Tuesday, May 30, 2017

MD and DNP: WHy 20,000 Hours of Difference in Training and Experience Matters

As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation.  While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base.  They should not identify themselves as “doctors” despite having a Doctor of Nursing Practice (DNP) degree.  It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP.  Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.
After residency, a physician has accrued a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate.  As healthcare reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower healthcare spending overall should be revisited.  While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.
Nurse Practitioners already have independent practice rights in Washington State.  In my community, one independent NP has had 20 years of clinical experience working with a physician prior to going out on her own.  Her knowledge is broad and she knows her limits (as should we all); she prominently displays her name and degree clearly on her website. This level of transparency, honesty, and integrity are essential requirements for working in healthcare.  Below is a cautionary tale of an independent DNP elsewhere whose education, experience, and care leave much to be desired.  I thank this courageous mother for coming forward with her story.
After a healthy pregnancy, a first-time mother delivered a beautiful baby girl.  She was referred to “Dr. Jones,” who had owned and operated a pediatric practice focused on the “whole child” for about a year.    This infant had difficulty feeding right from the start.  She had not regained her birthweight by the standard 2 weeks of age and mom observed sweating, increased respiratory rate, and fatigue with feedings.  Mom instinctively felt something was wrong, and sought advice from her pediatric provider, but he was not helpful.  This mother said “basically I was playing doctor,” as she searched in vain for ways to help her child gain weight and grow.
By 2 months of age, the baby was admitted to the hospital for failure to thrive. A feeding tube was placed to increase caloric intake and improve growth.  I have spent many hours talking with parents of children with special needs who struggle with this agonizing decision.  It is never easy.  A nurse from the insurance company called to collect information about the supplies, such as formula, required for supplemental nutrition.  Mom was so distressed about her daughters’ condition, she could not coherently answer her questions.  As a result, the nurse mistakenly reported her to CPS for neglect and a caseworker was assigned to the family. 
Once the tube was in place, the baby grew and gained weight over the next three months.  At 5 months of age, mom wanted to collaborate with a tube weaning program to assist her daughter with eating normally again.  A 10% weight loss was considered acceptable because oral re-training can often be quite challenging.  As this infant weaned off the tube, no weight loss occurred over the next two months, though little was gained.  She continued to have sweating with feeds and associated fatigue.  On three separate occasions mom specifically inquired if something might be wrong with her daughters’ heart and all three times “Dr. Jones” reassured her “nothing was wrong with her heart.” 
However, “Dr. Jones” grew concerned about the slowed pace of weight gain while weaning off the feeding tube.  Not possessing the adequate knowledge to recognize the signs and symptoms of congestive heart failure in infants, he mistakenly contacted CPS instead.  After being reported for neglect a second time, this mother felt as if she “was doing something wrong because her child could not gain weight.”  This ended up being a blessing in disguise, however, because the same CPS worker was assigned and recommended seeking a second opinion from a local pediatrician. 
On the first visit to the pediatrician, mom felt she was “more knowledgeable, reassuring, and did not ignore my concerns.”  The physician listened to the medical history and upon examination, heard a heart murmur.  A chest x-ray was ordered revealing a right-shifted cardiac silhouette, a rather unusual finding.  An echocardiogram discovered two septal defects and a condition known as Total Anomalous Pulmonary Venous Return (TAPVR), where the blood vessels from the lungs are bringing oxygenated blood back to the wrong side of the heart, an abnormality in need of operative repair. 
During surgery, the path of the abnormal vessels led to a definitive diagnosis of Scimitar Syndrome, which explains the abnormal growth, feeding difficulties, and failure to thrive. This particular diagnosis was a memorable test question from my rigorous 16-hour board certification exam, administered by the American Board of Pediatrics.  If one is going to identify themselves as a specialist in pediatrics, they should be required to pass the same arduous test and have spent an equivalent time treating sick children as I did (15,000 hours, to be exact.)
A second take away point is to emphasize the importance of transparency.  This mother was referred to a pediatric “doctor” for her newborn.  His website identifies him as a “doctor” and his staff refers to him as “the doctor.”  His DNP degree required three years of post-graduate education and 1,000 patient contact hours, all of which were not entirely pediatric in focus.  His claim to have expertise in the treatment of ill children is disingenuous; it is absolutely dishonest to identify as a pediatrician without actually having obtained a Medical Degree. 
The practice of pediatrics can be deceptive as the majority of children are healthy, yet this field is far from easy.  Pediatricians are responsible for the care of not only the child we see before us, but also the adult they endeavor to become.  Our clinical decision making affects our young patients for a lifetime; therefore it is our responsibility to have the best possible clinical training and knowledge base.  Acquiring the aptitude to identify congenital cardiac abnormalities is essential for pediatricians, as delays in diagnosis may result in long-term sequelae such as pulmonary hypertension which carry with it a shortened life expectancy. 
Nurse practitioners have definite value in many clinical settings. However, they should be required to demonstrate clinical proficiency in their field of choice before being granted independent practice rights, whether through years of experience or formal testing.  In addition, the educational background of the individual treating your sick child should be more transparent.  When it comes to the practice of medicine, the knowledge and experience required are so vast that even the very best in their field continue learning for a lifetime.

Raising our children is the most extraordinary undertaking of our entire lives.  Parting advice from this resolute mother is to “trust your gut instinct, and no matter what, keep fighting for your child.” Choosing a pediatrician is one of the most significant decisions a parent will make.  This child faced more obstacles than necessary as a result of the limited knowledge base of her mid-level provider.  A newly practicing pediatrician has 15 times more hours of clinical experience treating children than a newly minted DNP.   When something goes wrong, that stark contrast in knowledge, experience, and training really matters.  There should be no ambiguity when identifying oneself as a “doctor” in a clinical setting; it could be the difference between life or death. 

Tuesday, May 23, 2017

Memorial Day: My Reflection on 10 Years Without My Brother

This week is the 10th anniversary of the loss of my younger brother, Laith. On the
Saturday morning of Memorial Day weekend 2007, my life changed forever.

Our practice lost two individuals to drownings this year, and I am always reminded how precious life can be. The pain of loss never goes really away, rather we do our best to live with it.

Siblings are a part of you before they are born and remain in your heart long after they are gone. I was five and a half years old when my mother first told me she was expecting. After 37 years, this particular childhood conversation is crystal clear in my mind.

My mother had a beautiful baby boy in September 1980 and he grew up to become an extraordinary young man. It seems so long ago, yet his time here went all too fast. He took his final breath, due to an accidental fall, ten years ago. Those of us who knew him and loved him have yet to catch our breath and probably never will. It is hard to believe a decade has passed since I last looked into his sparkling brown eyes.

Much is written about grief accompanying the loss of a child, spouse, or parent. When it comes to losing a sibling, however, the literature is oddly scarce. No other relationship mimics that between siblings. It is a unique closeness forged in happiness, anger, love, frustration, and understanding, altogether coupled with similar genetic ingredients.

I naively believed lightening would not strike twice. My parents already buried one child, my older sister Laila, who drowned when she was two years old. As the oldest of the remaining four, I was fiercely protective of my three younger brothers. As we embraced adulthood, we relished the fact we were the best of friends, partners in crime, and confidantes.

These three young men shaped the woman I became, giving me a glimpse into the often elusive male world. Siblings are supposed to be our partners for life. One brother has been with me for 40 years, the youngest clocks in at 31 years, and Laith was with me for 26 before his untimely death. Many people are not married that long, no matter how many times they try.

But nothing remains perfect and nothing lasts forever. That is the first of many lessons I have learned over the last decade. Unavoidable obstacles sometimes cause time to run out for some far earlier than expected. There is no map and compass to guide us through the tragedies along the way. You just keep putting one foot in front of the other, moving forward because you must. The sun rises and sets each day despite your wishes to the contrary. Time never stops.

I never imagined saying goodbye to my younger brother so soon. His tragic death has left a deep wound that will never completely heal. It has scabbed over, but gets ripped off unexpectedly serving as a reminder of our unbearable loss.

Ironically, my husband and I were married one month after my brothers’ death. On my wedding day, he was missing. His birthday in September brings me to tears. I will never hear that voice I miss so much. I will always remember the last time we hugged and said, “I love you.” It was the final goodbye that never should have been.

A few weeks after his belongings had been sorted; I found a Ziploc bag in which he kept things most precious to him. He collected letters from his first serious girlfriend, pictures of friends, and a few birthday cards from Mom and Dad. Then I discovered assorted postcards, notes, and pictures from me. He kept those mementos, picked them up from time to time, and knew how much I loved him.

Something that cannot be lost is almost 27 years of shared memories. His smile is indelibly imprinted on my brain, his laugh can be found tucked away deep inside my soul, and his infectious personality is intricately woven into each story I share. Preparing him for those job interviews, giving him advice about girls, and helping him clean his perpetually messy apartment are experiences to be cherished for the rest of my life.

For me, the most valuable lesson learned over the past decade is how unpredictable life can be; there are no guarantees. After having four children of my own, my parenting goals are so much simpler than they might have been before. The “best-I-can-do” is good enough; everything does not have to be perfect.

My little brother grabbed life with both hands and experienced everything he possibly could in the moment. I strive to make the most of each and every day with my own children and be grateful for that time, however long or short, in honor of my little brother. He would not have wanted it any other way.

Wednesday, May 17, 2017

GEHA's Seven-Year "Glitch"

In a little piece of legislation known as the Affordable Care Act, preventive services are mandated to be covered with no out-of-pocket expense to consumers.  According to the Healthcare.gov website, approved insurance plans must cover a “list of preventive services for children without charging a copayment or coinsurance.”  Number 18 on that preventive care list is:  childhood immunizations for children from birth to age 18, acknowledging regional variation in the standard recommendation schedule.  After all, vaccinations are the cornerstone public health achievement of the last century and have saved countless pediatric lives. 
Alas, all fairy tales must come to an end.  For government employees choosing GEHA insurance coverage, that type of prevention comes at a definitive out-of-pocket cost.  According to Wikipedia, GEHA is a self-insured, not-for-profit association providing health and dental plans to federal employees and retirees and their families through the Federal Employees Health Benefits Program (FEHBP) and the Federal Employees Dental and Vision Insurance Program (FEDVIP). According to the US Census Bureau 2014 statistics, Washington State has approximately 341,000 state and local government employees.  My hometown has three very large installations, the Puget Sound Naval Shipyard, Naval Undersea Warfare Center Keyport, and the Bangor Naval Submarine Base employing a large number of full-time employees and contractors.   Many of these individuals have health insurance coverage provided by the Government Employees Health Association (GEHA) insurance plan. 
Surely, the benevolent executives at GEHA are familiar with the Affordable Care Act and its preventive provision mandate.  They must also realize immunizations for children under 18 years of age qualify under the umbrella of preventive care.  So what seems to be the problem? 
For the past fifteen months, EVERY single explanation of benefit (EOB) paperwork mailed to physicians who are practicing in the Pacific Northwest and patients who are employed by the government shows $50-100 of “out of pocket” cost per visit for immunizations and their administration being kicked to patients.  Isn’t it terrible the government can no longer afford comprehensive health insurance coverage in compliance with the ACA for the hardworking men and women they employ? 
Can you imagine what will happen to these families when GEHA continues to operate unchecked and refuses to bear the costs of cholesterol testing, diabetes screening, or annual mammograms?  Washington State already has a mumps outbreak which is massively out of control.  Forcing employees of the federal government to fork over for each and every vaccination for their child is certainly not going to help improve health outcomes. 
After reviewing more than 100 EOB’s personally, a clear and definitive pattern of fraud emerges demonstrating GEHA makes every single patient responsible for $50-100 in out-of-pocket costs for immunizations.  Language in our GEHA contract clearly states we must follow their specifications according to each EOB we receive.  Being the diligent small pediatric office we are, a bill for the amount is sent off to the patient each and every time. 
At first, families would call to inquire why they were “responsible” for “out-of-pocket” preventive care costs.  My answer was simple.  “It violates the central statute of the ACA, but no one can stop the government from ignoring the law of the land.”  Underneath it all, the GEHA fraud is likely just another one of those oversights “allowed” to continue while the federal government looks the other way. 
One meticulous parent called GEHA to figure out what the problem was. GEHA was “shocked” about this small, insignificant computer “glitch” and the customer service representative assured her the mistake would be corrected.  (That was 15 months ago with still no correction in sight.)  The mother forced GEHA to send us a corrected EOB reimbursing us properly for preventive services provided in accordance with ACA guidelines and removing the balance from the patient responsibility category. 
Over the last 15 months, despite many employees complaining to their respective HR departments, patients complaining to the GEHA customer service line, and my office complaining to provider relations about the difficulty getting paid correctly for preventive visits the first time, all of our efforts have been in vain.  The mysterious “glitch” simply cannot and will not be fixed.  (My guess is it may be the same incompetent information technology team who were involved in the healthcare.gov site debacle working on this befuddling “glitch.”)
It got me to wondering about the number of offices who miss the fact GEHA is shorting them by $50-100 per patient well child check-up?  And then I realized the indirect benefits of the GEHA “glitch” to the insurance company.  GEHA must be saving an awful lot of money this way.  This indomitable “glitch” might even be occurring nationwide, in which case, it is saving millions upon millions of cold hard cash. 
Slowly the realization dawned on me that the chance GEHA will fix their innovative money-saving “glitch” is about the same chance a man with a wooden leg has of escaping a forest fire.  I can tell you exactly who the one-legged man in the forest fire is – it is the primary care physician.  Why does the insurer always get to strike the match, start the forest fire, and watch us burn?  When will GEHA be forced to comply with the provisions mandated in the Affordable Care Act and who pray tell is going to enforce the law of the land?

Tuesday, May 9, 2017

Dear President Trump

I hope you read this letter.  I doubt you will.
I know you’re busy rebuilding Washington, reshaping the international order, and doing a lot of other weighty stuff.  Full disclosure, I voted for you.  Not because you promised to repeal the Affordable Care Act, or because you tweeted at me about it, but because our healthcare system is hopelessly broken and requires an overhaul that does not simply convert over to a single payer system.
Recently you were quoted in an interview with Reuters: “I loved my previous life… I had so many things going… this is more work than my previous life. I thought it would be easier." Yes.  I did too.  Welcome to the frustrating world of shaping health care for a nation.  It should be about making others’ lives better, but instead it is about padding lobbyist pockets. 
There are people who say you’re the wrong man for this job. I am undecided on this.  You’re famous for your hatred of complicated solutions.  They annoy you. They annoy you because you know they’re a waste of time and energy.  Time and energy that can be put into more important things.
You’re also well known for your distrust of experts, who you’ve learned to dislike after years of doing business and listening to boring presentations by people who don’t know what they’re talking about. There are more experts in healthcare than any other area of the economy.  Does that tell you something? I think it should.
If you want any chance of being re-elected next go around, we must get cracking on building the healthcare infrastructure from scratch.  It is not going to be easy, but you already learned this lesson per your statement above.  So how do we streamline health care reform and get ‘er done? 
There are two main problems:  access (coverage) and runaway cost.  The Affordable Care Act provided coverage to many and coupled it with cost control to no one.  This made affordability unachievable for the long-term and things will continue to get worse. 
Congress is currently on the wrong track headed to an empty station.    The general approach of the American Health Care Act is to decrease costs by cutting coverage to the people.  Please go back to the drawing board and start again.  Throwing support behind the American Health Care Act is just flogging a dead horse.  People in this country want affordable healthcare choices and freedom from fear of no access for chronic conditions and unforeseen catastrophic events.  They no longer want to worry about health issues bankrupting them.  Struggling families are one catastrophic illness away from losing their American Dream and that must change.  Step back and take in the big picture. 
Stop focusing on the minutiae.  Instead, start small to overhaul healthcare one phase at a time.  Develop a system which provides immunizations, annual screenings, and simple but necessary medical interventions to every person in the country.  Call it basic care.  You can expand the Community Health Clinic model or utilize the existing Public Health system which is sorely underfunded and underutilized, yet remarkably cost-effective.  Physicians are not required to administer immunizations, take blood pressure, and check cholesterol levels.   Save money by putting mid-level providers in these roles. 
Some basic specialty care could be provided at the public health facilities or community clinics and mid-level specialty providers could fill these positions.  If an individual becomes severely ill or injured and requires more specialized care, needs hospitalization, or surgical intervention, then their catastrophic insurance plan will kick in to cover these needs. 
This is how insurance was created to work, by covering the expense of unanticipated events. Embrace the idea that health insurance should be for:  cancer, heart attacks, car accidents, and other unexpected issues.  The cost of health insurance would decrease considerably if it functioned more like actual insurance and less like a system to reimburse physicians for routine, expected health maintenance.  Third party payers distance patients and physicians from being cognizant of real cost. 
Finally, allow the free market to play a role by giving people options.  80% of healthcare can be handled in a Direct Primary Care practice, where patients pay the physician and enter into a more contractual relationship.  This provides the options many physicians and patients are afraid of losing in a single payer system, an idea that was extremely unpopular in the past.  Health savings accounts could be set up to cover out-of-pocket costs for those who are interested in care outside of the public health system or name brand medications, which are more expensive than generics.
Last but not least, ignore the special interest groups for the time being.  No one else has tried to overhaul health care without kowtowing to them and it is high time someone with big (Ahem) aspirations just went for it.  You are the right person for an unconventional approach.  The Big Four are:  the AMA ($20 million on lobbying in 2016), the American Hospital Association ($20 million), the American Health Insurance Plans (AHIP, $7 million), and Pharmaceutical Research and & Manufacturers of America (PhRMA, $20 million but the industry total was $240 million altogether.)  Special interests cannot help you cultivate the Public Health system or grow the network of community clinics.  Leave them out of it.
I realize the longer this letter becomes, the less likely it will be read, so I will close by saying healthcare is the SINGLE most important task you must accomplish to have any hope of being re-elected.  You have nothing to lose by giving something simple a chance.  The AHCA is trying to pound a square peg into a round hole.  Find the round peg and with it, the right solution. 

Niran S. Al-Agba, MD
(just google me if you want to talk more)

Tuesday, May 2, 2017

What is the Cost of a Single Hospital Bed in Kitsap County? $225 Million

May 1st, the Washington State Department of Health will rule on the Certificate of Need (CON); whether or not CHI closes hospital operations in Bremerton and moves all services to Silverdale. CHI will invest $680 million to expand campus size and build a state-of-the-art facility; they will save $9 million annually in improved efficiency.  It will take just 75.5 years to recoup the cost. 

To put the size and expense of this project into perspective, Becker’s Hospital Review compiled a list of the most expensive hospital expansion projects in the nation for 2016.  CHI is listed at number 13 because the cost prediction was initially $530 million; however, expenditures are now predicted at $680 million, bringing CHI up to the 6th most expensive project in the United States. 

Reviewing the list of the top 20 carefully, a few trends emerge.  Most expansion projects involve demolishing aging facilities and building new structures with more beds, private rooms, ER bays, and goals of enhancing the “hospital” experience.  NOT ONE other hospital expansion involved closing the doors and walking away from an “aging” structure, leaving it empty, and never looking back. 

The “aging” facility in Bremerton has an assessed value of $72 million and a property tax bill of approximately $950,000, from which CHI is currently exempted, as they provide charitable care to the uninsured.  The whole idea of exempting nonprofits from paying taxes is based on the belief these entities provide charity for the underserved and underinsured and value the facilities in which they provide healthcare for communities.  This will no longer be the arrangement for CHI and the City of Bremerton.

Hospital bed availabilities are expressed in number of beds/1,000 population.  According to the Kaiser Foundation, Washington and Oregon are the two lowest states in the nation with bed ratios at 1.7 bed/1000 population.  After the 6th most expensive hospital expansion project in the United States is complete, Kitsap County will have a mere 1.3 beds/1,000 population.  The expansion does nothing to help this important disparity in our region, which is considerably underserved. 

The most expensive hospital expansion of 2016 is at Jackson Health in Miami, Florida which will spend $1.8 billion for new facilities and adding 20 beds.  That works out to $90 million/bed.  Florida has 2.6 beds/1,000 population, twice that of Kitsap County.  The most frugal expansion being completed is at the University of Virginia Medical Center, adding 80 beds for $394 million, which works out to $4.9 million/bed.  Virginia has 2.1 beds/1,000 populations.

At both Harrison Hospital campuses, there are currently 347 beds, 24 of which are NICU designated.  Once the $680 million expansion project is complete, the final bed tally will be 350 beds.  Kitsap County will gain 3 beds for the 680 million dollar expenditure, which is about $225 million per bed in cost. 

There are THREE core issues with walking away from the hospital facility in Bremerton:  1) no charity care will be provided in exchange for the generous tax exemption of almost $1 million provided by the City each year and 2) there has been no definitive provision for emergent, urgent, and primary care for the populace within the city limits and 3)  the aging facility on 7 acres of unusable land being vacated and leaving environmental hazards such as asbestos and legionella with no plans for its future. 

To look from another angle, we should ask what Kitsap County is gaining from this $680 million expansion? All services will be in one place.