Healthcare Exchanges: Who Should Run Them?

It was all over our local news this past week: Governor Jan Brewer came out with her decision to reject the federal government’s offer to establish a state-run healthcare exchange. Many were surprised by this decision, which appeared to be contrary to Republican ideology that is centered on smaller federal government and bigger local government. Others were greatly satisfied with her decision, such as the conservative advocacy group the Goldwater Institute, which has long held Brewer’s position.

While everyone has their own opinions about the Affordable Care Act, commonly referred to as Obamacare, I would like to avoid illustrating further bias here and instead lay out the arguments for and against a state-run healthcare exchange.

Argument #1: Who has control?

Those opposing state-run healthcare exchanges argue that state control is only an illusion. They believe that the federal government will maintain major oversight and limit the state’s ability to adapt the exchange for its unique patient population.

Obviously, those in favor of state-run exchanges believe that states really will control their programs. They believe that states will be able to design and develop their own unique programs and have a better handle on the health insurance market, which will ultimately drive down consumer prices and make healthcare more affordable and accessible for everyone.

Argument #2: Loopholes in the legislation

Many in opposition to the ACA are arguing that the actual legal document only offers tax credits and subsidies to state-run exchanges. This would leave the states with federal-run exchanges without extra help for their constituents to buy affordable insurance. However, this would also potentially create a loophole for states to then avoid the federal mandate that all employers with over 50 employees provide health insurance.

Advocates on the other side argue that while a literal interpretation of the document does appear to give benefits only to state-run exchanges, this was not the intention of those who drafted the legislation. Tax credits and subsidies are meant for everyone in the country to obtain more affordable health insurance. It is unclear if states will even be allowed to take up this kind of a lawsuit, and if anyone will really be up for trying to legally attack the ACA after its monumental upholding by the Supreme Court.

Argument #3: Who will pay?

Opponents of state-run exchanges, such as Governor Brewer, contend that states would have to pay for their own exchanges, while federal-run exchanges would be funded by the federal government. They argue, why would we want to pay for something that the government is forcing us to do and will have control over anyway?

Those in favor of state-run exchanges do not agree with this difference in funding sources. The federal government has already sent Arizona roughly $31 million in grants to assist in the planning of a possible state-run exchange. Furthermore, the federal government has promised to provide financial assistance to state-run exchanges until 2015. After that, states can be eligible for additional aid by meeting certain milestones regarding their exchange development.

These arguments present the tip of the iceberg in the fiery debate across our country right now regarding healthcare reform. The biggest questions in my mind at this point are: What will this mean for our patients? How will things be different in Arizona with a federal-run healthcare exchange? And how will this affect us as providers?

What do you think?

*You can refer to articles here, here, and here for the above information and more.

Appropriate Antibiotic Use

Did you know that November 12-18 was national Get Smart About Antibiotics Week? According to the CDC, the Institute of Medicine has declared antibiotic resistance a key threat to health in the United States. They propose decreasing the inappropriate use of antibiotics as the main solution (CDC, 2010).

According to the CDC website (found here) the campaign aims to reduce the rate of rise of antibiotic resistance by:

1.      promoting adherence to appropriate prescribing guidelines among providers,

2.      decreasing demand for antibiotics for viral upper respiratory infections among healthy adults and parents of young children, and

3.      increasing adherence to prescribed antibiotics for upper respiratory infections.

 

On Sunday November 18^th the Arizona Republic published an article (Painter, 2012) citing data from the Center for Disease Dynamics, Economics & Policy (CDDEP). (Find more information about the recent CDDEP report and related media coverage here.) The data shows that while antibiotic use is decreasing across the nation (down 17% from 1999-2010), some Southeastern states have decreased their use very little and could be posing a threat to others across the nation. According to the article, a recent Pew study indicates that 79% of adults know they can harm their own health by taking unneeded antibiotics but only 47% know they could harm others including family and community members by spreading antibiotic resistant organisms.

 

So, what influence do we as healthcare providers have in antibiotic resistance?

1.      We need to ensure that we are prescribing antibiotics only when clinically indicated,

2.      educate our patients about the appropriate use of antibiotics, and

3.      provide thorough patient education about the importance of taking antibiotics as prescribed.

 

References

Center for Disease Control and Prevention. (2010). About the get smart campaign. Retrieved

from http://www.cdc.gov/getsmart/campaign-materials/about-campaign.html

Painter, K. (2012, November 18). Study tracks U.S. antibiotic use. The Arizona Republic, p. A25.

End of Life Communication

It is important as a primary care provider to have effective communication skills for quality health 

 management. Communication skills come from experience in the classroom and in the practice setting 

 spending time talking with patients and gaining confidence in the art of communication. It is just as important 

 that providers have effective skills at discussing end of life care for patients and their loved ones. Learning 

 this vital skill allows the patient and loved ones have a full understanding of the diseases process and the 

 stages to the process of dying. According to Metzger, August, Srinivasan, Liao & Meyskens (2008) primary care providers form the backbone of an integrated team by providing an unbiased medical perspective, providing continuity during a stressful disease course, supporting patients and their families through emotional ups and downs, negotiating or mediating decisions, monitoring for complications, and providing perspective on the illness.

            Providing guidance for patients and their loved ones during end of life care needs to be viewed as a special gift that providers are allowed to be a part of.  Developing the skills needed to be an effective communicator needs to be honed by the practitioner. Han, Keranen, Lescisin & Arnold (2005) stated that no educational intervention has yet been devised to allow residents to learn and demonstrate communication skills with actual seriously ill patients in real clinical settings, although several experts argue that this would be ideal. In addition, skill development requires practice; educational interventions that simply increase knowledge may not necessarily lead to improved action. According to the JAMA (2000) physical care is expectedly crucial, but is only one component of total care. Whereas physicians tend to focus on physical aspects, patients and families tend to view the end of life with broader psychosocial and spiritual meaning, shaped by a lifetime of experiences. In addition, providers should recognize that there is no one definition of a good death and quality care at the end of life is highly individual and should be achieved through a process of shared decision making and clear communication that acknowledges the values and preferences of patients and their families.

            Provider’s patients and loved ones all play a critical role in creating the experience at the end of life. As our experience on death and dying expands, further research is needed to define our role during the period of the dying process and provide quality end of life care. The challenge for providers is to understand the feelings of patients and loved ones and  be effective at communicating the disease processes and permit a variety of expressions for a good death for everyone involved.

Reference

Han, P., Keranen, L., Lescisin, D & Arnold, R. (2005). The Palliative Care Clinical Evaluation      Exercise (CEX): An Experience-Based Intervention for Teaching End-o-Life Communication Skills. Academic Medicine: 80(7), 669-676

Metzger, Q., August, K., Srinivasan, M., Liao, S & Meyskens, F. (2008). End-of-  Life Care:        Guidelines for Patient-Centered Communication. American family Physician, 77(2) Steinhauser, K., Christakis, N., Clipp, E., McNeilly, M., McIntyre, L., Tulsky, J. (2000). Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers. The Journal; Of the American Medical Association, 284(19), 2476-2482. doi:10.1001/jama.284.19.2476

Theophylline: What you need to know

         As a future Adult Nurse Practitioner, I am seeing the effects of chronic disease on the human body. One disease I encounter every time I am working on my residency hours is chronic obstructive pulmonary disease (COPD). COPD is progressive disease that basically blocks airflow as you exhale making it harder for the individual to breathe. One medicine that is a common treatment for COPD is Theophylline. The main action of Theophylline is to relax bronchial smooth muscle to help the individual breathe easier. But there are other effects on the body such as increased heart rate, blood pressure and central nervous stimulation. Theophylline is absorbed orally and metabolized by the liver and the half life is 3-15 hours normally. This medication should be used with caution in individuals with arrhythmias, peptic ulcers, hyperthyroidism, hypertension, alcoholism, GERD, and impaired hepatic function. Almost every patient come in contact with deals with one or more of these conditions.

            Besides the drug warnings, there are different drug interactions with theophylline practitioners need to be aware of. Several of the common drugs that inhibit or increase the effects of theophylline are ciprofloxacin, ketoconazole, erythromycin, and rofecoxib. The drugs that are an  inducer or they decrease in the effects of theophylline are phenytoin, carbamazepine and rifampin. It is very important as a healthcare provider to monitor for Drug toxicity. Therapeutic range for an individual is 10-20 mcg/ml and toxic levels are >20. When a patient presents with nausea, vomiting, and tachycardia and are found to be on Theophylline, the practitioner should check levels as a differential diagnosis. The treatment for Theophylline toxicity is treatment with a short acting beta blocker and monitor for arrhythmias.

Reference

Semla, T., Beizer, J., Higbee, M. (2008). Geriatric Dosage Handbook (13^th ed.). Hudson,   OH,Lexicomp

The Study Drug

They call her “Addy”, and she’s become known on college campuses as the steroid of academics. She’s frequently sold to students in libraries when they just need a boost to stay up late studying for their big exam the next morning. She’s requested at college health centers by students who answer “yes” to questions about distractibility and trouble concentrating. And then she’s blamed for students’ demise when they are carted off to jail after being discovered as controlled substance dealers.

Addy is Adderall, a well-known stimulant used in the treatment of attention deficit hyperactivity disorder (ADHD). While there are many other brands and types of stimulants—such as Ritalin, Concerta, and Vyvanse—Adderall seems to be the favorite of college students who are looking for an edge in a fiercely competitive academic world.

The problem? Stimulants are not candy, or smart drugs (as they’re often referred to), and on top of being controlled substances, they can have serious effects on those who are not meant to take them. Stimulants can raise blood pressure and heart rate and can cause severe moodiness and depression in those who do not have ADHD.

I bring this up because a recent segment on NBC’s Rock Center with Brian Williams caught my eye, featuring an ambitious Columbia University student who became caught up in the Addy craze. You can watch the video here.

As a psychiatric nurse practitioner student in the student health center on ASU’s downtown campus, I am keen to the many student requests for stimulants for their supposed ADHD that is affecting their school performance. Now, I want to make it clear that many of these students actually do have ADHD, and may not have been diagnosed before due to denial on the part of their parents. Or they have been successfully treated for years and just need to continue their treatment on campus. However, I suspect that there are many others who have heard about the wonder study drug and have been coached on what to say so that they can convince the provider (sometimes me) that they have diagnosable symptoms of ADHD.

The unfortunate reality, given the current state of our neurobiology advancements, is that we cannot diagnose ADHD definitively with any type of biological data. As psychiatric providers, we essentially conduct a comprehensive psychiatric interview with a thorough history, and then may supplement with an ADHD rating scale. But savvy college students—or any patients, for that matter—will know what they need to say and fill out on the rating scales in order to win an ADHD diagnosis.

So while there is no current way to diagnose ADHD with 100% accuracy and weed out every fraudulent request, it is advantageous to at least become more aware of college students’ (and others’) tactics, while also refreshing our knowledge on the DSM-IV-TR criteria for ADHD.

The symptomatology of ADHD is split up into two categories: inattention and hyperactivity/impulsivity. Patients can be diagnosed with either ADHD combined type (meeting full criteria in both categories), ADHD inattentive type (meeting inattention criteria only), or ADHD hyperactive-impulsive type (meeting the latter criteria only). Diagnosable criteria require the patient reporting at least 6 symptoms from either or both symptom categories.

There are a few key points here. First, symptoms must have persisted for at least 6 months. Also, symptoms must be causing interference in functioning in at least two areas of life, such as socially and academically. And finally, at least some symptoms must have been present before the age of 7. That is the kicker. While some patients may be savvy enough to know about this criterion, many will not, and this may be where we can really hone in on the critical assessment.

While I see a lot of ADHD complaints as a psychiatric provider, I am well aware that all nurse practitioners encounter these complaints in a variety of settings. My advice is to be vigilant of patients seeking a “smart drug” or “study drug”, and perform a comprehensive assessment guided by the current DSM-IV-TR every time. Your license and your patients’ well being depends on it. 

[photo credit]