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Robert Whitcomb

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Trying to reduce red tape for traveling nurses


For Kaiser Health News

Lauren Bond, a traveling nurse, has held licenses in five states and Washington, D.C. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

The 27-year-old got into travel nursing because she wanted to work and live in other states before settling down. She said she wished more states accepted the multistate license, which minimizes the hassles nurses face when they want to practice across state lines.

“It would make things a lot easier — one license for the country and you are good to go,” said Bond, who recently started a job in California, which does not recognize the multistate license.

The license, known as the Nurse Licensure Compact (NLC), was launched in 2000 to address nursing shortages and enable more nurses to practice telehealth. Under the agreement, registered nurses licensed in a participating state can practice in other NLC states without needing a separate license. They must still abide by the laws that govern nursing wherever their patients are located.

About half of the states joined the original compact, which was modeled on the portability of a driver’s license. Some states that declined to sign on cited a major flaw: The agreement didn’t require nurses to undergo federal fingerprint criminal background checks.

Last month, the National Council of State Boards of Nursing launched a new version of the NLC that requires those checks. Twenty-nine states have passed legislation to join the new agreement.

Jim Puente, who oversees the compact for the council, said he expects even more states to sign the agreement now that criminal background checks are required. He noted that nine states have legislation pending to join.

Among states participating in the new nurse licensing compact are Iowa, Kentucky, Tennessee, Delaware, Idaho and Arizona.

California does not plan to join the new compact, largely because of concern about maintaining state training and quality standards. The state, like many others, already requires nurses to undergo background checks. Washington, Oregon and Nevada are among the other states that do not accept the multistate license.

Proponents of the nurse licensing agreement — both the old and new versions — argue that it helps fill jobs in places where there aren’t enough nurses and enables nurses to respond quickly to natural disasters across state lines.

“The nurse shortage tends to wax and wane regionally, so being able to move nurses where the needs are is really, really important,” said Marcia Faller, chief clinical officer at AMN Healthcare, a San Diego-based medical staffing company that employs Bond. The multistate license “really helps with that mobility … to deliver care to patients across state lines.”

Similar cross-state agreements exist for physicians, psychologists, emergency medical technicians and physical therapists.

In some states, the multistate nursing license is helpful because it streamlines the process for nurses doing case management or telehealth, said Sandra Evans, executive director of the Idaho Board of Nursing. Getting nurses to work in the rural areas of Idaho is a challenge, and hospitals often rely on telemedicine in places where the closest health care facility might be in Montana, she said.

Before Idaho joined the original NLC in 2001, nurses doing telehealth or case management needed numerous licenses to work across state lines, but now they “can travel virtually — electronically or telephonically — to help their clients,” she said.

Joey Ridenour, executive director of the Arizona State Board of Nursing, said one of the biggest advantages of the compact for her state is that it allows authorities to share information and collaborate with other states to investigate and discipline problem nurses. “We are able to take action faster,” she said.

Opponents of the compact argue that states have different standards, course requirements and guidelines and that nurses licensed in one state may lack the necessary knowledge or experience to practice in another one.

“The ability to control the standards of training and quality are of some concern to us,” said Linda McDonald, president of United Nurses and Allied Professionals union in Rhode Island, which participated in the original NLC but hasn’t signed on to the new one. “We want them trained in Rhode Island. We want them licensed in Rhode Island.”

Nurses in California have similar concerns. “We really want to make sure that nurses who are entering our state and taking care of our patients are competent and qualified,” said Catherine Kennedy, a Sacramento-area nurse who is secretary of the California Nurses Association. Some traveling nurses haven’t been, she added.

Kennedy said California does not have difficulty recruiting nurses, even without the compact, because of the state’s relatively high salaries and strict nurse-to-patient ratios in hospitals.

Research has shown that California’s minimum nurse staffing requirements, which were the first in the nation, can reduce workloads and burnout, improve the quality of care and make it easier for hospitals to retain their nurses.

Lauren Bond, a traveling nurse who has a temporary position at UCLA Medical Center, Santa Monica, has held licenses in five states and the District of Columbia. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

Massachusetts, which has never participated in the nurse licensing compact, requires nurses licensed there to take courses on treating victims of domestic violence and sexual assault, said Judith Pare, director of the division of nurses for the Massachusetts Nurses Association. If the state allowed out-of-state nurses to practice in Massachusetts without getting a license there, they wouldn’t necessarily have that training, she noted.

Bond, the traveling nurse, said additional courses don’t make her more qualified to do her job. “Across the board, wherever you go to nursing school, everybody comes out with a similar experience,” said Bond, who works at UCLA Medical Center in Santa Monica. “Then most of the training you are going to do is on the job.”

Jenn Stormes works as a nurse and formally cares for her 18-year-old son, who has a severe seizure disorder and developmental disabilities. Stormes is licensed in Colorado, which participates in the multistate compact.

She has been able to use that license in some states. But she has also had to get several individual licenses so she can continue serving as her son’s nurse in other states where the family travels for medical care. Stormes estimated she has spent about $2,000 on licenses.

“It took me over a year to get all these licenses,” she said. “I had to prove to every state the same education, the same experience, the same fingerprints. I think it is a duplication of efforts and is a waste of everybody’s time and money.”

Study sees benefits in ‘home hospital’ model for acute care

A study  by researchers at Boston’s Brigham and Women’s Hospital suggests that a “home hospital” care model in which patients receive hospital-level acute care at home may cut costs without hurting quality, including patient safety.

Although many  patients prefer to receive care at home, there are few “hospital at home” programs in America.

FierceHealthcare reports that gaps continue between hospitals and home-based care providers, which can pose patient-safety issues. “Home health workers are often provided incomplete or inaccurate information, and they often lack access to electronic health records to doublecheck patient information,” the news service reported.

The Brigham and Women’s Hospital’s  small randomized control trial on its pilot home hospital program found that it cut healthcare costs by half.

 The program included a daily visit from a physician and two daily visits from a home health nurse with patients also linking to physicians outside of those visits through video and/or texting.

“We haven’t dramatically changed the way we’ve taken care of acutely ill patients in this country for almost a century,” David Levine, M.D., a primary-care doctor at Brigham and the study’s lead author, said in an announcement about the study.

“There are a lot of unintended consequences of hospitalization. Being able to shift the site of care is a powerful way to change how we care for acutely ill patients and it hasn’t been studied in the U.S. with intense rigor,”  Dr. Levine added.

He and his team plan to expand the study to include a larger number of patients.

To read the study, please hit this link.

To read FierceHealthcare’s take on this, please hit this link.

Very skeptical about healthcare ‘disruption’


Kent Bottles, M.D., has talked with Alan J. Burgener, a former Iowa hospital executive, about  why Mr. Burgener is so skeptical that the Amazon-Berkshire Hathaway-JPMorgan Chase venture and the proposed CVS-Aetna merger might actually disrupt our dysfunctional healthcare system.

He concludes:  “Ultimately, it’s much more important for commentators and health policymakers to understand these ‘market realities’ of healthcare in the U.S. than it is for them to understand the inner workings of the latest alleged disruptive innovations.”

To read the dialogue, please hit this link.



AI app alerts physicians of potential stroke


This is from FierceHealthcare:

“The Food and Drug Administration (FDA) approved an application that uses artificial intelligence to alert physicians of a potential stroke, signaling a notable shift in the way the agency reviews clinical decision support software used for triage.

The application, called Viz.AI Contact, uses an AI algorithm to analyze computed tomography (CT) scans and identify signs of a stroke in patients. The application notifies a neurovascular specialist via smartphone or tablet when it has identified a potential blockage in the brain, reducing the time it takes for a specialty provider to review the scans.”

To read more, please hit this link.

Female physicians might be more vulnerable to burnout


Physicians Practice reports:

“Some research indicates that women physicians are more likely to suffer from burnout than their male colleagues. One oft-cited study found women’s risk of burnout was a whopping sixty percent greater.   Other studies clearly show that female physicians are at greater risk of depression than are male physicians, and certainly burnout is a common driver of depression. In addition, according to a survey of women physicians conducted by Katherine Gold, M.D., family physician and mental health researcher at the University of Michigan , women doctors are particularly concerned about the consequences of reaching out for help.’

However, woman physicians may have better skills than do male doctors in trying to address burnout.

To read more, please hit this link.

Telemedicine still lagging at many healthcare organizations

Med City News reports:

“A new survey from Sage Growth Partners, a healthcare-research firm, found 44 percent of healthcare executives have not yet adopted telemedicine at their organization. Of that group that hasn’t implemented telehealth, 86 percent said doing so is a medium to high priority.

“The other 56 percent said they have implemented telehealth initiatives at their organization.”

To read more, please hit this link.

Budget deal would cut Medicare Advantage bonus payments


This from FierceHealthcare:

“Buried in the budget deal that Congress passed Friday morning is a provision that will save the government money at the expense of Medicare Advantage plans’ bonus payments.

‘The provision—titled “preventing the artificial inflation of star ratings after the consolidation of Medicare Advantage plans offered by the same organization”—is projected to reduce spending by $520 million over 10 years, according to the Congressional Budget Office.

“The upshot of the new policy change is that when a Medicare Advantage organization consolidates two separate plans, the Centers for Medicare & Medicaid Services will adjust the new plan’s star rating ‘to reflect an enrollment-weighted average of scores or ratings for the continuing and closed contracts.’

”The way the rules work now, insurers can consolidate two plans and have the star rating of the better-quality plan apply to the new entity, according to Politico PULSE. That practice effectively gives insurers a way to boost the quality bonus payments associated with lower-rated plans, hence the provision’s use of the phrase ‘artificial inflation of star ratings.’

To read more, please hit this link.

UCSF Health gets $500 million donation toward building new hospital

FierceHealthcare reports:

“A $500 million donation will help the University of California at San Francisco accelerate plans to build a new hospital at its Parnassus Heights campus.

“UCSF Health patients are currently treated in one of two buildings at Parnassus Heights—the Moffit and Long hospitals—and at an ambulatory surgery center. The Moffit building, which was first built in 1955, must be rebuilt by 2030 to meet seismic codes, and the Helen Diller Foundation donation will allow that process to begin a bit sooner, the university announced.

“The hospital project will cost an estimated $1.5 billion.

“The new hospital, which will be built where the Langley Porter Psychiatric Hospital and Clinics sits now, will be outfitted with new technology, including virtual reality and robotics, according to the announcement. Langley is scheduled to move to a new location and open in 2020. ”

To read more, please hit this link.


NYC Health program pushes care-management program in ERs


NYC Health + Hospitals, the city’s public hospital system, has run  a care-management program in six of its emergency departments, aimed in part at getting more patients into stable primary-care programs and reducing  the number of unneeded visits to emergency rooms.

The country’s largest municipal health system started the pilot program in September 2014 under a grant from the Center for Medicare and Medicaid Innovation.

Over  three years, the system enrolled more than 94,000 emergency patients in the care-management intervention, according to a NEJM Catalyst post.

To read more, please hit this link.


Senate bill would boost some health programs


For Kaiser Health News

BIn a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a two-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.

Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R.-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.

The deal does appear to include almost every other health priority that Democrats have been pushing the past several months, including two years of renewed funding for community health centers and a series of other health programsCongress failed to provide for before they technically expired last year.

“I believe we have reached a budget deal that neither side loves but both sides can be proud of,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor. “That’s compromise. That’s governing.”

Said McConnell, “This bill represents a significant bipartisan step forward.”

Senate leaders are still negotiating last details of the accord, including the size of a cut to the ACA’s Prevention and Public Health Fund, which would help offset the costs of this legislation.

According to documents circulating on Capitol Hill, the deal includes $6 billion in funding for treatment of mental health issues and opioid addiction, $2 billion in extra funding for the National Institutes of Health, and an additional four-year extension of the Children’s Health Insurance Program (CHIP), which builds on the six years approved by Congress last month.

In the Medicare program, the deal would accelerate the closing of the “doughnut hole” in Medicare drug coverage that requires seniors to pay thousands of dollars out-of-pocket before catastrophic coverage kicks in. It would also repeal the controversial Medicare Independent Payment Advisory Board (IPAB), which is charged with holding down Medicare spending for the federal government if it exceeds a certain level. Members have never been appointed to the board, however, and its use has not so far been triggered by Medicare spending. Both the closure of the doughnut hole and creation of the IPAB were part of the ACA.

The agreement would also fund a host of more limited health programs — some of which are known as “extenders” because they often ride along with other, larger health or spending bills.

Those programs include more than $7 billion in funding for the nation’s federally funded community health centers. The clinics serve 27 million low-income people and saw their funding lapse last fall — a delay advocates said had already complicated budgeting and staffing decisions for many clinics.

And in a victory for the physical-therapy industry and patient advocates, the accord would permanently repeal a limit on Medicare’s coverage of physical therapy, speech-language pathology and outpatient treatment. Previously, the program capped coverage after $2,010 worth of occupational therapy and another $2,010 for speech-language therapy and physical therapy combined. But Congress had long taken action to delay those caps or provide exemptions — meaning they had never actually taken effect.

According to an analysis by the nonpartisan Congressional Budget Office, permanently repealing the caps would cost about $6.47 billion over the next decade.

Lawmakers would also forestall cuts mandated by the ACA to reduce the payments made to so-called Disproportionate Share Hospitals, which serve high rates of low-income patients. Those cuts have been delayed continuously since the law’s 2010 passage.

Limited programs are also affected. The deal would fund for five years the Maternal, Infant and Early Childhood Home Visiting Program, a program that helps guide low-income, at-risk mothers in parenting. It served about 160,000 families in fiscal year 2016.

“We are relieved that there is a deal for a 5-year reauthorization of MIECHV,” said Lori Freeman, CEO of advocacy group the Association of Maternal & Child Health Programs, in an emailed statement. “States, home visitors and families have been in limbo for the past several months, and this news will bring the stability they need to continue this successful program.”

And the budget deal funds programs that encourage doctors to practice in medically underserved areas, providing just under $500 million over the next two years for the National Health Service Corps and another $363 million over two years to the Teaching Health Center Graduate Medical Education program, which places medical residents in Community Health Centers.

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