shocker

A NYT article from Tuesday examines why some many people enrolled in Medicaid in New York State fail to re-enroll at the appropriate time. The major reason: the re-enrollment process is inefficient, untimely, and, according to one participant in focus groups, "takes a lawyer to figure out". The necessary documents fail to reach their intended recipients, or do so after they are due back to the state.

This is totally unsurprising. I work part time at a facility for formerly homeless people, packaging meds and giving shots. There are about 45 residents here who need aggressive case management by their social workers, and one of the social workers' most significant time commitments is working on these programs' red tape. One social worker told me it can take up to one third of her time (although she said lately it had been much better) and another told me it was about a sixth. They both work 35 hours per week; if we average those two, we get eight hours and forty five minutes spent per week on Medicare/Medicaid. On the one hand, yes, they are managing about a dozen people. But the head of a household whose healthcare comes via Medicare/Medicaid could easily have to act as a caseworker for three or four people, without the benefit of a Master's degree, colleagues to help them sort things out, or a paycheck for their time. No wonder people are failing to re-enroll.

two things

One, three more patient on Thursday who were losing their health insurance, and one who was developing an ulcer because he is stressed at work, since half his group got fired. Awesome.

Two, make sure you check out the Idealist in NYC blog. It's got a potpourri of stuff that might be of interest. Today's post is on PlaNYC, an NYC development project.

discouraging, but with a silver lining

As I have mentioned in a previous post, part of my MS in Nursing involves working with a nurse practitioner one day per week. The NP I work with is in private practice in downtown Manhattan, and has a healthy HIV caseload. On a typical day, I see about 12 of her 20ish patients, and my participation in the visit can range from being the primary provider (as in cases where someone is there for their annual exam) to just observing (as when someone needs a pap smear, something I haven’t been trained in yet.) Last week, I saw eleven patients. They were a diverse group, representing a wide range of ages, backgrounds, and health conditions. Three had one thing in common: they were about to lose their health insurance.

To be honest, the current economic crisis has not affected me much personally. As a student, I have debt, not savings. My parents, like so many other people who followed the commonsense strategy of long term, diversified investing, have taken a bath, but my finances have been largely unaffected. Only one person I know has even been in danger of losing his job, and ultimately he didn’t. So the crisis has been more or less abstract to me up to this point. That said, for three of my patients, it was very real. Below is a little bit about them, although I should note I have changed some important info in the interest of patient privacy.

One patient lost her job a few months ago and will only have health insurance until the middle of 2009. She was in the office for her annual physical, but she has a significant heart defect, for which she has already had serious surgery, that makes it incredibly risky for her to go without health insurance for any length of time. She is also overweight (although she is using the opportunity unemployment provides to go the gym and cook more). Another patient was in for a quick follow up; he had come in as soon as he lost his job for a bunch of tests, so he would have the chance of dealing with anything that might come up before his insurance ran out. Fortunately, he was in good shape. Finally, there was a young man pursuing a graduate degree who for reason would be dropped from his school’s insurance policy within a month or two; I believe he intended to take a semester off for financial reasons, but the calculus of his decision was obviously affected by the fact he would have to go without health insurance during that time. The third patient’s situation is perhaps not as much a consequence of the recession as the other two, but it does reinforce the point that’s been made over and over, that Americans need to have access to affordable insurance not tied to education/employment.

The silver lining last Thursday was the three patients who presented for a full STI panel. None of them had any signs or symptoms of an STI, or even any reason to think they had been exposed; they just had either recently switched partners or felt “it was time”. All had been tested less than two years ago. As a future provider, I’m sure I’ll wish all my patients were as conscientious and engaged as that group, and they definitely made a frustrating day better.

facebook for condoms

Like social networking and sexual health? Then the NYC Department of Public Health's new Facebook page for condoms is made for you. The site, which aims to promote sexual health and to raise awarenesss of the city's HIV statistics, gives users the opportunity to send "e-condoms". Over 6500 condoms have been sent as of Thursday afternoon, although a ranking of the senders has revealed a bunch have been sent by employees of the health department's communications office. Facts listed on the site include that NYC has more HIV cases than LA, San Francisco, DC, and Miami combined, and that one in four MSM in Chelsea has HIV. The site also features health updates from the health department and lively short videos encouraging condom use.

For Valentine's Day 2007, the City's health department introduced the official "city condom"; since it's introduction, over 70 million have been given away.

stimulus summary

This is the best summary I've found thus far on how health-related spending is faring in the stimulus package. To be brief: not well.

nursing and moral distress

Interesting article from the NYT about the changing ethics of nursing and medicine in general. The article focuses on "moral distress" the condition in which a doctor or nurse feels they know what's best for the client but in some way feels prevented from implementing it. This phenomenon is one I noticed even during my clinical rotations; sometimes a really good nurse would have a useful perspective about a client, but wouldn't talk about it with the team because she'd assume they'd brush her off. That said, I also saw a number of situations in which a nurse would see a problem, talk to the doc, and get someone in there to evaluate pretty quickly.

The study discussed in the article can be found in the February 2007 issue of Critical Care Medicine. As mentioned in the article, nurses at both the surveyed sites reported higher levels of moral distress than physicians. Both groups reported the highest incidence of moral distress when they were pressured to "unwarranted aggressive treatment". RNs who had higer moral distress scores also reported a lower perception of ethical environment, a lower satisfaction with the quality of care, and a lower perception of collaboration.

Thanks to Ella Gray, RN, for drawing my attention to this article.

primary care proposals

Great primary care oriented blog post written by Kevin Brumbach, MD, the chair of family medicine at UCSF. Part One gives the arguments for better primary care, and Part Two suggests interesting solutions to the shortage with an eye to cost.

budget cuts create controversy

Two powerful health care groups are mounting an aggressive public relations campaign against Governor Paterson's proposed reductions in health care spending, the New York Times reported Sunday. The two groups, Union 1199 and the Greater New York Hospital Association, are purchasing radio and TV spots, funding a phone bank, and mailing flyers throughout the state to protest the governor's $3.5 billion in health care spending cuts, part of a larger $15 billion package designed to balance the budget. The NYT estimates the radio and TV ads alone will cost more than $1 million per week.

Yesterday Paterson and Senate Democrats balanced this year's fiscal budget, which ends March 31, with many small cuts that collectively covered the $1.6 billion deficit. This cost health care in New York "$359 million...including cuts for nursing homes and health maintenance organizations, grants and higher assessments for health insurers" according to Reuters. Also among the cuts: $75 million for the Environmental Protection Fund, and $306 million from the Power Authority.

For FY2010, there is a projected $13-15 billion dollar deficit. In December 2008, the Governor proposed an additional $3.5 billion in health care spending reductions. The centerpiece of the cuts, profiled on the Governor's website , would cap Medicaid spending in New York at $16 billion, which would nevertheless be an increase over spending in 2008-2009. However, it is over $1 billion less than the projected need of $17.2 billion during FY2010, and would reduce the amount of federal aid spent in New York state. More later on other proposed cuts.

Union 1199, more formally 1199 S.E.I.U. United Healthcare Workers East, is the health care portion of Service Employees International Union, covers New York, NJ, Maryland, DC, and Massachusetts. Its members are typically technicians who work in the health care field: certified nursing assistants, xray technicians, home attendants, etc. There are also members who are registered nurses, but these are relatively few. The union boasts 300,000 members and claims to be the largest local union in the world. The GNYHA covers more than 300 hospitals in the greater NY area.

nursing school

So despite the fact that this blog is formally about grad school, I've had very little to say about my graduate experience thus far. That's largely because class for this semester only started last week. I'm in three courses: Genetics, Diagnosis and Management, and Seminar on Primary Care. It's the second semester worth of classes for my MS, and I'll have two more semesters to go after this.

In addition to my coursework, I am at a clinical site one day per week. The site is a private practice with two NPs near Union Square. The NP I work with seems knowledgeable and competent, and I am confident I'll learn a lot from her.

I'll have more to say as the semester progresses; if anyone reading this has any questions about becoming an NP, please don't hesitate to ask and I will do my best to respond.