people need to promote health—the approaches to health care will become clear. Here’s hoping that the AMA achieves an understanding of this essential point soon.

I’ve grown weary of the public continuing to rate nurses as the most trusted profession (annual Gallup polls every year of this decade except 2001 when fire fighters understandably led the ratings), only to have leaders in health care agree but ignore us.

The Robert Wood Johnson Foundation released a Gallup poll that surveyed over 1500 opinion leaders in health care, including government officials, health care and insurance executives, and university faculty.

The survey found that:

• Doctors (54%) and nurses (42%) are the information sources about health and healthcare in whom opinion leaders have a great deal of confidence.
• Government (75%) and health insurance executives (56%) are viewed as most likely to exert a great deal of influence on health reform, compared to only 37% for doctors and 14% for nurses.
• 51% say nurses have a great deal of influence in reducing medical errors and improving patient safety
• 18% say nurses exert a great deal of influence on increasing access to care, including primary care.
• 39% say nurses will not have much influence on reforming health care over the next 5 to 10 years, compared with 10% of MDs.

Nothing new here to most nurses. We continue to have to be vigilant about whether nurses are included at decision-making and advisory tables, as speakers at national and regional conferences on quality and safety in health care, and on boards of health-related organizations. The next time you’re in a meeting on health care, look around the table and ask whether nurses are included — and not just a token RN. If they aren’t, ask why not and call for RNs to be appointed. Organizations and the nation are missing out if we don’t all change our expectations about who is at the table.

I was stunned to learn that New York City’s Bellevue Hospital was closing its birth center, leaving low income women in the city with no access to a birth center that accepts Medicaid.

Why are childbirthing centers in this country struggling to survive when they ought to be spreading? We know that they provide a wellness-model of pregnancy and birthing (as opposed to a disease model that hospitals have traditionally taken), use best practices in birthing, have excellent clinical outcomes, and save money. Staffed and usually managed by certified nurse midwives, childbirthing centers have been endorsed by the American College of Obstetricians and Gynecologists.

At the end of the Bush administration, someone in the Centers for Medicare and Medicaid Services realized that there was no mandate to pay these centers a “facility fee” that provided support for overhead. So, after years of paying this fee, CMS stopped paying it to childbirthing centers and now pays it only to hospitals.

The numbers I’ve seen suggest that a vaginal delivery in a hospital costs 5 to 6 times more than in a childbirthing center. Ruth Watson Lubic, one of the pioneers of the childbirthing movement, founder of the Family Health and Childbirthing Center in Washington, DC, and a Disruptive Woman, has estimated that using these centers for just Medicaid births could save the nation $1-2 billion each year.

As our nation struggles to figure out how to pay for reforming the insurance industry, we can start to reform health care delivery in affordable, quality ways by ensuring that all pregnant women have access to the childbirthing centers. For those who want to act now, you can sign a petition calling for restoration of the Bellevue Hospital center. Or learn more about legislation to require CMS to restore the facility fee to childbirthing centers.

As the nation focuses on how to cut the cost of so-called health care reform, maybe it’s time to pay attention to demonstrated methods for improving care while reducing costs that are not yet supported by Medicare and other payers. We cannot afford the system we have and changing it should be on the top of the agenda for anyone who wants to extend coverage of health care to all and improve health outcomes.

For example, many readers of this blog will have had the experience of being a patient or family caregiver for someone who is older and has multiple chronic health problems that periodic become acute and require hospitalization. Once discharged from the hospital, the patient and caregiver often feel at a loss for how to manage some of the problems that can arise even within hours of discharge. A study published in the New England Journal of Medicine in April of this year reported that one in five Medicare patients who are discharged from a hospital will be readmitted within 30 days. That number keeps increasing with time, so that by the end of one year, about half of these patients will have been readmitted. This is costing the nation an estimated $17 billion.

Mary Naylor is a nurse researcher at the University of Pennsylvania who has spent more than 20 years developing and studying what she calls a Transitional Care Model (PDF). Under this model of care, an advanced practice registered nurse (APRN) goes into the hospital when high risk (for readmission) patients are admitted. The APRN assesses the patient and family caregiver, clarifies the plan of care and coordinates the input of sometimes multiple health care providers, prepares the patient and family caregiver for discharge, then makes a home visit within the first 24 hours after discharge and continues to work with the patient and family caregiver for up to 90 days post-discharge. Naylor says this is more than “care coordination.” She sees it as an opportunity to help patients and families rethink how they approach and manage their care. The APRN will even go with the patient and family caregiver on a follow up visit to the physician’s office to model how to make the best use of this time.

Naylor isn’t the only one doing this work. Eric Coleman of the University of Colorado at Denver Medical Center and Chad Boult of the John Hopkins University Health Institute have developed variations on the Naylor model. All show that hospital readmission rates decrease, money is saved and health outcomes improve in some way.

Now AARP has worked with Congress to develop a Medicare Transitional Care Act (H.R. 2773/S. 1295) that has been introduced into both houses of Congress. The Act calls for Medicare to pay for a transitional care benefit, first for high-risk patients and then, if the outcomes of this first phase are satisfactory, for low- and moderate-risk patients. It’s long overdue. I now believe it to be unethical for hospitals to discharge patients knowing that they don’t have the knowledge and resources to help them through this difficult transition to home. To read about the details of the bill, go to http://www.govtrack.us/congress/billtext.xpd?bill=s111-1295. The bill needs advocates who will urge Senators and Representatives to sign on as co-sponsors or, at the very least, support this important legislation.

While many people celebrate Barack Obama being the first African-American president, I was celebrating having intelligence back in the White House. He’s so smart, he’s surrounding himself with other smart people. The latest “smart” appointment is Mary Wakefield, PhD, RN, FAAN, to head the Health Resources and Services Administration. I’ve known Mary for a number of years and can tell you that she is sharp as a tack. She’s been the Director of the Center for Rural Health at the University of North Dakota, but her credentials include chairing the Institute of Medicine Committee on Health Care Quality for Rural America, serving on the other quality commissions of the IOM, and serving as Staff for United States Senator Kent Conrad (D-ND) from January 1993 to January 1996 and as Legislative Assistant and Chief of Staff to Senator Quentin Burdick (D-ND). HRSA has oversight of the nation’s community health centers and other initiatives that will be key to building a coordinated health care system with improved access and quality. We are in very good hands.

For several years, my family has held a grab bag holiday get-together. People are to bring inexpensive gifts, often intended more for laughs than for use. My extended family includes nieces and nephews ranging in age from 15 to 30, some with children and others who are sexually naïve, even if not virgins. Mine is not a family that discusses sex. My living siblings are reborn Christians, who deem appropriate only discussions of abstinence for those youth not yet married. However, as a nurse, I’ve made it clear that their auntie will not shy away from sexual discussions. I have been known to initiate such conversations with a niece or nephew and even their friends when I have some time with them.

“ONE PREMIUM LUBRICATED Lifestyles® LATEX CONDOM”

So this year, one of my grab bag gifts was condoms. My courage to make this a visible ‘gift’ at the holiday party arose from New York City’s model of making condoms available anywhere and everywhere. The city has rightfully been aggressive in distributing condoms since Thomas Frieden assumed the position of Commissioner of the Department of Health and Mental Health and saw that a large proportion of people in the city who are HIV-positive don’t know it and can be spreading it unintentionally by having unprotected sex. In 2007, the city launched a NYC-branded condom and has since given out over 70 million of them for free. (more…)

What’s not to like about the idea of Sanjay Gupta being the next Surgeon General of the United States?

It may be viewed as a brilliant move since Gupta is widely known because of his work on CNN and well known among journalists. It could be a great way to get media to pay attention to your message when you’re in a position that may be considered by some to be largely ceremonial.

But that should not be the case. Certainly, C. Everett Koop learned how to use the position as a platform to advance important public health initiatives, such as quitting smoking. The surgeon general heads up the large Public Health Service that does important work on things like disaster preparedness and response, disease control and prevention, mental health, and even international health. Gupta is a neurosurgeon. The Public Health Services Act specifies that the Surgeon General be experienced in public health.

Of course, his role with CNN has equipped him—out of necessity—to focus more on public health matters. But why would President-elect Obama not select one of the many highly qualified public health professionals? For example, Thomas Frieden is the bold commissioner of health for New York City. He’s been brilliant on issues such as diabetes, changing what people know about healthy versus unhealthy foods, banning transfats from restaurants, and more. He knows the breadth of public health, what works and what doesn’t in this field, and is a pretty good spokesperson. I’ve interviewed him on a radio program I produce in New York City and he was excellent in discussing the priority issues for promoting the health of New Yorkers. (Note: He has not told me that he wants the position.)

I also don’t believe that the position has to be filled by a physician. For example, Kristine Gebbie is a nurse who is the former commissioner of health for Washington State and Oregon. (Note: She has not told me that she wants the position.) And other non-nurses with public health experience should be considered.

Regardless, it will be interesting to see what unfolds. Koop’s appointment was not supported by the American Public Health Association because he was a pediatric surgeon, not a public health expert. But by most counts, Koop’s performance as Surgeon General earned him kudos for taking on some controversial issues. Perhaps the lack of unanimous support from the public health community spurred him to rise to the occasion.

Maybe Gupta will do likewise.

So-called “medical homes” are finally receiving national attention from the Centers for Medicare and Medicaid and foundations after their purported inception over 30 years ago by pediatricians (home care nurses have been coordinating health care for people with chronic illnesses for more than a century). But we’re about to make the same mistake that we’ve made in developing other approaches to improving health care nationwide—we’re medicalizing it, instead of focusing on health.

Medical homes are proposed to be primary care practices where people can get help with coordinating their care, particularly for chronic illnesses. The U.S. health care system emphasizes specialty practice rather than primary care. It’s one of the reasons why we pay more than any other nation for health care but have outcomes that lag behind those of even moderately developed nations. If I have diabetes and heart failure, I go to one specialist for treatment of my diabetes, the cardiologist for my heart failure, the gynecologist to get my annual GYN exam, a podiatrist, a retinopathist or ophthamologist, a dentist who may prescribe medications before and after procedures, a shrink to help me cope with this mess, and possibly others to screen my various body parts for myriad diseases. Each is prescribing medications that may interact in adverse ways. In fact, I may end up with a costly hospitalization because of these adverse effects. No one knows all of me or focuses on my overall health—unless I have a primary care provider who can oversee all of these specialties, follow all of my treatments and medications, and coordinate my care. (more…)

Regulate–deregulate. Can we really solve the crises in the economy and health care by doing one or the other? Is it really so simple?

I’m not an economist, but I am a nurse and journalist who can tell you that regulations in health care serve to protect the public. They can also get in the way of better care.

Consider the story of Dr. Meridean Maas, RN, and Dr. Janet Specht, RN, two advanced practice geriatric nurse specialists who had extensive expertise in long-term care of people with dementia. Based in Iowa, they realized that the facilities where they had worked were not places in which they would put their own parents. They believed they could provide a better model of care and decided to prove it. They took out a loan for $350,000 and a received a grant from the Iowa Development Corporation to purchase a ranch-style home with acreage that they called Liberty Country Living. They created a home-like atmosphere for people with dementia who dressed in their own clothes and could walk the fenced-in property without fear of becoming lost. Staff ate with the residents and got to know their interests and backgrounds, often encouraging the residents to engage in activities that held meaning for them. Family were told to come any time and supported in being with their loved ones as much as possible. (more…)