Posts Tagged ‘patient satisfaction’

On the other side of the equation (from the doctor won’t see you now)- is the on-going physician shortage, which will impact millions of Americans just as the aging baby boomer generation places increased demands on our strained health care system..  Rural areas will be the hardest hit (and already have the hardest time attracting physicians and other care providers).

In this article by Beverly Miller, [re-posted below] the author suggests solutions to the blooming crisis.

 I would like to add my own.  In her article, Ms. Miller gives short shift to nurse practitioners and physician assistants filling the gap.  This is unfortunate as multiple studies have shown that NPs and PAs provide an excellent level of care, and patient satisfaction – and have served as the mainstay of primary care in many rural and inner-city communities since the late 1970’s.  Nurse practitioners and physician assistants are currently hampered by several federal and state legislative issues which limit compensation and billing by nonphysician providers.  Several attempts at open and earnest dialogs among legislators, nurse practitioners and physicians have been hampered by physician attitudes.  A new report from the Institute of Medicine on the future of nursing emphasises the need to utilize nurse practitioners in this role (as we discussed here) but without further community and public support – much of the utility of NPs will fail to be realized**.

But as this author (Dr. Richard Cooper) points out – there just aren’t enough NPs, PAs and MDs combined to fill the projected shortfalls.  (So we shouldn’t argue amongst ourselves – there are plenty of patients to go around.)

PBS special on Nurse Practitioners a look at NPs in primary care.

To support your local NPs – take legislative action!  Right now, NPs are lobbying to be able to order home health and hospice for our patients as part of the ‘Medical Home’ bill.

How to handle the physician shortage  – Beverly Miller

The primary goal of health care reform deals with providing health coverage for all Americans. Policymakers tell us that it will pay for itself, but with the influx of an estimated 40 to 50 million people who were previously uninsured and the baby boomer generation now becoming eligible for Medicare (some say at a rate of eight per second), who do these policymakers believe is going to take care of these patients?
The problem is one of basic economics: supply is simply not keeping pace with demand.
The physician shortage in the U.S. is not a new problem caused solely by health care reform. Twenty-two states and 17 medical specialty societies are already reporting shortages today, long before the 2014 influx under the provisions of the Patient Protection and Affordable Care Act. Aging and population growth have created a greater demand for physicians than ever before.
Family practice, internal medicine, and geriatric specialists will be the gatekeepers under the reformed system. These specialties require more knowledge in a broader spectrum of diseases than other specialty physicians, yet are paid less for these services. For those doctors choosing family practice, internal medicine or geriatrics as a career, it is often a social decision.
A large number of physicians, mirroring the rest of the population, are reaching retirement age. The American Medical Association (AMA) has reported that in 2017, more than 24,000 physicians will turn 63. The number of retiring physicians could be even higher if the economy rebounds and many who delayed retirement for financial reasons decide to retire.
For the fifth year in a row, family practice and internal medicine have topped the Merritt Hawkin’s recruiting and retention survey.
It has been noted that new physicians are:

– opting for higher paying specialties since student loan debt often exceeds $150,000 – opting to practice at hospitals and health care systems where better technologies are available – desiring more flexible scheduling for family time and social activities – desiring to live in high-population areas  leaving vast areas of the U.S. underserved.

Also, the availability of residency slots is not keeping pace with the demand for new physicians and often residency slots for family medicine and internal medicine often go unfilled. A cap on Medicare-funded residency programs by the Balanced Budget Act of 1997 has not kept pace with needs. Also, there has been less availability of graduate medical education (GME) funding through state Medicaid programs
The Patient Protection and Affordable Care Act does include a provision for redistribution of residency positions by the Health and Human Services (HHS) secretary if residency positions have been unfilled for three Medicare cost reporting periods. The slots, which appear to number approximately 600, will be redistributed giving preference to hospitals located in states with a low resident physician to population ratio; or with a large population living in primary care health professional shortage areas, rural hospitals, and urban hospitals with accredited rural training tracks.
Need is driving the demand for primary care physicians. Groups and hospitals are rushing to form Accountable Care Organizations, patient-centered medical homes and other employment models, all of which are centered around the foundation of primary care.
As we moved to a managed care delivery system, the overriding belief was that good primary care promotes better outcomes and prolongs life. In many respects, it was a success since preventive care was added to coverage and patients began to think in terms of quality rather than quantity of care.
Moving to the next stage, most believe that it must better connect consumers to the health care system and that it must use information technology to better manage costs and patients.
Demand for services will continue to increase as the economy rebounds, resulting in more covered workers, and the baby boomer generation continues to attain Medicare coverage. And if the provisions of the legislation stay on track, there will be even more demand in 2014.
What do we do?
Varying solutions are being discussed.
Nationally, medical school enrollments have been flat over the past 20 years. Policymakers are calling for a significant increase in new physicians, recommending increases in medical school enrollments and increases in GME positions.
Signing bonuses, relocation expense reimbursement and medical education allowances remain standard in most physician recruitment incentive packages. Higher base salaries and productivity bonuses are slowly becoming the norm for family practice and internal medicine.
The 2009 stimulus package and health reform law have designated nearly $300 million for the National Health Service Corps to offer medical loans repayment to new physicians who practice in underserved areas.
Increase in reimbursements for family practice and internal medicine services are necessary to entice physicians to specialize in these areas.
Nurse practitioners and physician assistants can fill some of the void, along with non-U.S. trained physicians becoming eligible to practice in the U.S.
Shorten the training time for primary care physicians from an average of ten years to a more targeted education taking five to eight years by eliminating undergraduate majors and moving straight to medical curriculum and clinical training.
Expand the role of telemedicine as technology becomes more widely adopted by healthcare providers and patients.
There are no certain answers to the problem, but physicians have always been flexible and innovative. In conjunction with other players in the system, physicians themselves will be the ones with the right ideas and solutions. [unfortunately, physicians have also used their strength and influence to prevent alternative solutions in the past – cartagena surgery].

Beverly A. Miller, CPA, CAPPM , is Manager of Physician Services with Hayflich & Steinberg, CPA’s, PLLC and the current president of the National CPA Health Care Advisors Association. She has been heavily involved in practice startups, as well as aiding existing practices with billing issues, accounting issues, staff modeling and selection, project analysis, financial management, compliance issues, and tax planning. Beverly can be reached at (304) 697-5700.

Hayflich & Steinberg, CPA’s, PLLC is also a proud member of the National CPA Health Care Advisors Association (HCAA). HCAA is a nationwide network of CPA firms devoted to serving the health care industry. Members provide proactive solutions to the accounting needs of physicians and physician groups. For more information contact the HCAA at info@hcaa.com.

** As mentioned previously on this site, Nurse Practitioners work in a variety of specialty medicine and surgery practices. As an acute care nurse practitioner in specialty surgery practice – I work directly with a surgeon (versus a NP in primary care practice.)


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One of the questions I field frequently in both practice and here at Cartagena surgery is – What is an acute care nurse practitioner (ACNP)?  This is usually bracketed by statements such as, “I didn’t know NPs could work in surgery.  I thought you only worked in [primary care] clinics.”  Sometimes it’s patients asking the questions – sometimes it’s the surgeons themselves.

This is usually followed by questions or statement about whether ACNPs belong in this role, and if we function at a ‘satisfactory level’ in acute care settings such as intensive care units, emergency departments and specialty surgery practices.

The answer lies in the research, and the overwhelming majority of the literature states that we do, in fact, function very well, in our role to augment  (not replace) physician services.  We do so well, in fact, that the most recent literature is primarily focused on surgeons in other countries and their efforts to import the NP models to their countries (Japan, the UK specifically) over the last few years.

But I don’t expect readers to take my word for it.  Hopefully by now, you’ve all become informed consumers – so I’ve posted some references with links below.  In many cases the entire article was not available [without subscription] so in those cases, particularly long articles – I’ve posted a link to the abstract.  In some cases, there is no abstract available on-line so I’ve included the citation.

Unfortunately many of the larger studies on patient satisfaction are based in the primary care setting, so I have omitted them.

Since I’ve gotten quite a bit of interest on this topic from medical providers, other nurses and readers – I’ve added a section for literature relating to nurse practitioners, which I will try to update periodically, since it is too large of a project for a single post.

Nurse Practitioners in Surgical Specialties/ Acute Care Settings: Review of the available literature

1. The role, productivity, and patient satisfaction of surgical nurse practitioners compared to medical surgeons at VA outpatient clinics.  Palmquist, D. (2010).  Graduate dissertation at Tui University.  This is actually a head to head comparison of NPs to MDs which showed greater productivity by MDs (saw more patients) but greater patient satisfaction with care by NPs. [abstract only].  This isn’t surprising in that surgeons have an enormous amount of responsibilities and demands placed on their time.

2. Patient satisfaction with a nurse practitioner in a university emergency service. Rhyee, K & Dermyer, A. (1995). Annals of Emergency Medicine, Volume 26, Issue 2 , Pages 130-132, August 1995.    Study showed no difference between patient satisfaction with care by either MD or NP. Notably, the primary author was a physician [abstract only].

3. Acute care pediatric nurse practitioner: a vital role in pediatric cardiothoracic surgeryOkuhara CA, Faire PM, Pike NA.  J Pediatr Nurs. 2011 Apr;26(2):137-42  [abstract only].  These NPs are actually dually certified in most cases – in pediatrics and acute care.

4.  The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs.  Cowan MJ, Shapiro M, Hays RD, Afifi A, Vazirani S, Ward CR, Ettner SL.  J Nurs Adm. 2006 Feb;36(2):79-85.  Reduced length of stay, reduced patient costs, and hospital costs on teams with nurse practitioners.

5. The evolving role of the acute care nurse practitioner in critical care.  Howie-Esquivel J, Fontaine DK.  Curr Opin Crit Care. 2006 Dec;12(6):609-13. A nice article that talks about how the NP role is expanding internationally to copy American health care models.

6. The advanced practice nurse in an acute care setting. The nurse practitioner in adult cardiac surgery care.  Callahan M.  Nurs Clin North Am. 1996 Sep;31(3):487-93.  [abstract only].  This article was actually written by researchers at my alma mater, Vanderbilt.

7.  Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons.  Bevis LC, Berg-Copas GM, Thomas BW, Vasquez DG, Wetta-Hall R, Brake D, Lucas E, Toumeh K, Harrison P.  Am J Crit Care. 2008 Jul;17(4):357-63. [full text article].  This is a nice study that actually compares NP/ MDs performing invasive procedures – in this case, chest tube placement.

8. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners.  Russell D, VorderBruegge M, Burns SM.  Am J Crit Care. 2002 Jul;11(4):353-62. [full text article].  This article is one of a series of articles published by researchers at UVA which led the changes in the University of Virginia policy – (the results were so compelling that UVA)  to advocate for exclusive use of nurse practitioners in all acute care areas.  It showed shorter length of stays, less infections for patients care for by NPs versus residents.

Several Japanese researchers are looking at the role of nurse practitioners, as mentioned above.

1.  Nurse practitioners in surgical services in the United States.  Okano A.  Nippon Geka Gakkai Zasshi. 2011 May;112(3):207-10. Japanese.  No abstract available.

2.  Considering the feasibility of introducing nurse practitioners into Japanese thoracic services.  Komatsu T, Coutler L, Henteleff H, Johnston M, Bethune D. Ann Thorac Cardiovasc Surg. 2010 Aug;16(4):303-4  [full text article].  An interesting article, written by Canadians, who have just started to recognize NPs in the acute care/ surgical settings.The comments from the surgeons at the Canadian facility are quite interesting as well.   I wouldn’t mind helping the thoracic surgeons in Japan get used to ACNPs..  🙂

3.   [Surgeons’ hope: expanding the professional role of co-medical staff and introducing the nurse practitioner/physician assistant and team approach to the healthcare system].  [Article in Japanese]  Maehara T, Nishida H, Watanabe T, Tominaga R, Tabayashi K. Nippon Geka Gakkai Zasshi. 2010  Jul;111(4):209-15.

Summary: The healthcare system surrounding surgeons is collapsing due to Japan’s policy of limiting health expenditure,market fundamentalism, shortage of healthcare providers, unfavorable working environment for surgeons, increasing risk of malpractice suits, and decreasing number of those who desire to pursue the surgery specialty. In the USA,
nonphysician and mid-level clinicians such as nurse practitioners (NPs) and physician assistants (PAs) have been working since the 1960s, and the team approach to medicine which benefits patients is functioning well. One strategy to avoid the collapse of the Japanese surgical healthcare system is introducing the NP/PA system. The division of labor in medicine can provide high-quality, safe healthcare and increase the confidence of the public by contributing to: reduced postoperative complications; increased patient satisfaction; decreased
length of postoperative hospital stay: and economic benefits. We have requested that the Ministry of Health, Labor and Welfare establish a Japanese NP/PA system to care for patients more efficiently perioperatively. The ministry has decided to launch a trial profession called “tokutei (specifically qualified) nurse” in February 2010. These nurses will be trained and
educated at the Master’s degree level and allowed to practice several predetermined skill sets under physician supervision. We hope that all healthcare providers will assist in transforming the tokutei nurse system into a Japanese NP/PA system.

Note: This is also ground-breaking, as other countries have been slow to implement nurse practitioners in any areas of their medical care system.  The fact that this is a surgical setting is  even more encouraging. These researchers have also published research on the introduction of NPs in other surgical specialties.

NPs and Residents: a delicate balancing act

In fact, nurse practitioners are the reason that recent changes (July 2011) in surgical/ medicine residency hours are even possible. Without the services that NPs provide, it would be impossible for large teaching institutions to implement the new mandated resident hour restrictions.

Even before the newest restrictions – nurse practitioners have been called to take up the slack (when resident hours were previously reduced both here and in Canada.)  However, it was these restrictions that gave us our greatest opportunities for larger acceptance in the acute care specialties.  (Nurse practitioners have worked in acute care since our inception but were not widely known in this acute care role.)  Fortunately, the data shows that not only have NPs made up for the lack of residents, we’ve actually improved the level of care and patient satisfaction [in comparison to care given by residents].

More information of resident hour restrictions

Next time – I’ll include several more articles, including some more looking at my own specialty – cardiothoracic surgery.

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