DRGs and HENRY MAYO NEWHALL HOSPITAL: was there malfeasance by the hospital's Board of Directions or the Medical Executive Committee?

THE EFFECT OF Diagnostic Related Groups (DRGs) and Nurse Practitioners (NPs) on hospital policy and Economic Credentials and Corporate Income


When the DRGs were originally thrust upon the unwitting medical profession in 1982, the purpose was to determine how much Medicare would be obliged to pay hospitals for "products" where "products" became the new word for services, e.g., an appendectomy became a "product" instead of a service or an operation. Application of DRGs has since widened and may be used for non-Medicare patients. Some healthcare pundits find DRGs effective for controlling Medicare costs and hospital costs in particular. An early challenge occurred when Hillary Clinton's father was admitted to hospital and was allowed more than the DRG-allotted time for his hospital stay and more advanced diagnostic studies than the DRGs recommended. Most physicians, this one among them, favored the doctors' decisions in favor of the patient and the hospital's willingness to set the DRGs aside.


Now enters Henry Mayo Newhall Hospital in Santa Clarita which has just determined that Nurse Practitioners (NPs) can have admitting privileges. We will discuss how the two  problems have common ground, namely, cost and reimbursement control. Keep in mind that only one year ago a California Senate Bill (SB 491) to give advanced recognition to NPs failed passage.


Here's the story according to our correspondent, Gene Uzawa Dorio, MD, from his guest commentaries in the SCV Beacon. Doctor Dorio is at the time of this writing, to the best of my knowledge, a member of the hospital's Medical Executive Committee (MEC).


For the last three years, the hospital administration has sought to allow NPs to practice at the hospital. The NPs will be employees of the hospital. That means that the hospital  administration will be able to influence admission and discharge decisions. That there is a likely financial relationship is obvious, for instance, it's why physicians are not allowed to own pharmacies and refer their patients to them. When the effect of the DRGs became of concern to the hospital management, statistics were developed. If a heart attack patient with a DRG of 4 days stayed more than 4 days in the hospital then the additional days were an extra "cost" to the hospital and would not be reimbursed under the DRGs. Doctors whose patients stayed longer than the DRG designations became a liability. The name of the game was how to control these doctors. Doctor Dorio said in his piece on the subject that "every primary care admitting physician was given a total dollar amount ... claiming now the MD was responsible for this 'lost' money." So how did the hospital's BOD bring about change?


The hospital had received an NP application for practice privileges which the MEC rejected when it was determined by the MEC that the hospital had withheld information which Dr. Dorio's editorial asserted showed "the candidate was not qualified to care for hospitalized patients." In any case, the MEC decision not to accept the NP's application was set aside by the BOD which granted practice privileges to the NP in question. That is how matters stand now. While broad-based legislation to grant practice privileges may have failed, one hospital, on its own, has managed to install an NP in precisely the role that the hospital's own MEC found incompatible with the applicant's education and training. Stay tuned: we don't think this issue is finished.


Editor's confession:  I have  testified in Congress on the issue of economic credentials for physicians, see references below. My opinion in the Henry Mayo Newhall Hospital case is that the hospital's BOD wants to wrest control over medical decisions and their economic impact on the hospital from the Medical Executive Committee in particular and from the physicians in general.


References


"Why is Private Practice on the Way to Obsolescence?" (www.politicsofhealthcare.com, 6/10/13)


"Medical Red-Lining, Economic Credentials for Physicians," San Francisco Examiner, 1/12/96


The Congressional Record,  Vol.  144,  # 118, with  comments by former Representative Tom Campbell, R-CA, 09/09/98

Nurse practitioner bill, SB 491 (Hernandez), is down but not out

In part because of its own hypocrisy, the nurse practitioner bill has for the present taken an inglorious swan dive. Nonetheless, we believe it'll come to the surface again. But first, let's get to the juicy hypocrisy.

 

Political readers on healthcare will no doubt recall the nurses' efforts this summer to stop schools from allowing teachers and parents to administer insulin injections to diabetic students. The argument the nurses used was that teachers and parents weren't educated and trained to recognize when insulin injections should be given, what harm might occur were such injections not timely given or withheld, and what adverse side-effects might be expected, let alone treated.  It was a "safety" issue, nothing to do with job preservation.

Physicians identified with these arguments because these arguments were the same that the physicians' lobbies were using to fend off passage of SB 491 (Hernandez).  That the nurse practitioner lobby let itself use these arguments on one hand while arguing against them on the other hand turned out to be the very essence of poor political timing. We doubt they'll repeat the mistake when the bill resurfaces which, in due course, we think it will. So the word we issue to the CMA and its allies is CAVE CANEM (beware of the dog, the sign that was found in the Roman rubble of an ancient eruption of Mt. Vesuvius).

 

In essence, relying on the idea that Obamacare will cause a shortage of physicians, emboldened by Senator Hernandez' willingness to take on the traditional physicians' organizations, the nurse practitioners (NPs) sought the right to practice at levels beyond their education and training and to do so without physician supervision. One argument the NPs used was the shortage of sophisticated medical care in rural  areas. What they didn't say was that the NPs would actually populate these areas and stay there. They  didn't promise to accept lower pay, either. In fact, why  should they?  If the NPs are licensed to practice medicine as physicians, shouldn't they then be entitled to equivalent remuneration? That, we say, would be the logical next step for the nursing lobby. But first it was necessary to get SB 491 passed and signed into law. That is why it's inevitable that the NPs will try again sooner or later.

 

The California Medical Association (CMA) successfully argued that quality and safety in medical care was dependent upon proper education and training. Physicians well know that it's hard enough  to make diagnoses and render treatment even with 12 to 15 years of college, medical school, and advanced internship and residency training.

 

The Union of American Physicians and Dentists (UAPD) weighed in heavily on the side of the CMA. The UAPD  and the CMA acknowledged the importance of nurse practitioners but stopped short of allowing their level of education and training to be legislated as equivalent to physicians' level of education and training. Both organizations argued that the right way to fix anticipated physician shortage problems would be to expand post-graduate residency training positions for newly minted physicians and to expand the number of medical schools. The key  is to provide "properly trained individuals," not simply to invoke a "quick fix" by giving higher priority to the number of licensed professionals as opposed to the quality of the education and training of those professionals.   

 

Other organizations that helped to  oppose SB 491 included the California Neurology Society (CNS), California Academy of Family Physicians, Diabetes Coalition of California, California Society of Anesthesiologists, Blind Children's Center, California Academy of Eye Physicians and Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, Latino Physicians of California, Chinese Medical Dental Association, Let's Face it Together, Minority Health Institute, Dream Machine Foundation, Canvasback Missions, Lighthouse Mission, Time for Change Foundation, Here 4 Them, Osteopathic Physicians and Surgeons, etc (if we've left out your organization, just let us know).

 

References

 

See our blog of 6 August 2013 and references

 

The Daily Journal, San Mateo County, "A Slipper (sic) Slope Indeed," Robert L. Weinmann, MD, 8/13/13

Sacramento Bee, "Expanding role of nurses a recipe for malpractice lawsuits," Robert L. Weinmann, MD, 4/24/13 

 

 

SB 491 (Hernandez) Gets Stopped  in  Assembly Committee on Business Professions and Consumer Protection

A united coalition including the California Medical Association (CMA), the Union of American Physicians and Dentists (Local 206 of the American Federation of State, County, and Municipal Employees, AFL-CIO),  the California Society of Physical Medicine and Surgery (CSPM&R),  the California Neurology Society (CNS), and several others helped to convince the committee that allowing healthcare professionals, no matter how well intentioned, to practice beyond their levels of education and training was unwise and a recipe for disaster. Accordingly,  SB 491 failed today to clear the Assembly Committee on Business Professions and Consumer Protection. The name of the game was consumer protection.

In one of our previous blogs we pointed out that nurses and/or nurse practitioners (NPs), once enfranchised to practice medicine without physician supervision, already well disciplined and organized into a proper union would be well poised to negotiate for equal pay. It was not expected that the newly enfranchised nurses would rush to the hinterlands of California where medical back-up in the form of well trained physicians and surgeons would be lacking or that the nurses would rush to places where resources and money were scarce.

One should not expect the nurses to quit this quest. A new campaign should be expected as soon as the old wounds have healed and their  regenerative powers have been regained.

References and a footnote

"SB 491 (Hernandez) clears committee," www.politicsofhealthcare.com, 5/17/13

"If the work is equal, shouldn't the pay be equal?" www.politicsofhealthcare.com, 4/26/13

"No, no, no on SB 491, 492,  493," www.politicsofhealthcare.com, 4/18/13

Footnote: notice that in this instance an AFL-CIO union was on the same side as the CMA  and other traditional physician organizations -- editor.



 

"Equal Work with Unequal Pay" Revisited

In a recent communique sent privately, I was asked about the meaning of  "equal work with unequal pay" from an earlier blog about pending legislation in California re SB 491, 492, and 493 where nurse practitioners, optometrists, and pharmacists would be equated with physicians. The writer asks "in what sense is the work of a nurse practitioner ever quite the same as the work of a board-certified neurologist?" The writer said "I personally would not be willing to pay a nurse practitioner as much as I would cheerfully pay my neurologist. How about you?"

I agree with the challenger that nurse practitioner education and training is not comparable to the training of a physician, much less  to a physician who  has also done additional specialty training. I agree with the writer.  I would not expect to pay the same for the lesser trained practitioner.

But since that wasn't the point of my editorial I'll take another whack at it. My point is that if SB 491 et al pass in California, the decision as to who gets paid and at what rate will pass into new and untested hands. Unless the nurses' union is asleep at the switch, once SB 491 passes, it can be expected that the nurses' union will lobby to make sure that the newly minted nurse-physicians get paid the same as graduate physicians. The argument will be a legal one, namely, that the legislature, having designated nurses as equivlalent to physicians, is now obligated to see that they get equivalent pay.

In this case I asked my challenger to explain why a certain physicians and surgeons organization wasn't lobbying against SB 491. I was told that the group was "focused on other things." My response is that if the Hernandez series,  SB 491, 492, and 493 get signed into law it won't be long before there are no "other things" on which to focus.

Physicians' groups should oppose SB 491 et al in the interest of making sure that optimal medical care remains the goal, not watered down versions thereof.  So far we know that the California Medical Association, the Union of American Physicians and Dentists, and the California Neurology Society have taken up the campaign and so have many individual physicians.

SB 491 (Hernandez) CLEARS COMMITTEE

NURSES WIN KEY COMMITTEE VOTE

First, the facts

In a stunning victory for Nurse Practitioners SB 491 (Hernandez) cleared the Senate Appropriations Committee by a 4 to zero vote (DeLeon, Hill, Lara, and Steinberg). There were
no votes against the bill (Walters, Gaines, and Padilla were not recorded to have voted). No matter, the measure needed only the 4 votes it got.  

The California Medical Association, opposed to the bill, said in its Hot List that "this bill gives nurse practitioners independent practice" because "nurse practitioners will no longer need to  work pursuant to standardized protocols and procedures or any supervising physician and  would basically give them a plenary license to practice medicine."

One of the arguments by Senator Hernandez that proved particularly attractive to proponents was his assertion that allowing Nurse Practitioners to practice medicine "can reduce the cost of medical care by allowing lower-cost workers to  do more routine tasks in place of higher-paid MDs." In this blog, we have already asserted why this fanciful concept may well prove to be illusory. The nurses are well organized and have a strong union. In the opinion of this author the nurses' unions would be asleep at the switch were they to stand idly by while their colleagues got paid less than physicians for doing the same work.

Milton Lorig, MD, Union of American Physicians and Dentists, wrote in the Sacramento Bee that "physicians like myself have undergone far more rigorous training" and that he doubted that a mid-level practitioner "would have made the diagnosis of NMDA-Receptor Autoimmune Encephalitis" that he recently treated. Lorig argued that "patients deserve ready access to providers who are adequately trained." He did not, however, persuade DeLeon, Hill, Lara, or Steinberg -- just one would have been sufficient to save the day for optimal care.

Author's amendments may still be introduced, for instance, a provision to delete the authority for nurse practitioners to make diagnoses of patients and to perform procedures. Allowing expanded use of skilled nurses should not be done by lowering practice standards that physicians, nurses, and scientists have worked centuries to develop.
 

IF THE WORK IS EQUAL, SHOULDN'T THE PAY BE EQUAL?

Senate Bills 491, 492, and 493 (Hernandez) would allow RNs with advanced training, optometrists, and pharmacists to practice medical care without the pesky obligation of going to medical school, doing internships, or submitting to residency programs under the supervision of faculty. Indeed, most surgery would remain out ot bounds (not all surgery, mind you!).  The nurses, optometrists, and pharmacists would be allowed to undertake primary care. The RNs with advanced training would be qualified as Nurse Practitioners.  Proponents argue that this largesse will reduce medical costs because lower-cost workers would take over some of the tasks done by physicians. Just where to draw the line is one of the problems. For instance, how does one "draw the line" when the differential diagnosis of, say, "numbness" is the chief complaint?  Should an evaluation  for multiple sclerosis be considered? The patient who is misdirected to the lower level diagnostician will find out the hard way.

The San Jose Mercury News, in an editorial on April 12, 2013, said "these bills ... would allow nurse practitioners to establish indpendent practices and deliver limited care without a doctor's oversight." It has also been argued that the lesser-level practitioner would be paid less. Herein lies a problem: if the NP, optometrist, or pharmacist is delivering medical care equal to or on a par with physicians, shouldn't the lesser level practitioners be paid at the same level?

The Affordable Care Act is supposed to expand access to care, not to water it down.

Recently, we learned that the Union of American Physicians and Dentists negotiated a raise for physicians by showing that a  group of nurses was being paid more than their physician counterparts. The opportunities in Hernandez's  legislation make it worthwhile for physicians, nurses, optometrists, and pharmacists to organize into collective bargaining units lest the Hernandez package be used to create equal work with unequal pay. 

If the Hernandez  package is passed,  the nurses' unions would be asleep at the switch if they did not seek equal pay for equal work.

A BONANZA OF MALPRACTICE LITIGATION IS IN THE OFFING

STATE SENATE BILLS 491, 492, AND 493 ARE BILATERAL TRIPLE MALPRACTICE BONANZAS FOR TRIAL LAWYERS -- ON BOTH SIDES.

Senator Ed Hernandez's bills to promote expanded scope of practice for nurses, optometrists, and pharmacists,  scheduled for hearing on April 22nd, got pulled from committee just hours before the hearing.

In our previous post on this topic we pointed out, as did others, that these bills lower the level of education and training for healthcare professionals especially with reference to  differential diagnosis and selection of diagnostic and treatment modalities. If it is determined that a lower level of education and training is acceptable, then the same level of reduced education and training should also be acceptable for physicians. Since these bills allow reduced levels of required education for the same or similar services, we should expect increasing levels of malpractice litigation should any of these bills get voted into law -- a boon to  both plaintiffs' and defense bars, a veritable bonanza of malpractice litigation.

Late notice: we're advised that the Hernandez bills will be brought up in committee on April 29th.

NO, NO, NO ON SB 491, 492, AND 493!

Do we as citizens agree to reduce the level of education and training of our physicians while increasing the number of healthcare providers by expanding the healthcare pool to include nurses and others? Some say the Hernandez Trio, SB 491, 492, and 493 would do just that. The critical question is whether so doing  would be advantageous or detrimental to the provision of healthcare generally.

SB 491 would let Nurse Practitioners (NPs) practice medicine on their own, just as physicians do. The argument for so doing is that there is a dearth of physicians especially in rural areas that NPs could fill.
The counter argument is that physicians are better educated and trained in terms of diagnostics, differential diagnosis, and therapeutics, that is, how to distinguish what may seem to be an inocuous illness as opposed to the harbinger of a medical catastrophe. The issue is whether or not the exchange is worth the candle. The probable result of passage of SB 491 is that NPs, once licensed, will skedaddle from rural practice as fast as their physician colleagues and will set up shop where the money is and compete with their more advanced and more highly trained counterparts. THAT'S the underlying issue. The rest is window-dressing.

SB 492 would allow optometrists to act as ophthalmologists without the pesky interval of real honest-to-gosh medical education and training. Under SB 492 optometrists would be allowed to administer and prescribe drugs including controlled substances. Never mind that right now at the same time various task forces are trying to make it increasingly difficult even for well trained physicians to prescribe narcotics. SB 492 implies that full blown medical education is not necessary for safe ophthalmology practice. If one believes that then SB 492 isn't a problem.

SB 493 would allow pharmacists to dispense medications. In some cases, as when a renewal isn't attended to promptly by a physician, pharmacists already do just that. Their argument is that their training in pharmacology is actually more than most physicians get. On the other hand, conveniently ignored is that pharmacists aren't educated or trained in physical diagnosis and often are not equipped to deal with the adverse consequences of medications. The upshot is that they may prescribe and leave it to some physician somewhere to deal with the complications.

Commentary

"Nurse practitioners battle for right to treat patients" is the title of a piece by Shannon Pettypiece, Bloomberg Businessweek reporter. She describes the predicament of Christy Blanco, Nurse Practitioner in El Paso, who has a doctorate degree in nursing practice. Blanco asserts competence in treating diabetes, asthma, high blood pressure, and other conditions. Blanco's problem is that in Texas she is required to contract with a doctor to sign off on medical charts. By contrast no such requirement  exists in New Mexico so Blanco is considering moving there. In her suboptimally used El Paso office she states she is "spending money and making no profit." Ruefully, she adds, "it is a business."

Yessirree, "it is a business," one that has been learned by managed care organizations and corporate American generally and is about to be upgraded by Accountable Care Organizations and pharmacies that are opening their own clinics to be staffed by nurse practitioners and, maybe, even by some physicians (we don't say "even by some doctors" since in due course the NPs will have doctorate degrees in nursing practice).

Competition is not precluded by Hernandez' three bills. Physicians usually leave Nursing Plans in the hands of nurses. They're not required by law to do so. So if competition is the name of the game, one possibility is for physicians to add nursing practice to their own armamentaria. So doing makes more sense than trying to maintain the status quo. We can expect that universities, ever on the prowl for profitability, just like corporate America anywhere, will hire physicians to teach the nurses and then award them "Equivalency Certifications" suitable for framing and display. Physicians can also construct practices entitled to collective bargaining so they can be on equal footing with the nurses who've developed significant enough clout to be direct members of the AFL-CIO (meanwhile, not far behind, is the Union of American Physicians and Dentists, otherwise known as the UAPD or Local 206 of AFSCME, the largest union within the AFL-CIO).

A little known fact, recently revealed by Stuart Bussey, MD, JD, president of the UAPD is that in 2012 the doctors' union was obliged to negotiate with San Francisco County to raise the salaries of the doctors to equal the salaries of the FNPs. The predicament was a kudo for union power on both sides. Unfortunately for the doctors, their preferred professional associations and societies are not unions and are not allowed to negotiate collectively. The nurses don't suffer from this form of erudite elitism.

Professional education has always been considered the democratic equivalent of royal titledom.  We defer to titles, e.g., "doctor. " The nurses' and optometrists' answer is to upgrade alternative forms of education so that the "doctor" title can be bestowed.  Pushing the fact that the higher education and training that physicians get has intrinisic worth is held to be an elitist argument. The answer is to downgrade elitisim. That's where we're headed: less education, less training, equivalency certification, upgraded titles, and a race to the bottom where money lies in tempting repose.

The Affordable Care Act is supposed to upgrade healthcare for all. The expanded application of SB 491, 492, and 493 will downgrade healthcare for all but will expand access to some form of care. This triumverate of bills allows otherwise well trained professionals to work beyond their levels of training. We anticipate in the long run malpractice premiums will increase to accommodate the addition of suboptimally trained new professionals. We recommend a no vote on SBs 491, 492, and 493.