Tuesday, December 2, 2014

Brave New World



Source: "Accountable Care Organizations Aim to Provide Better Health Care" Neurology Reviews, September, 2014.

32 comments:

Anonymous said...

I re-read the excerpt several times, but I can't decide on the inflection intended by "red flags".

Is that "red flags" in a clinical context, as in FYI, this guy should be seen ASAP because of scary things on history/physical/testing or as in, oh, BTW, you should know this fellow is a drug-seeker, a SOB, is mean to children and small dogs, etc.

Anonymous said...

I believe what he is referring to is that a nurse decides whether the referral made by a MD/DO was appropriate.
'Red flags' is a well understood medical term.

Marni said...

Gee, as a primary care physician, I am SO EXCITED to know that if I think a referral is indicated, an RN is going to have to final say as to whether or not it's appropriate.

Screw med school and residency, eh?

BizzyMomma said...

Another clip board carrying nurse gets to make a decision! SMH....

Anonymous said...

The implication is that patients deciding on their own to see a neurologist is absolutely verboten.

And people thought HMOs were bad . . .

Anonymous said...

I need to find out what the nurse likes to drink and get a bottle to bribe her! ;p

clairesmum said...

I am an RN....a smart one who sees this as an incredibly useless and potentially dangerous plan...useless cuz it adds another layer of bureaucracy (requiring time and money) that delays prompt care for a patient AND potentially dangerous because RNs do NOT know more than MD/DOs in this area of knowledge!
If the ACO were to retrospectively track referrals to neuro and address inappropriate referral patterns by specific providers (if indeed they find any), that would perhaps be a reasonable strategy.

Anonymous said...

As an RN-NOT MY JOB-wouldn't feel qualified to have that responsibility.

The Condign Gentleman said...

"Then a medium consults a specially selected panel of spirits, who will render a binding recommendation."

Anonymous said...

Whatever happened to the days of rationale decision making...Eanie meany miny mo...

Ivan Ilyich said...

It seems the original article is available to subscribers only. Is the concern here about ACOs generally, or only the role played by nurses?

ACOs aim to make health care more cost-effective, something which is clearly needed. This is a developing area.

As for nurses, I have complete confidence in my (former) nurses and my neurologists. I want everybody on the same team. I don't have a problem with RNs participating in this way, in fact I welcome it.

Anonymous said...

As a non-medical person, my question is why is this a "change"? As written, it sounds like the current state is to refer patients to neurologists without giving the neuros any info.

Anonymous said...

Doctors do not order tests for the fun of it...WOW...is the nurse at least a CNS or are they an RN?

Anonymous said...

The referring Dr's nurse, the neurologist's nurse, or the insurance company's nurse? Inquiring minds want to know. Because if it's the first two, it won't restrict access to care. If it's the third, well...game on.

Anonymous said...

The point is that the screening nurse, in the interest of saving bucks, apparently has the authority to deny the referral regardless of what the patient and/or referring doc think.

Think HMO on steroids.

Anonymous said...

Anonymous at 2:28:

By accepting financial risks, doctors in an ACO have a monetary interest in limiting the access patients have to care, and essentially become indistinguishable from the insurers. It's an ethical mess that no one is interested in discussing. Hats off to Dr. G for bringing this up.

brent said...

Get used to more and more "gatekeepers" (or the keeper of the purse strings).
Let's face it. A lot of folks order a whole lot of unnecessary tests looking for zebras or practicing defensive medicine.
Used to be, have a headache, take two aspirin and call me in the morning. Now, its labs, CT, MRI, LP and referral to Neuro. Oh, everything normal, good. Take two tylenol and call me in the morning.

Anonymous said...

oh, that's the insurance company nurse for sure - no complaints about the nurse, but I doubt with this system you'll get in sooner. In my town it's a 2 month waiting list even for people I have concerns about. If I want them sooner I have to have them go to the ER. Crazy.

Anonymous said...

I'm pretty confused here. Whose nurse is this? If it's the neurologist's nurse, then why doesn't this make sense? Shouldn't the neurologist's nurse have a pretty good idea of what conditions a neurologist actually treats? And in the interest of saving my own bucks (and time) I'd be grateful if a neurologist's nurse rejected an inappropriate referral that had been made on my behalf by a primary care provider who didn't know, for example, that my particular spinal condition would be better treated by an orthopedist. Also, this says "initial screening," which is not the same as "final say."

Candida Gomez said...

Initial screening = final say far too often in both government and private insurance.

Unless the RN is both educated and experienced in the field in question, he or she should not be even initially screening any referral for appropriateness. I'd trust a final-year student doctor in the field more, because they at least have the education to make a reasonable decision.

My aunt is a retired ICU nurse, and my stepmother is a retired pediatric nurse, and both acknowledge that once you step outside of their fields, all they can do is point you to professionals who know that particular subject.

Loren Pechtel said...

I'm thinking the *INTENT* here is to screen out the "I want to see a [specialist]" referrals without medical reason to back them.

I can easily see how it could go wrong, though.

Anonymous said...

Pharmacists are getting a little hot under the collar, too, with having to spend a lot of time anticipating how many ways things can be screwed-up. Pharmacy schools graduate only pharmacy doctors, and, yet, nurses go back to school after their 2-4 year BS for NP credentials and essentially 'practice medicine', albeit under the 'auspices' of a licensed physician, writing scripts for all kinds and sorts of things. Luckily, most nurses I know have a great deal of commonsense. But, in some (for now) situations, nurses are chosen for jobs 'over' medical doctors, and pharmacists spend more time educating these NPs. It's a newer 'team' approach, but a little jarring nevertheless. Pharmacists have this conflict within their profession, too, with all these technicians and their pieces of paper telling them what they can do, or telling patients what they can do, as if they are a registered pharmacist. On the other hand, at least it's a nurse that is providing an 'initial screening' and not some hoi poloi whose degree is in actuarial science or finance and working as a investment consultant for a benefits manager that is determining whether the referral is 'appropriate'.

Anonymous said...

Ins. company screeners, who approve tests or drugs etc. have a high school diploma. Neurologists get a nurse wow.

Anonymous said...

I think we all secretly knew that nurses were the ones who made all the important decisions at the hospital.... we just know for sure now.

Anonymous said...

When it comes down to it, it all gets thrown out the window in the end because we all know the insurance company makes the decisions anyway.

Nothing like fighting the insurance company for a specialized GI surgery (GI stimulator to lessen some of the effects of severe idiopathic gastroparesis) that was denied by a dermatologist (no disrespect to any Dr. Skin's reading) @ the insurance company using medical research from 2000 despite it being 2006! This was despite the 100+ pages of the most recent info that was sent was the request. I ultimately fought & won the appeal using common sense & logic! My MD was pleased (& grateful) he didn't have to call. The irony, Medicaid has never denied the surgery even when the research was in its infancy (& the stimulator is roughly $25,000)!

I feel like insurance companies are making it even harder for doctors to treat their patients. I didn't think it could get worse!

Can any MD's reading this chime in? Do you feel it's worse?

Happy Holidays!

Anonymous said...

I would LOVE to have an RN screen the referrals we make to a certain specialist because that would be a huge improvement from the current method in which a secretary whose only prior experience in the medical field was as a billing clerk is the one screening neurosurg consult requests.

Anonymous said...

Chardonnay.

Anonymous said...

Ivan, clearly you are a communist.

Ivan Ilyich said...

Most people here seem to assume that the RN has the last word on this. That is not evident from the little excerpt given here and I can't see the full article. I assume that the person doing the screening would discuss questionable referrals with the referring physician and the neurologist.

And BTW, "Anonymous," I am not now and have never been a communist. That is just an idiotic comment.

RehabRN said...

At the Hotel, RNs are the enforcers when other hospitals think we sent the patient there with a blank check. Our docs write the "hell no" orders and the RNs get to be the messengers (glad I don't do that job!)

They know our protocols, but still try billing for stuff we do (when we ask them not to do it) and weird stuff no one pays for.

And yes, I have worked in some areas where they expect a clerical person to determine if something is "appropriate". I actually saw an insurance job posted a few months ago to do something similar that required a high school education and no health care experience.

It's a scary world out there...

rapnzl rn said...

This nurse thinks "rather a medical professional than a bean counter". Still, this is wrong on so many levels I'd need a doctorate in physics to figure it out. Hmm....would a nurse with a PhD be qualified?

Yeesh...definitely scary.

Anonymous said...

Oh it's already here. I had a hematology clinic refuse to see a patient with a myelodysplastic syndrome because the screening nurse was sure it was just "minor anemia."

 
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