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Jun. 22 2010 - 11:32 am | 294 views | 4 recommendations | 16 comments

The ‘nurse fix’ for American healthcare

I’ve said it before and will, no doubt, say it again – lowering health care costs in America will not happen by grand, national legislation. It will happen locally and it will happen when the stakeholders in the healthcare system begin to creatively focus on the problem in a meaningful way.

We now have a case in point that proves the point.

Geisinger Health System operates clinics, hospitals and primary practice physician’s offices in northeast and central Pennsylvania. They also offer a health insurance plan that covers about 250,000 people, most of whom get their health care from Geisinger’s network of care providers.

Following the logic that expensive hospital care can be avoided if patients – particularly those with chronic illnesses – are treated more effectively in the doctor’s office, Geisinger’s insurance company began experimenting with the medical home concept whereby more attention is paid to patients at the time when something can still be done to control these illnesses.

The idea is simple. Using diabetics as an example, we know that when diabetes is not effectively treated it will often lead to heart attacks and other serious complications requiring expensive hospitalization – an experience potentially lethal to the patient and dramatically more expensive to the insurance company who will pick up the tab.   Geisinger suspected that providing care designed to head off hospitalizations at the ‘front end’ could save a lot of money and produce happier and healthier patients in the long run.

Of course, merely desiring to focus more on patient health at the primary care stage is easier said than done . Primary care physicians are already forced to see huge numbers of patients each day just to keep their doors open and earn a living.  Their schedule typically allows only 15 minutes for a patient visit and leaves no time at all for follow-up and ongoing communication with chronically ill patients.

Enter the nurses.

Recognizing that physician office nurses could play a major role in solving the problem, Geisinger’s insurance operation went out and hired the additional nurses and paid for their employment. Not only did Geisinger Insurance pay for the added nursing staff’s at the physician offices they own, they also did it for physician’s offices that, while not owned by Geisinger, accepted Geisinger insurance.

The nurses would get into the mix with a patient during the patient’s physician visit. From there, the  nurses stayed in touch with patients on a weekly basis, checking in to see how medicines were working, how patient’s were feeling, monitoring changes in condition, diets, etc.

The results have been interesting, to say the least.

Not only are patients staying healthier due to the reach-out efforts by the nurses, they are also finding that they are more comfortable calling the doctor’s office when they fear something is wrong, heading off more dramatic illnesses before they require hospitalization.

Rose Ann Cox, 69 years old, began working a few years ago with a Geisinger-paid nurse, Karen Thomas, to control her diabetes, talking by phone at least once a week. Ms. Cox had gone to the emergency room when her blood sugars were too low, but she has not been in the hospital for about three years now.
“You don’t always think you should call the doctor,” Ms. Cox said. But she has no qualms about reaching out to the nurse.
Via New York Times

Here’s the payoff.

In an unpublished review of 2008 data, Geisinger experienced an 18 percent drop in hospital admissions; overall medical expenses fell 7 percent.

In the world of health care, these numbers are huge. Who wouldn’t like to see their health care insurance premiums actually fall by 7% as a result of just this one, simple change in the system? The notion that our chances of hospitalization could fall by nearly 20% is not such a bad bonus either.

The idea is beginning to catch on as the big, for-profit health insurance companies are now experimenting with the “nurse fix”.

While the experiment of a small, Pennsylvania based health insurance company may not seem like much, the reality is that this is a very serious step forward in bending the curve of health care costs. It did not take an act of Congress or become fodder for cable television talking heads. Nobody was screaming about it at town hall meetings of hanging elected officials in effigy. No politician is going to get votes as a result of the effort.

All that happened here is that patients were cared for with greater success and a dramatically lowered price.

Health care costs are local. The sooner we recognize this, the sooner we can begin to gets our costs under control.


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  1. collapse expand

    Nurses are a key part of care that could help a lot with costs and the speed of care. I know I ask them questions about what is going on, and if there is no response or a funny look, I know I better see another Dr!

  2. collapse expand

    You can’t argue with the results, but this post does beg the question “why are doctors so unapproachable?” Could it be the training they’re getting at med school and internships? Busy schedules aside (because nurses are busy, too), patients should not be too intimidated to ask questions of their doctors. If they are, I’d say there’s something wrong with the way doctors think of themselves and their role in interacting with patients.

    • collapse expand

      You are likely correct about doctors and their inflated self worth, but the corporatization of medicine has refined the pyramidal notion of healthcare (doctor at the apex, reachable only after a long hard climb, slip-backs frequent). The rarity of primary care doctors has also contributed (thank you AMA). Corporatization to me in this realm refers to the domination of our healthcare by “how, what, when, where and why” insurance companies pay for care. If it were a more sociable (or socialist) model, where doctors did not get filthy rich, those personality types would become financiers (not doctors) and the personalities who want to care would get into med school. Actually these days we are well on the way to putting Nurse Practitioners and Physicians Assistants in charge of primary care, which is fine with me (humble little me) because frankly I think they are better at it. Used to be that most primary care doctors liked providing primary care, now it seems NP and PA like providing it. It is all determined by economic forces and societal expectations. UK does not need “care extenders” as we do because their system values primary care doctors, selects them, educates them and reimburses them for primary care. Same in most other first world countries. The US is really “into” the doctor-as-scientist model, having left the doctor as healer model in the past.

      In response to another comment. See in context »
      • collapse expand

        renzo – while you speak with authority and I know you’re a doctor – with all due respect- I think you have some of this wrong.
        Doctors, in general, do not get filthy rich. Those days are long gone. There are a few specialities that still pay pretty well, but, as a class, smart people who once went to med school so they could make lots of money long ago switched into MBA programs so they could go to Wall Street.
        Further, I’m not sure why you are blaming the AMA for the rarity of primary care doctors. Indeed, the AMA only represents 25% of all doctors today and virtually all of them are primary care doctors. They have become the lobby for primary care doctors – as the specialists will certainly attest to. Indeed, the AMA is proving very effective at switching the balance of Medicare payments in favor of primary care doctors to the detriment of specialists.
        I also don’t quite understand where you get the impression that the UK system selects and educates primary care doctors. While I have many good things to say about the UK medical system, they do not pay for medical educations of primary care doctors – or anyone else. That is something they do in France, a system I also think highly of.
        The problems with healthcare are not as ‘political’ or ‘corporate’ as most would like to believe in order to fit the ideological narrative. It is nowhere in the universe of being quite that simple. I am also a big fan of NPs and PAs – but not because they take the place of doctors who don’t care. They provide the ability for doctors to focus on the more complicated cases while ‘run of the mill’ conditions, like my diabetes for example, can be handled effectively – and more cost efficiently – by the NP.

        Our changes in the realities of heathcare are not the result of doctors no longer caring as they did ‘in the old days’ – it is the result of many things – including the higher costs of technology that, while more expensive, allows people to live longer and healthier, and a cost curve less the result of corporate greed than you would appear to think.

        One more note – it is not only the US that is feeling the pain of the out of control cost curve. This is happening in every industrialized nation in the world. The tendency to say ‘there’s is great – ours sucks’ is truly counterproductive towards working our way to a better health care system. There are good and bad parts of many health care systems in the world, but we all share the common problem of addressing out of control costs. And while we will see an increased involvement by the government – simply because they will, by default, be the only ‘bank’ large enough to handle the payor system – there are many examples where government can over-control the system into crisis. See Japan. The answers just aren’t that easy.

        In response to another comment. See in context »
    • collapse expand

      Doctors are not, in general, unapproachable. When you are a general practitioner getting paid between $45 and $75 a visit, you have absolutely no choice but to run a very tight schedule if you are going to keep the practice open. The entire point is to staff up with nurses so they are there to fill in these gaps. And it is working. I’d say you are much too hard on doctors. Try running a health care system without them! Believe me when I tell you that I have had to spend far more than my fair share with doctors as a patient and I do not have any problem at all with the docs. Indeed, quite the contrary.

      In response to another comment. See in context »
  3. collapse expand

    Good as the results are from this model of care delivery, it is not in itself a new model. Nurses used to be part of the patient visit, for example, way back in the 1980’s when I got out of Internal Medicine residency. I wrote legible notes while with the patient, then passed the patient on directly or indirectly to the nurse (private office) who reviewed with the patient all we had accomplished (dr to patient), arranged the follow up tests ( blood xrays ultrasounds etc and next visits ), reviewed goals and pitfalls, and planned to call or follow up with patient by phone or in-office BP check, etc. It worked really well.
    I worked in office and in hospital with very good nurses and nothing makes a doctor feel more reassured than knowing that another professional is on the case. Nurses are healers too.

  4. collapse expand

    What a novel idea. You take a field that is harmed by lack of personnel due to costs, but when you actually bother to hire that personnel you save costs because you become more effective at what it is you are trying to do. Huh. Man, if only that line of thought could be applied to other fields, maybe something to do with helping kids to learn to do things like math and reading. I’m sure there’s a term for it. Gimme a second, I know this, I went to private school after all…

  5. collapse expand

    Doctors, in general, do not get filthy rich. Those days are long gone. There are a few specialities that still pay pretty well.
    ——————————-
    Here in washington it is bottom line $165 just to walk in the door. These docs are driving 45-50K cars and can eat whatever, whenever they like. They take vacations and the likes without a care. Yes, they make much more compared to the majority of middle class as they are above that. I work at Microsoft as a contractor and don’t make as much as they do and I make a pretty damn good wage. I don’t get benefits out of the deal and this is the worst part. It is ridiculous that we have to pay darn near 200 just to walk in the door. A visit to the ER? Don’t get me started, my wife had six stitches put in her finger and was charged 1600.00 dollars. Yes that’s right, 1600.00. 1200 from the hospital and 400 from the doctor. The stitches took a whole 20 minutes while we sat in an empty ER for 3.5 HOURS waiting to be seen. No I beg to differ, these guys are making a killing off of us. Like lawyers, we need them and they know it. Our entire health care system is loaded with corruption and waste and fraud and nobody wants to clean it up so that we can enjoy healthy lives. I was a mechanic and I’ll tell you that our bodies are much the same in the fact that an ounce of maintenance is worth a pound of cure. They have the right idea with pre-emptive care, it will always be better but at what cost?

    • collapse expand

      It’s hard to know where to begin with this, frankly, silly comment.

      1. I randomly phoned three general practitioner offices in Washington DC and three in Seattle, Washington as you were unclear as to which Washington you are speaking of. Not only did not ONE of these offices have a list price of close to $200 per visit, each was receiving dramatically less in payment from the insurance companies they accept. So – do you have health insurance? Are you looking at the ‘retail’ column on your bill or the amount insurance actually pays which is typically one half of the retail list?

      2. How in the world could you know what kind of car “they” are driving? I spoke with an old friend in Tacome who is a doc – he’s driving a Ford that costs nowhere near the 40-50K you say all docs spend on cars. I spoke with two doctors in DC – one was driving a Kia, one a Toyoto – neither in the price range you describe. I didn’t have the nerve to ask them where they eat because to do so would be so ridiculous.

      3. Did you pay the doctor who sewed up your wife’s finger $400? Or did the insurance company pay him/ her something much less?

      4.Just curious – in preparing to be a Microsoft contractor, did you have to spend hundreds of thousands of dollars to get the necessary education? Did you have to spend an additional four years following school working for slave wages in an internship and a residency? Oh – and no offense to contractors anywhere – but do you really value your service to society in the same way you value someone who may save the life of your child?

      5. I think we would all agree that pre-emptive care is a great way to go – but wouldn’t you still be complaining about what your doctor charges to give you that annual physical designed to keep you healthy?

      I’m afraid your argument is so much like many Tea Party arguments. Lots of anger and positions that haven’t been thought through – very short of facts. How do you hope to help to improve a system when you simply accept arguments that are false and useless? It might make you feel better but you should consider the long-range impact. At the end of the day, do you want to fix it – or simply complain about it?

      In response to another comment. See in context »
  6. collapse expand

    Love these comments.

    Certainly there is a perception that doctors make lots of money, I know a heart surgeon who makes a ridiculous amount of money but if its my heart he is worth every penny. I know lots of doctors offices have yachting and golf magazines but I really don’t know how much they make, my doc works at a clinic for medi-cal patients, he doesn’t remotely seem rich, tired and ragged yes, but rich I doubt it.

    I couldn’t agree more with your piece. While in Oregon my primary doctor was a nurse-physician and he sent me to a specialist occasionally but for years served my needs as well as any fully accredited doctor.

    Today I went to get a cat scan for some spot on my lung. I was met by a nurse student at St. Johns in Santa Monica, who took a blood sample and tested it before my eyes, notified the doctor of the results, led me to the scanner, inserted some iodine, did the scan and I was out the door. Ten minutes tops. Now I know that I didn’t really need a doctor there, but one was there but not present. It was impressively efficient.

    Most of our visits to the doctor do not involve life and death issues but a series of questions that lead to a diagnosis and a prescription. Most of our ailments are common and could easily be handled by a nurse. In addition age factors in many of our health problems so a once a year trip to see a doctor for a exam sets the stage for much of that year’s treatments and precautionary tests and most of that again could be handled by a nurse. I like to see a doctor when there is something going on that is unusual for me and only then.

    So if the solution for the scarcity in Primary Doctors is nurse-physicians and nurses in general I am in full support.

  7. collapse expand

    You are on the right track but don’t go far enough. The nursing model of heath care, each person is assessed for potential and actual health problems at each contact, then provided acute care, prevention care, education and anticipatory guidance fits so well with the demands of the coming ACO model, I think we may see much of primay care going entirely over to nurses. See http://www.onsconnect.org/2010/06/nurse-managed-healthcare-centers-the-primary-care-world-is-your-oyster.

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    About Me

    I am an attorney in Southern California, and a frequent writer, speaker and consultant on health care policy and politics. To that end, I am active member of the Association of Health Care Journalists. Based in beautiful Santa Monica, California, I'm very pleased to have the opportunity to be a contributing editor to True/Slant. I've recently finished a book designed to make the health care debate understandable to the average reader, and expect it to be out in the next five months or earlier. In my 'spare time', I continue to write for television and, occasionally, for comic books.

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