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Posts tagged ‘medications’

Walmart Humana Merger


While nurses like us and other clinicians have been worrying about patient care, documentation and the new CoPs, Walmart and Humana have been getting cozy in the back room working out the details of yet another mega-deal.

The idea has an upside. A full 90 percent of Americans live within 15 minutes of a Walmart. That could go a long way to eliminating any access to care problems. Walmart’s drug prices are often less than competitors’ and could possibly be lower if they were the preferred pharmacy for Humana. Folks could see a physician or nurse practitioner, ask that their scripts be electronically sent to the pharmacy to be filled and go shop for everything from an oil filter for their car to Roma tomatoes while they wait- how convenient.

This sounds so good that maybe the good people involved in this potential deal are blind to the downside. Or, maybe they have never been to a Walmart.

Why do you go to Walmart? I go because stuff costs less. I do not expect sales associates to ask if I need help or because they play catchy background music. I dont expect anyone to help me pair cheese and fruit although to be honest, Kraft singles go with just about anything. I go to Walmart because stuff is cheap and in return, I lower my quality expectations. Have you ever compared a Walmart T-shirt to one from The Gap? Gap T-shirt’s make me happy. I would have to be sedated if I found a better T-shirt.

Walmart employees tend to be good people but the retail giant’s recruiting strategy is putting a computer in a conspicuous spot in the store to interview prospective employees. There is rarely just one person answering the questions so they must be hard.  To be fair, Walmart offers mostly entry level positions – starter jobs. I have never worked for Google or Microsoft but I don’t think this is how they filter through countless applicants.

I have to ask myself if this is the approach they will take to hiring the health care professionals that staff the Walmart and Humana clinics. ‘Our Mediocre doctors and nurses are the backbone of our clinic’, their tagline might read. ‘We’ve lowered our standards so you can pay less’. Do you want a mediocre practitioner in a starter job taking care of your child or grandmother?

And if someone has the flu, a standard script (computer generated from Humana’s algorithm) is probably all that’s needed for a patient who will spend the next 45 minutes infecting everyone else in the store. Watch as Walmart clinics go viral. Literally.

When flu season comes to a halt, things get trickier. As a recovering Walmart shopper, I am confident when I say that pretty much every one in the store is a potential patient. Unlike Whole Foods where you may run into your Yoga friends wearing yoga pants, the Walmart shoppers squeezed into a Spandex Lycra blend are not practiced in the art of Ashtanga.

And Walmart goes out of their way to perpetuate an endless supply of patients. Ramen noodles sell for a dime a piece but it is cost prohibitive for low income families of four to eat a meal including boneless, skinless chicken breasts. Red beans and rice, a perfect protein thats easily affordable always has directions to add sausage which enhances the flavor as much as it plumps up those thighs. The cheap high fructose corn syrup disguised as fruit juice costs only a fraction of the price of the real stuff. In the South where Roman Catholic values prevail, grocery bills rise each time a sibling is added and these low prices are appealing even if they kill folks eventually.

What happens if one of the Walmart shoppers/victims with a history of eating on the Walmart plan

falls out in the store? Can you see the utter chaos as the mediocre care practitioners try to read their CPR pocket card and perform chest compressions simultaneously? How many potential patients will remain loyal to Humana after they see a patient die because, after 22 attempts, there were no more IV catheters left in the crash cart and emergency drugs could not be administered.

If this deal goes through, it will be a failure for everyone involved. Humana may save money on drugs but by the end of a year, Blue Cross will emerge as the premiere insurance carrier by default. Physicians and Nurse Practitioners with restricted licenses rendering mediocre care may be an effective cost savings approach but without being surrounded by competent colleagues who can teach them or at least watch their backs, million dollar payouts will become the norm.  After all, there will be a lot of witnesses.

Walmart needs to spend their cash on improving the experience of their employees and Humana might think about increasing the speed of paying claims. And I need to be able to sleep without worrying about receiving Walmart branded healthcare.

But the most important reason to speak out against this deal is because it is nothing more than business – a way to make money.  They could have respected us enough to at least pretend they were aiming to meet needs of the people who made them successful in the first place.

Your thoughts?

The Z-Factor

Nurses have been trained to not bother physicians, especially referral sources with petty concerns. But, there is a balance between irritating a physician to the point that your competitors gain a new referral source and responsible patient care. If you have to choose, go for responsible patient care.

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Hospice Meds and Medicare Part D


If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

How to Reduce Hospitalizations


First of coumadinall, I am getting some really good information from the Medicare 101 quiz posted Sunday evening.  When the responses stop coming in, I will share some of the more interesting results with you.  It will certainly give us some useful information to use when writing posts in the future.

As I suspected, Coumadin should be a schedule II medication controlled to the same degree as Oxycontin and other medications that shouldn’t be distributed freely due to the risk of untoward side effects up to and including death.  Now, I have proof.  Medscape has a new, very short CE activity that offers evidence to support my position.

After reading the CE article, I am sure you will agree with me that the best way to prevent unavoidable hospitalizations is to discontinue Coumadin on all of your patients.  Seriously, if I was an ambulance chasing lawyer, I wouldn’t spend money on TV commercials for my law practice. I would advertise Coumadin.  If your stodgy MD’s don’t agree with my assessment, at least consider upgrading your communication processes related to Coumadin.

(By the way, in case you think Pradaxa is the answer, you may want to rethink your position.  Four days ago, the FDA issued this warning about Pradaxa.  I only skimmed through it but I believe it said something about post marketing reports of bleeding putting the patient at risk for hospitalization or even death.   That is never good and almost always messy.)

So I guess that leaves us with good old fashioned nursing care as a solution.  Consider using SBAR-C communication when communicating with others about Coumadin.

    • S – Situation
    • B – Background
    • A – Assessment
    • R – Recommendation
    • C- Communication

Example:

Situation:  I just drew lab on Ms Smith as ordered a week past her last dosage change of Coumadin.  She is currently on 7.5 mg daily and her INR is now 4.2.

Background:  She had a mechanical valve replacement two years ago and did fine on her Coumadin until recently.  Her INR’s decreased to sub-therapeutic in recent months.  Her two most recent INR’s and corresponding dosage changes are: (give example).

Assessment:  She has no signs of external or internal bleeding.  (give vital signs)

Recommendation:  Do you want me to hold Coumadin for a couple of days and then restart?  If so, what do you want her dosage to be?

Communication:  Gave above orders to JUDY, patient’s daughter who stated she was removing the Coumadin from the patient’s med planner box now and putting the bottle of Medicine on top of the refrigerator so it wouldn’t be mixed up with normal meds.

All of these steps are important but detailed communication of orders is the most frequently missed step.  It is also the step that could get you into serious trouble if the patient ends up in the hospital with a bleed to the brain.  Documenting that you told the patient’s daughter is all well and good if she only has one.  It is always best to document the name of the person you told and the time and date of the phone call.  Details lend credibility.  (And details are always easier to provide if you document contemporaneously with your work but that is a subject for another post.)

Sometimes, there is nobody reliable to instruct on changes.  In that case, an additional skilled nurse visit should be ordered so the nurse can go to the house and remove the Coumadin herself.  Since we know that unstable Coumadin patients are going to have a lot of unanticipated lab and orders, conservative scheduling with PRN orders for medication updates should accommodate the needs of the patient without breaking your budget.

Or, you can go back to my original advice and discontinue Coumadin on all of your patients but before you do that, let me explore some of the regulatory issues that may arise if you don’t follow physician orders.  I seem to remember reading something about that somewhereSmile.

Medication Competency


Vicodin
Zocor
Lisinopril
Synthroid
Norvasc
Prilocec
Zithromax
Amoxicillin
Metformin
Hydrochlorothiazide
Xanax
Lipitor
Furosemide
Metoprolol
Ambien

This list of the top 15 drugs prescribed in the United States thus far in 2011.  The good news is that they are all generics meaning they are available at a lower cost.  The bad news is that because they have become so common, we forget that these are major pharmaceuticals that can cause major problems.

If you’ve been paying attention, you will realize that the key to doing well in 2012 is directly related to your ability to keep patients out of the hospital.  In reviewing hospitalizations and  Reason for Transfer OASIS assessments, I would bet the farm that medication errors are a direct or indirect cause of a lot more hospitalizations than are reported.

When I read charts, I also see very vague medication teaching.  In reviewing clinical records it is not unusual to see ‘teaching’ such as:

  • Taught patient to take meds exactly as MD ordered.
  • Call MD for any side effects.
  • Take insulin at the same time each day.
  • This medicine helps to lower your cholesterol

I understand that patients have different learning abilities and that sometimes the best we can do is teach the patient the bare minimum.  But whether we teach a lot or a little about medications, it isn’t working.

The first step in providing really effective teaching about medications is to know your medications.

To see how well you or your staff know your meds, click here to take a basic medication competency test.  Until you are able to answer the questions with complete confidence, keep researching.

Of course, not every can know every medicine but there are tools that can be used.  My favorite for when I work offsite is the Medscape app (available for iPhone, Droid and Blackberry) which has two options for download.  One is a smaller download and the larger download includes the entire database for use offline.  Using the larger download option, nurses are able to look up drugs and interactions on their phone even when the internet isn’t available.  It is amazing the things I find when I use it.  The downside of the app is that it does provide every possible drug interaction in the world.  I try to focus on the most serious interactions and read through the remainders to see if they apply to a particular patient.

By really looking at meds and planning teaching as you write a careplan, you can gather all sorts of appropriate teaching materials for the patient.  Medications are also my favorite hunting ground to see if any diagnoses have been missed.

Let me know what you think about the competency test and how you scored.  If you have any other questions to add, please feel free to email them to me or to post below.  Heaven forbid I made an error in the test.  If that’s the case, please post below.

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