Managing Editor

No woman looks forward to menopause (except, perhaps, for the cessation of menses). The "change of life" brings with it hot flashes, night sweats, mood swings, sleep disturbances, and loss of libido. Menopausal women are often miserable, and those around them may suffer secondhand.

It's no wonder, then, that women seek relief from their symptoms. But since the Women's Health Initiative hormone replacement therapy (HRT) trials ended abruptly in 2002, menopausal women and their clinicians have abandoned conventional HRT in droves. That left a huge void: How could women ease their transition through menopause? What could clinicians offer that was safe and effective?

Into the gap rose bioidentical hormones. Touted by proponents as superior to their conventional HRT counterparts, bioidenticals have seen a surge in use for menopausal symptoms. But not everyone is convinced by these claims—nor by the expanded use of bioidenticals as a veritable "fountain of youth."

Are women succumbing to the allure of feeling younger and more vibrant in their later years? Or are we just waiting for the science to catch up with the not-so-conventional wisdom?

A Question of Quality, Part 1
Stephen Nunn, MPAS, PA-C, has been in practice for 35 years, almost entirely in women's health (obstetrics and gynecology, as well as infertility). And he has a pretty radical perspective on menopause.

"There is nothing natural about it," he says. "If you look back, in 1910, average life expectancy for women in the US was 47. It's only in the past 75 years or so that women have lived long enough to spend a significant amount of their time—a third of their lives—in menopause."

For years, Nunn saw women with menopause and other hormonal issues for whom he couldn't do enough. "Based on the guidelines I was given, I couldn't really effect significant change for a lot of them," he says. "They would come in complaining that they felt a little better, but the available treatment didn't really do the job. And yet we were at what was considered the maximum dosing."

Some of those patients pursued other avenues of treatment—namely, bioidentical hormones—and reported back to Nunn how well they were doing and how happy they were. So when he was looking for a change, Nunn joined (full disclosure) SottoPelle, a Scottsdale, Arizona–based practice dedicated to bioidentical HRT in pellet form.

Although he has a vested interest in promoting bioidentical HRT, Nunn does raise an intriguing point when he notes that the ovary is "the only endocrine organ that gets ignored when it stops functioning." By contrast, he points to the avalanche of new products that address andropause, which is treated long-term.

"I think the quality-of-life issue, as well as the health benefits, say that we really should be treating women with—my bias—bioidentical hormones for the rest of their lives," he concludes.

His viewpoint is shared by independent clinicians. In her Covington, Louisiana, practice, Pamela Egan, FNP-C, CDE, focuses on wellness and preventive medicine. Egan completed a fellowship with the American Academy of Anti-Aging and Regenerative Medicine and will receive her master's degree in Metabolic and Nutritional Medicine within the next six months. Bioidentical HRT is a component of her patient care plan.

"It's all about keeping the body balanced nutritionally and metabolically—that is going to slow down aging, which ultimately will prevent disease," she says. "I have patients who come in and say they can't sleep at night, they're depressed, they have no libido, they have hot flushes. When we get everything balanced, they have much better quality of life. They sleep better, they want sex again, their hot flushes are gone, and anxiety and depression are diminished or alleviated altogether."

Egan isn't a fan of the term anti-aging because, she says, its use in relation to cosmeceutical products has made it "sound a little flaky." What she is trying to achieve with her patients is a lifestyle change through a holistic approach that includes nutrition and weight loss in addition to hormonal balance. "Once people are balanced," she says, "many of them get off their diabetes meds, blood pressure pills, cholesterol pills."

Major medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Clinical Endocrinologists (AACE), have a very different position on the role of bioidentical hormones. And this is where a degree of confusion creeps in, because "bioidentical hormone replacement therapy is not really an FDA-recognized term," says Jennifer Hofmann Ribowsky, MS, RPA-C, Academic Faculty/Pre-clinical Coordinator of the Pace University–Lenox Hill Hospital Physician Assistant Program in New York. "It's more a term used for marketing purposes."

That said, bioidentical hormones are essentially plant-derived hormones that are chemically similar or structurally identical to those produced by the body. And there are FDA-approved estrogen and progesterone products that are technically considered naturally occurring or bioidentical.

But traditionally, the term bioidentical hormones has referred to compounded preparations. The reservations, if not downright concerns, of groups such as ACOG and AACE generally relate to two factors: the origins of the bioidentical hormones (FDA-approved products vs compounded products) and how they are used.

Compounding is performed by a licensed pharmacist to specifications prescribed by a health care provider. But compounded products are not regulated by the FDA (they are regulated by the states), and by their nature are not standardized (though the raw materials are US Pharmacopeia–approved products). Therefore, issues of quality—purity and potency—may arise, and there is a lack of safety and efficacy data.

For example, when a clinician prescribes an estradiol patch in a dosage of "0.05 mg per 24 hours," that is precisely what the patient will receive from an FDA-approved product. "It's standardized, so you have that level of comfort that when you're prescribing a certain amount, that's what the patient is getting," Ribowsky says. "That's not always the case with compounded products."

In an August 2012 opinion paper, committees from ACOG and the American Society for Reproductive Medicine concluded that evidence in favor of bioidentical (ie, compounded) HRT was insufficient: "Patients should be counseled that menopausal hormone therapies that are proved to be safe and effective by the FDA are more appropriate for their use than individual pharmacy-compounded preparations."

But in practice, there may be additional considerations. "I leave it up to the patient whether they want compounded bioidentical hormones or FDA-approved bioidentical hormones," Egan says (though she recommends bioidenticals over synthetics). "If a patient doesn't have insurance and has to pay out of pocket, obviously it's financially feasible to get them compounded."

What's Appropriate?
In a 2007 position statement that also recommended "FDA-approved commercially available hormonal preparations," AACE added the proviso that these should be prescribed "following the guidelines published by the various medical societies." This is where the discussion of bioidentical hormones enters the grayest area.

"Estradiol and progesterone are used for the management of vasomotor symptoms that are troubling to the patient, and they should be used within usually the first five years of menopause—the lowest dose, for the shortest amount of time," Ribowsky summarizes. "In terms of being a fountain of youth or a way to stay or look younger, there's not really any support for those types of claims. They're not even studied for that purpose."

Neither Egan nor Nunn refers to a "fountain of youth"; their aim is to keep patients healthy and feeling better. (Although, yes, patients often comment that they feel younger, too.) Both emphasize that patients are monitored and HRT is adjusted accordingly. As Nunn says, the goal is physiologically normal levels—literally replacing lost hormones—not bodybuilder levels.

In terms of safety, Nunn in particular defends estrogen. "If you go back to the Women's Health Initiative study, the one that was 'the estrogen sky is falling,'" he says, "the women who were taking only the [conjugated estrogen] product didn't have an increased risk for breast cancer—only the women who were on the [estrogen plus progestin]. So you really can't blame the estrogen here."

Egan says she doesn't prescribe oral estrogen products because "it's too hard on the liver. The liver methylates it to estrone, which can increase risk for breast cancer."

In terms of cardiovascular risk, Nunn also prefers nonoral routes of administration for estrogen. "If you absorb your estrogen, it doesn't increase your clotting factors, because you avoid the first pass through the liver," he says. "So absorbed estrogen—patches, creams, pellets—doesn't increase your risk for stroke and heart attack."

Even so, patients are encouraged to have regular health screenings, as appropriate. "We certainly have our patients continue to get bone mineral density scans, keep current on their mammograms and Pap smears, and follow all the other things you should do for good health maintenance," Nunn says.

One point on which everyone agrees is the need for additional research to establish what benefits bioidentical HRT offers. The Cochrane Collaboration is expected to publish a review later this year that examines the evidence on bioidentical hormones for vasomotor symptoms; that may shed some light on their safety and efficacy. But Ribowsky, for one, would like to see some head-to-head randomized controlled trials comparing bioidentical HRT with conventional HRT.

"I think when we have studies like that available, we can make recommendations to our patients more clearly and more confidently," she says.

Egan notes that everything she learned in her fellowship was based on available evidence, but wonders if additional research would alter the view of organizations such as ACOG. "I'm just sad to say that the FDA and ACOG are about 20 years behind the times," she says, adding that insurance companies also send her letters requesting that she use conjugated estrogen preparations instead of (FDA-approved) bioidenticals.

"I'm not going to do anything to harm my patients, and we know those drugs cause breast cancer," she adds. "Why would I use those? I think the biggest thing is that we have to identify the difference between synthetic chemicals and the bioidentical hormones in the right form."

No woman looks forward to menopause (except, perhaps, for the cessation of menses). The "change of life" brings with it hot flashes, night sweats, mood swings, sleep disturbances, and loss of libido. Menopausal women are often miserable, and those around them may suffer secondhand.

It's no wonder, then, that women seek relief from their symptoms. But since the Women's Health Initiative hormone replacement therapy (HRT) trials ended abruptly in 2002, menopausal women and their clinicians have abandoned conventional HRT in droves. That left a huge void: How could women ease their transition through menopause? What could clinicians offer that was safe and effective?

Into the gap rose bioidentical hormones. Touted by proponents as superior to their conventional HRT counterparts, bioidenticals have seen a surge in use for menopausal symptoms. But not everyone is convinced by these claims—nor by the expanded use of bioidenticals as a veritable "fountain of youth."

Are women succumbing to the allure of feeling younger and more vibrant in their later years? Or are we just waiting for the science to catch up with the not-so-conventional wisdom?

A Question of Quality, Part 1
Stephen Nunn, MPAS, PA-C, has been in practice for 35 years, almost entirely in women's health (obstetrics and gynecology, as well as infertility). And he has a pretty radical perspective on menopause.

"There is nothing natural about it," he says. "If you look back, in 1910, average life expectancy for women in the US was 47. It's only in the past 75 years or so that women have lived long enough to spend a significant amount of their time—a third of their lives—in menopause."

For years, Nunn saw women with menopause and other hormonal issues for whom he couldn't do enough. "Based on the guidelines I was given, I couldn't really effect significant change for a lot of them," he says. "They would come in complaining that they felt a little better, but the available treatment didn't really do the job. And yet we were at what was considered the maximum dosing."

Some of those patients pursued other avenues of treatment—namely, bioidentical hormones—and reported back to Nunn how well they were doing and how happy they were. So when he was looking for a change, Nunn joined (full disclosure) SottoPelle, a Scottsdale, Arizona–based practice dedicated to bioidentical HRT in pellet form.

Although he has a vested interest in promoting bioidentical HRT, Nunn does raise an intriguing point when he notes that the ovary is "the only endocrine organ that gets ignored when it stops functioning." By contrast, he points to the avalanche of new products that address andropause, which is treated long-term.

"I think the quality-of-life issue, as well as the health benefits, say that we really should be treating women with—my bias—bioidentical hormones for the rest of their lives," he concludes.

His viewpoint is shared by independent clinicians. In her Covington, Louisiana, practice, Pamela Egan, FNP-C, CDE, focuses on wellness and preventive medicine. Egan completed a fellowship with the American Academy of Anti-Aging and Regenerative Medicine and will receive her master's degree in Metabolic and Nutritional Medicine within the next six months. Bioidentical HRT is a component of her patient care plan.

"It's all about keeping the body balanced nutritionally and metabolically—that is going to slow down aging, which ultimately will prevent disease," she says. "I have patients who come in and say they can't sleep at night, they're depressed, they have no libido, they have hot flushes. When we get everything balanced, they have much better quality of life. They sleep better, they want sex again, their hot flushes are gone, and anxiety and depression are diminished or alleviated altogether."

Egan isn't a fan of the term anti-aging because, she says, its use in relation to cosmeceutical products has made it "sound a little flaky." What she is trying to achieve with her patients is a lifestyle change through a holistic approach that includes nutrition and weight loss in addition to hormonal balance. "Once people are balanced," she says, "many of them get off their diabetes meds, blood pressure pills, cholesterol pills."

Major medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Clinical Endocrinologists (AACE), have a very different position on the role of bioidentical hormones. And this is where a degree of confusion creeps in, because "bioidentical hormone replacement therapy is not really an FDA-recognized term," says Jennifer Hofmann Ribowsky, MS, RPA-C, Academic Faculty/Pre-clinical Coordinator of the Pace University–Lenox Hill Hospital Physician Assistant Program in New York. "It's more a term used for marketing purposes."

That said, bioidentical hormones are essentially plant-derived hormones that are chemically similar or structurally identical to those produced by the body. And there are FDA-approved estrogen and progesterone products that are technically considered naturally occurring or bioidentical.

But traditionally, the term bioidentical hormones has referred to compounded preparations. The reservations, if not downright concerns, of groups such as ACOG and AACE generally relate to two factors: the origins of the bioidentical hormones (FDA-approved products vs compounded products) and how they are used.

Compounding is performed by a licensed pharmacist to specifications prescribed by a health care provider. But compounded products are not regulated by the FDA (they are regulated by the states), and by their nature are not standardized (though the raw materials are US Pharmacopeia–approved products). Therefore, issues of quality—purity and potency—may arise, and there is a lack of safety and efficacy data.

For example, when a clinician prescribes an estradiol patch in a dosage of "0.05 mg per 24 hours," that is precisely what the patient will receive from an FDA-approved product. "It's standardized, so you have that level of comfort that when you're prescribing a certain amount, that's what the patient is getting," Ribowsky says. "That's not always the case with compounded products."

In an August 2012 opinion paper, committees from ACOG and the American Society for Reproductive Medicine concluded that evidence in favor of bioidentical (ie, compounded) HRT was insufficient: "Patients should be counseled that menopausal hormone therapies that are proved to be safe and effective by the FDA are more appropriate for their use than individual pharmacy-compounded preparations."

But in practice, there may be additional considerations. "I leave it up to the patient whether they want compounded bioidentical hormones or FDA-approved bioidentical hormones," Egan says (though she recommends bioidenticals over synthetics). "If a patient doesn't have insurance and has to pay out of pocket, obviously it's financially feasible to get them compounded."

What's Appropriate?
In a 2007 position statement that also recommended "FDA-approved commercially available hormonal preparations," AACE added the proviso that these should be prescribed "following the guidelines published by the various medical societies." This is where the discussion of bioidentical hormones enters the grayest area.

"Estradiol and progesterone are used for the management of vasomotor symptoms that are troubling to the patient, and they should be used within usually the first five years of menopause—the lowest dose, for the shortest amount of time," Ribowsky summarizes. "In terms of being a fountain of youth or a way to stay or look younger, there's not really any support for those types of claims. They're not even studied for that purpose."

Neither Egan nor Nunn refers to a "fountain of youth"; their aim is to keep patients healthy and feeling better. (Although, yes, patients often comment that they feel younger, too.) Both emphasize that patients are monitored and HRT is adjusted accordingly. As Nunn says, the goal is physiologically normal levels—literally replacing lost hormones—not bodybuilder levels.

In terms of safety, Nunn in particular defends estrogen. "If you go back to the Women's Health Initiative study, the one that was 'the estrogen sky is falling,'" he says, "the women who were taking only the [conjugated estrogen] product didn't have an increased risk for breast cancer—only the women who were on the [estrogen plus progestin]. So you really can't blame the estrogen here."

Egan says she doesn't prescribe oral estrogen products because "it's too hard on the liver. The liver methylates it to estrone, which can increase risk for breast cancer."

In terms of cardiovascular risk, Nunn also prefers nonoral routes of administration for estrogen. "If you absorb your estrogen, it doesn't increase your clotting factors, because you avoid the first pass through the liver," he says. "So absorbed estrogen—patches, creams, pellets—doesn't increase your risk for stroke and heart attack."

Even so, patients are encouraged to have regular health screenings, as appropriate. "We certainly have our patients continue to get bone mineral density scans, keep current on their mammograms and Pap smears, and follow all the other things you should do for good health maintenance," Nunn says.

One point on which everyone agrees is the need for additional research to establish what benefits bioidentical HRT offers. The Cochrane Collaboration is expected to publish a review later this year that examines the evidence on bioidentical hormones for vasomotor symptoms; that may shed some light on their safety and efficacy. But Ribowsky, for one, would like to see some head-to-head randomized controlled trials comparing bioidentical HRT with conventional HRT.

"I think when we have studies like that available, we can make recommendations to our patients more clearly and more confidently," she says.

Egan notes that everything she learned in her fellowship was based on available evidence, but wonders if additional research would alter the view of organizations such as ACOG. "I'm just sad to say that the FDA and ACOG are about 20 years behind the times," she says, adding that insurance companies also send her letters requesting that she use conjugated estrogen preparations instead of (FDA-approved) bioidenticals.

"I'm not going to do anything to harm my patients, and we know those drugs cause breast cancer," she adds. "Why would I use those? I think the biggest thing is that we have to identify the difference between synthetic chemicals and the bioidentical hormones in the right form."

No woman looks forward to menopause (except, perhaps, for the cessation of menses). The "change of life" brings with it hot flashes, night sweats, mood swings, sleep disturbances, and loss of libido. Menopausal women are often miserable, and those around them may suffer secondhand.

It's no wonder, then, that women seek relief from their symptoms. But since the Women's Health Initiative hormone replacement therapy (HRT) trials ended abruptly in 2002, menopausal women and their clinicians have abandoned conventional HRT in droves. That left a huge void: How could women ease their transition through menopause? What could clinicians offer that was safe and effective?

Into the gap rose bioidentical hormones. Touted by proponents as superior to their conventional HRT counterparts, bioidenticals have seen a surge in use for menopausal symptoms. But not everyone is convinced by these claims—nor by the expanded use of bioidenticals as a veritable "fountain of youth."

Are women succumbing to the allure of feeling younger and more vibrant in their later years? Or are we just waiting for the science to catch up with the not-so-conventional wisdom?

A Question of Quality, Part 1
Stephen Nunn, MPAS, PA-C, has been in practice for 35 years, almost entirely in women's health (obstetrics and gynecology, as well as infertility). And he has a pretty radical perspective on menopause.

"There is nothing natural about it," he says. "If you look back, in 1910, average life expectancy for women in the US was 47. It's only in the past 75 years or so that women have lived long enough to spend a significant amount of their time—a third of their lives—in menopause."

For years, Nunn saw women with menopause and other hormonal issues for whom he couldn't do enough. "Based on the guidelines I was given, I couldn't really effect significant change for a lot of them," he says. "They would come in complaining that they felt a little better, but the available treatment didn't really do the job. And yet we were at what was considered the maximum dosing."

Some of those patients pursued other avenues of treatment—namely, bioidentical hormones—and reported back to Nunn how well they were doing and how happy they were. So when he was looking for a change, Nunn joined (full disclosure) SottoPelle, a Scottsdale, Arizona–based practice dedicated to bioidentical HRT in pellet form.

Although he has a vested interest in promoting bioidentical HRT, Nunn does raise an intriguing point when he notes that the ovary is "the only endocrine organ that gets ignored when it stops functioning." By contrast, he points to the avalanche of new products that address andropause, which is treated long-term.

"I think the quality-of-life issue, as well as the health benefits, say that we really should be treating women with—my bias—bioidentical hormones for the rest of their lives," he concludes.

His viewpoint is shared by independent clinicians. In her Covington, Louisiana, practice, Pamela Egan, FNP-C, CDE, focuses on wellness and preventive medicine. Egan completed a fellowship with the American Academy of Anti-Aging and Regenerative Medicine and will receive her master's degree in Metabolic and Nutritional Medicine within the next six months. Bioidentical HRT is a component of her patient care plan.

"It's all about keeping the body balanced nutritionally and metabolically—that is going to slow down aging, which ultimately will prevent disease," she says. "I have patients who come in and say they can't sleep at night, they're depressed, they have no libido, they have hot flushes. When we get everything balanced, they have much better quality of life. They sleep better, they want sex again, their hot flushes are gone, and anxiety and depression are diminished or alleviated altogether."

Egan isn't a fan of the term anti-aging because, she says, its use in relation to cosmeceutical products has made it "sound a little flaky." What she is trying to achieve with her patients is a lifestyle change through a holistic approach that includes nutrition and weight loss in addition to hormonal balance. "Once people are balanced," she says, "many of them get off their diabetes meds, blood pressure pills, cholesterol pills."

Major medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Clinical Endocrinologists (AACE), have a very different position on the role of bioidentical hormones. And this is where a degree of confusion creeps in, because "bioidentical hormone replacement therapy is not really an FDA-recognized term," says Jennifer Hofmann Ribowsky, MS, RPA-C, Academic Faculty/Pre-clinical Coordinator of the Pace University–Lenox Hill Hospital Physician Assistant Program in New York. "It's more a term used for marketing purposes."

That said, bioidentical hormones are essentially plant-derived hormones that are chemically similar or structurally identical to those produced by the body. And there are FDA-approved estrogen and progesterone products that are technically considered naturally occurring or bioidentical.

But traditionally, the term bioidentical hormones has referred to compounded preparations. The reservations, if not downright concerns, of groups such as ACOG and AACE generally relate to two factors: the origins of the bioidentical hormones (FDA-approved products vs compounded products) and how they are used.

Compounding is performed by a licensed pharmacist to specifications prescribed by a health care provider. But compounded products are not regulated by the FDA (they are regulated by the states), and by their nature are not standardized (though the raw materials are US Pharmacopeia–approved products). Therefore, issues of quality—purity and potency—may arise, and there is a lack of safety and efficacy data.

For example, when a clinician prescribes an estradiol patch in a dosage of "0.05 mg per 24 hours," that is precisely what the patient will receive from an FDA-approved product. "It's standardized, so you have that level of comfort that when you're prescribing a certain amount, that's what the patient is getting," Ribowsky says. "That's not always the case with compounded products."

In an August 2012 opinion paper, committees from ACOG and the American Society for Reproductive Medicine concluded that evidence in favor of bioidentical (ie, compounded) HRT was insufficient: "Patients should be counseled that menopausal hormone therapies that are proved to be safe and effective by the FDA are more appropriate for their use than individual pharmacy-compounded preparations."

But in practice, there may be additional considerations. "I leave it up to the patient whether they want compounded bioidentical hormones or FDA-approved bioidentical hormones," Egan says (though she recommends bioidenticals over synthetics). "If a patient doesn't have insurance and has to pay out of pocket, obviously it's financially feasible to get them compounded."

What's Appropriate?
In a 2007 position statement that also recommended "FDA-approved commercially available hormonal preparations," AACE added the proviso that these should be prescribed "following the guidelines published by the various medical societies." This is where the discussion of bioidentical hormones enters the grayest area.

"Estradiol and progesterone are used for the management of vasomotor symptoms that are troubling to the patient, and they should be used within usually the first five years of menopause—the lowest dose, for the shortest amount of time," Ribowsky summarizes. "In terms of being a fountain of youth or a way to stay or look younger, there's not really any support for those types of claims. They're not even studied for that purpose."

Neither Egan nor Nunn refers to a "fountain of youth"; their aim is to keep patients healthy and feeling better. (Although, yes, patients often comment that they feel younger, too.) Both emphasize that patients are monitored and HRT is adjusted accordingly. As Nunn says, the goal is physiologically normal levels—literally replacing lost hormones—not bodybuilder levels.

In terms of safety, Nunn in particular defends estrogen. "If you go back to the Women's Health Initiative study, the one that was 'the estrogen sky is falling,'" he says, "the women who were taking only the [conjugated estrogen] product didn't have an increased risk for breast cancer—only the women who were on the [estrogen plus progestin]. So you really can't blame the estrogen here."

Egan says she doesn't prescribe oral estrogen products because "it's too hard on the liver. The liver methylates it to estrone, which can increase risk for breast cancer."

In terms of cardiovascular risk, Nunn also prefers nonoral routes of administration for estrogen. "If you absorb your estrogen, it doesn't increase your clotting factors, because you avoid the first pass through the liver," he says. "So absorbed estrogen—patches, creams, pellets—doesn't increase your risk for stroke and heart attack."

Even so, patients are encouraged to have regular health screenings, as appropriate. "We certainly have our patients continue to get bone mineral density scans, keep current on their mammograms and Pap smears, and follow all the other things you should do for good health maintenance," Nunn says.

One point on which everyone agrees is the need for additional research to establish what benefits bioidentical HRT offers. The Cochrane Collaboration is expected to publish a review later this year that examines the evidence on bioidentical hormones for vasomotor symptoms; that may shed some light on their safety and efficacy. But Ribowsky, for one, would like to see some head-to-head randomized controlled trials comparing bioidentical HRT with conventional HRT.

"I think when we have studies like that available, we can make recommendations to our patients more clearly and more confidently," she says.

Egan notes that everything she learned in her fellowship was based on available evidence, but wonders if additional research would alter the view of organizations such as ACOG. "I'm just sad to say that the FDA and ACOG are about 20 years behind the times," she says, adding that insurance companies also send her letters requesting that she use conjugated estrogen preparations instead of (FDA-approved) bioidenticals.

"I'm not going to do anything to harm my patients, and we know those drugs cause breast cancer," she adds. "Why would I use those? I think the biggest thing is that we have to identify the difference between synthetic chemicals and the bioidentical hormones in the right form."

Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:

“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”

That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.

What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.

As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.

True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.

“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”

Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.

“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”

Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.

By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”

That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.

“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”

He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?

“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”

How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.

“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”

What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.

The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.

With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.

Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.

“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”

The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.

“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”

That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.

“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”

Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.

Even before that integration is completed, Parsons says, primary care providers should be networking with their psych/mental health colleagues. For one thing, a patient’s mental status can have a significant impact on his or her physical health and ability to take care of him- or herself. And for another, should a primary care provider have concerns about a patient’s mental status, having a specialist to call can be a lifeline.

“If you have a feeling that this person needs help, just saying ‘You really need to see a mental health provider’ and leaving it at that is probably not sufficient,” Parsons says.

She recommends knowing what specific resources are available locally, offering them to patients, and being prepared to make a phone call yourself if psych/mental health services are so scarce or overbooked that the patient can’t get an appointment for six or eight weeks. “Having relationships with folks who you can pick up the phone and say ‘I really have this urgent situation; can you see this patient or can you get me somebody who can see them within the next two or three days?’ is probably going to be our best bet,” she says. “And if we can integrate behavioral health on the same site, we have that ready access.”

Whatever the outcome of the latest gun control debate, there is no question that it is shining a spotlight on a critical issue for the US health care system. The lack of adequate care for the mentally ill impacts not only affected individuals, but also the public at large. It is a subject that must be handled with care, but everyone needs to participate in the discussion.

“Sticking our heads in the sand certainly is not the best option. I think we all have to take some responsibility for solving these problems,” Parsons says. “We have to engage all of these folks—the gun lobbyists, the gun control advocates, Congress, local leaders—in dialogue. How do we role model conflict resolution when we take very staunch positions and don’t communicate, don’t collaborate, don’t compromise?”

Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:

“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”

That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.

What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.

As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.

True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.

“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”

Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.

“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”

Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.

By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”

That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.

“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”

He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?

“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”

How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.

“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”

What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.

The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.

With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.

Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.

“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”

The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.

“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”

That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.

“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”

Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.

Even before that integration is completed, Parsons says, primary care providers should be networking with their psych/mental health colleagues. For one thing, a patient’s mental status can have a significant impact on his or her physical health and ability to take care of him- or herself. And for another, should a primary care provider have concerns about a patient’s mental status, having a specialist to call can be a lifeline.

“If you have a feeling that this person needs help, just saying ‘You really need to see a mental health provider’ and leaving it at that is probably not sufficient,” Parsons says.

She recommends knowing what specific resources are available locally, offering them to patients, and being prepared to make a phone call yourself if psych/mental health services are so scarce or overbooked that the patient can’t get an appointment for six or eight weeks. “Having relationships with folks who you can pick up the phone and say ‘I really have this urgent situation; can you see this patient or can you get me somebody who can see them within the next two or three days?’ is probably going to be our best bet,” she says. “And if we can integrate behavioral health on the same site, we have that ready access.”

Whatever the outcome of the latest gun control debate, there is no question that it is shining a spotlight on a critical issue for the US health care system. The lack of adequate care for the mentally ill impacts not only affected individuals, but also the public at large. It is a subject that must be handled with care, but everyone needs to participate in the discussion.

“Sticking our heads in the sand certainly is not the best option. I think we all have to take some responsibility for solving these problems,” Parsons says. “We have to engage all of these folks—the gun lobbyists, the gun control advocates, Congress, local leaders—in dialogue. How do we role model conflict resolution when we take very staunch positions and don’t communicate, don’t collaborate, don’t compromise?”

Since December 14, 2012, when Adam Lanza entered Sandy Hook Elementary School in Newtown, Connecticut, intent on taking the lives of innocent children and the adults tasked with protecting them, the topic of gun control in the United States has returned to the forefront. Some professional organizations, such as the American Academy of Pediatrics (AAP), have made their stance clear. In a letter to President Obama, AAP President Thomas K. McInerny, MD, FAAP, wrote:

“New federal firearms legislation that bans assault weapon sales and the sales of high-capacity magazines, strengthens mandatory waiting periods and background checks for all gun purchases, and promotes strict gun safety policies is a necessary first step. Next, the federal government must take action to improve access to services that meet the mental health and developmental needs of infants, children, and adolescents, and ensures that children and families exposed to violence have access to a medical home and other community supports.”

That “first step” is the central, divisive issue in the debate between gun control advocates and supporters of the Second Amendment, such as the National Rifle Association (NRA). But it is the next step—improving mental health services (and not only for children)—that may actually represent the crux of the matter. The risk is that, as both sides dig in their heels and try to out-shout each other, the nation will either miss or misuse an opportunity to address a complicated and unwieldy problem.

What Is Really At Issue
One week after the shooting at Sandy Hook, NRA executive Wayne LaPierre raised the idea of a “national database” of the mentally ill as one means of stemming gun violence. His comments also raised hackles, as some considered them a diversionary tactic and others worried that the mentally ill would become scapegoats in the debate.

As with all emotionally wrought topics, the intersection between violence and mental illness is complicated and controversial. Even setting aside personal positions on gun control leaves a realm of clinical uncertainty. There are no easy answers.

True psychiatric illness involves cognitive distortion (eg, the paranoia and hallucinations of schizophrenia). That positive symptomatology distinguishes mental illness from sociopathy, which entails a personality or a moral dysfunction.

“We know what neurotransmitters are involved in cognitive processes, and we can treat them,” says Cindy Parsons, DNP, ARNP-BC, FAANP, Associate Professor of Nursing, College of Natural and Health Science, University of Tampa, Florida. “When it comes to moral compasses being off-kilter, we don’t have a tried-and-true methodology that gives us even some hopefulness in terms of improvement. With Columbine and Sandy Hook, these young people were not so much paranoid about the world—they didn’t have a clear perspective on right and wrong.”

Currently, there is no treatment for antisocial personality disorder (which is diagnosed in those older than 18; in younger persons, it is known as conduct disorder). In fact, sociopathy—a particularly severe form of antisocial personality disorder—has not been a true classification in the Diagnostic and Statistical Manual of Mental Disorders. That will change this May, however, when DSM-V is published.

“Our ‘ticking time-bombs’ are probably our young people,” says Parsons. “How are we teaching young people to manage stress or conflict? We don’t. That’s not something we educate them on in school; we assume that families are educating them.”

Catherine R. Judd, MS, PA-C, who practices in Parkland Health and Hospital System’s Jail Health Program at the Dallas County Jail, recalls kids she encountered in the juvenile system. Many of them had been involved in vandalism, theft, animal cruelty, destruction of property, and arson—all criteria for a diagnosis of conduct disorder.

By contrast, “a lot of the seriously mentally ill people we see here in jail, their charges have nothing to do with weapons,” she says. “Their charges are criminal trespassing, stealing bologna out of the 7-11 because they’re hungry, urinating behind lampposts, hanging out under bridges, being ‘used’ by the real thieves to fence the copper they’re stealing off air conditioners, or to cash that ‘hot’ check.”

That isn’t to suggest that persons with mental illness are never violent. But are they necessarily more likely to be violent than those without a psychiatric diagnosis? And furthermore, who is determining that risk? These are just some of the concerns that Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa, has pondered since the subject of gun violence and the mentally ill has garnered renewed attention.

“If we define mental illness as ‘a DSM diagnosis,’ 25% of the population has had some kind of mental illness, lifetime prevalence,” he points out. “And the vast majority of people with a DSM-diagnosed mental illness are not at risk for doing anything like this.”

He has heard from patients who are concerned about being “labeled” based on their diagnosis. The question has been raised as to whether that increased stigma—already a huge issue with mental illness—will deter patients from seeking help. Another area of concern is how clinicians would respond: Will they avoid diagnosing patients because they don’t want the responsibility? Or will they be ultraconservative and write “paranoia” in the chart, when the patient may only have some mild anxiety?

“The problem is that when you start writing laws, [politicians] don’t have the understanding that we in medicine have about the difference between someone who’s at risk and someone who isn’t,” St. John says. “So some of it is going to be the definition—who is going to define it? And then how are they going to follow up on that?”

How information might be gleaned is another concern, and one that can be misleading. If medical charts or pharmacy records are mined, say, for specific diagnoses or medications, there is room for error.

“I have a patient with multiple sclerosis who takes an antidepressant for urinary incontinence,” St. John says. “She’s not taking it for depression. But, you know, she’s on an antidepressant—so, therefore, she must have a ‘mental illness.’”

What You Can Do
The mainstream media would have us believe that the individuals who represent the greatest threat to public safety walk into a clinic foaming at the mouth and with their eyes rolling back in their head—in other words, they should be identifiable at first glance. But identification of mental illness can be both more subtle and more complex, even for those with a psych/mental health background.

The key sign that someone has a mental impairment is disordered thinking. They may seem as if they can’t quite get their lives together; maybe they have difficulty following what a clinician considers a fairly straightforward regimen. They may appear disheveled or exhibit poor hygiene. Their responses to questions may seem “odd,” or they may convey a sense of fearfulness or paranoia.

With treatment, many people with mental illnesses do quite well. The difficulty is getting them adequate treatment, as well as monitoring to ensure they comply with it. Unlike other patients, who may be “willfully” noncompliant, those with mental illness are often incapable of keeping appointments or figuring out how to refill their prescription or follow the prescribed regimen without assistance.

Where does that assistance come from? That is precisely the problem the US has faced since deinstitutionalization occurred in the 1980s. Yes, there were asylums in which mentally ill patients were abused or neglected or otherwise treated as less than human. But for some patients, the facilities lived up to their names.

“There are a lot of people who actually did well in the institutions, because they needed that regimen—they got sleep, food, and shelter,” says St. John. “There are people who the best thing for them, and for society, is to put them in a place where they have protection. They call them asylums for a reason. And then we just kind of threw them out in the street and didn’t provide the services. That’s where we went wrong.”

The community-based services that were promised when the institutions closed have not materialized in a sufficient way. What is needed, advocates say, is adequate housing for the mentally ill—places where trained professionals can keep an eye on them and assist them with matters of daily living, including treatment plans.

“If you have that case management integrated into the housing component,” Parsons says, “if you have assigned and supportive housing for the chronically mentally ill, you’re going to do a better job getting them into treatment.”

That would rescue many of them from homelessness and perhaps cut down on some of the minor criminal offenses for which many mentally ill individuals find themselves incarcerated. It would also provide a layer of safety, as someone would be monitoring the patient for signs of deterioration.

“When symptoms worsen, what patients do is socially withdraw—they don’t want to be around people because they tend to be paranoid, their thoughts are more disordered,” St. John observes. “So then there aren’t people around to see them, and then you don’t hear anything until something bad happens.”

Equally important, and slowly starting to occur, is the integration of behavioral health services into primary care. Parsons is hopeful that the emergence of accountable care organizations and the expansion of the medical home concept will lead to better communication and coordination between providers, and ultimately better care for mentally ill individuals.

Even before that integration is completed, Parsons says, primary care providers should be networking with their psych/mental health colleagues. For one thing, a patient’s mental status can have a significant impact on his or her physical health and ability to take care of him- or herself. And for another, should a primary care provider have concerns about a patient’s mental status, having a specialist to call can be a lifeline.

“If you have a feeling that this person needs help, just saying ‘You really need to see a mental health provider’ and leaving it at that is probably not sufficient,” Parsons says.

She recommends knowing what specific resources are available locally, offering them to patients, and being prepared to make a phone call yourself if psych/mental health services are so scarce or overbooked that the patient can’t get an appointment for six or eight weeks. “Having relationships with folks who you can pick up the phone and say ‘I really have this urgent situation; can you see this patient or can you get me somebody who can see them within the next two or three days?’ is probably going to be our best bet,” she says. “And if we can integrate behavioral health on the same site, we have that ready access.”

Whatever the outcome of the latest gun control debate, there is no question that it is shining a spotlight on a critical issue for the US health care system. The lack of adequate care for the mentally ill impacts not only affected individuals, but also the public at large. It is a subject that must be handled with care, but everyone needs to participate in the discussion.

“Sticking our heads in the sand certainly is not the best option. I think we all have to take some responsibility for solving these problems,” Parsons says. “We have to engage all of these folks—the gun lobbyists, the gun control advocates, Congress, local leaders—in dialogue. How do we role model conflict resolution when we take very staunch positions and don’t communicate, don’t collaborate, don’t compromise?”

In a flu season that has been described in superlative terms (eg, Worst In Years), Massachusetts has perhaps been the poster child for just how widespread, virulent, and debilitating the virus has been. While the state reported a slight decline in flu activity in mid-January, Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP, who practices in the ICU and urgent care/emergency department settings of Good Samaritan Medical Center in Brockton, says, “We’re still seeing a lot of people who are very, very ill.”

Her description of the situation in Massachusetts will be familiar to clinicians in many of the 48 states that have reported widespread flu activity: “Emergency departments across the state are still packed. For the past three or four weeks, our ICU has been at full capacity every single day, and so has every other hospital in Massachusetts. There are just no beds to be had anywhere.”

The CDC’s FluView (www.cdc.gov/flu/weekly) for the week ending January 19 paints a national picture of epidemic proportions. About 26% of specimens tested by reporting laboratories were positive for influenza. The proportion of reported deaths attributable to pneumonia and influenza (9.8%) was above the epidemic threshold. Eight pediatric deaths were reported (although not all occurred during that particular week; there have been 37 pediatric deaths reported since flu season began). The cumulative rate (from October 1, 2012, to January 19, 2013) of laboratory-confirmed influenza-associated hospitalizations was 22.2 per 100,000 population; almost half of cases involved adults 65 and older.

In Massachusetts alone, about 11,000 people have already tested positive for flu. And as O’Rourke points out, “Those are just the folks who have shown up and been tested. There may be many more who are at home, just weathering it.”

All in all, it would be an understatement to say it’s been a pretty bad year for the flu.

Is It Really the Flu?
The CDC data focus on confirmed cases of influenza. But as O’Rourke notes, there are individuals who may not seek care (or, ironically, do not feel well enough to do so), as well as those who present too late in the course of illness for a flu test.

The CDC, though, also reports an increase in outpatient visits for influenza-like illness, which is defined as a temperature of at least 100°F, cough, and/or sore throat. While this description focuses on quantifiable symptoms, it does little to convey the malaise caused by the flu. When lifting your hand to pick up a glass of water on the bedside table seems like an insurmountable task, or standing upright long enough to shower becomes an unnecessary extravagance, you know you’re sick!

One of the confounding factors of this flu season has been the confluence of circulating viruses and infections. Besides influenza (three strains, no less), there have been outbreaks of norovirus and cases of mononucleosis, as well as the usual assortment of upper respiratory infections.

The distinguishing feature of flu, clinicians in the field say, tends to be fever. “If a child comes in with a high fever—101°F to 103°F—that child is more likely to have flu,” says Patrick E. Killeen, MS, PA-C, who practices at Danbury Hospital in Connecticut and holds academic posts in the Yale University School of Medicine’s Department of Pediatrics and the Quinnipiac University School of Health Sciences. “Whereas with RSV [respiratory syncytial virus] or rhinovirus, they have very similar symptomatology and x-ray findings, but they don’t have the high fever.”

Killeen and his colleagues have also observed that “children with the flu are more likely to develop secondary bacterial pneumonias. They’ve been sick for three or four days, they come into the hospital, and then their chest x-rays are showing significant infiltrate and they have high white counts.”

In the outpatient setting, Christopher M. Barry, PA-C, says a good history and physical examination can provide a lot of information. He echoes Killeen’s assessment that a quick-onset, high fever is often the first sign. But looking further, “We tend to see a person who just looks really sick. They often have a lot of nasal discharge, and sometimes the eyes have almost a glassy appearance. That gives us a little bit of a clue as well.”

At Jeffers, Mann, and Artman Pediatric and Adolescent Medicine in North Carolina, where Barry practices, they are fortunate to have access to a rapid antigen detection flu test. “We get a result back usually within five to 10 minutes,” he says. “So if there’s a suspicion, we typically run the test.”

At the other end of the age spectrum, O’Rourke has noticed that elderly patients tend to minimize their symptoms (as a general rule; this is not specific to flu). Many are appearing at urgent care centers and emergency departments when they’re already very ill.

“A lot of them are coming in with viral pneumonia,” she reports. “It quickly develops in them. They come in and they’re short of breath, they have really bad oxygenation, and they require a day or two in the ICU.”

Another observation that O’Rourke has made, and which has been noted extensively in national news broadcasts, is that “it’s a lingering illness this year; people are sick for a week, two weeks. Even though they may start to feel better, they’re still washed out, coughing, with chest symptoms that they need to pay attention to.”

To Treat Or Not To Treat
In some areas of the country (including Boston, where a state of emergency was declared), practicing clinicians have been so overwhelmed with patients that some have abandoned flu testing and decide to initiate antiviral treatment without a validated diagnosis. As Killeen says, “If it looks like flu and acts like flu, then people are going to treat it with [oseltamivir].”

With older patients, O’Rourke says, “I’m going to err on the side of giving it to them as opposed to not, because they are so vulnerable. A lot of them have comorbid conditions, such as diabetes or COPD, which puts them at greater risk. Any folks with chronic illnesses—asthma, HIV—you want to be more aggressive with their management.”

However, there may be patients for whom the gastrointestinal side effects of the medication do not sufficiently outweigh the benefits of a slightly reduced course of flu. “In many situations—and especially if we haven’t started treatment within the first 48 hours—we don’t necessarily recommend using an antiviral medication,” says Barry. “Even if we’ve caught it within 48 hours, if the child is otherwise healthy with no major underlying heart or lung issues, often I’ll leave it up to the parents.”

Barry has also learned to emphasize what antiviral medication can and cannot do in discussions with patients and families. “We try to make parents aware that it’s not a magic bullet,” he says. “It won’t cure the flu, boom, right there on the spot.”

While Killeen also supports the appropriate use of antiviral medications, he notes that there are some patients for whom clinicians will want to be more cautious about prescribing them. “A sickle cell patient, for example—if that person comes in with the flu, you have to think about other encapsulated organisms, like pneumococcus, that could be potentially detrimental to the patient, pending their vaccination status,” he says.

Clinicians have to rely on their clinical judgment when they don’t have the time or resources to confirm a flu diagnosis with a test. “If a pediatric patient comes in with petechiae and fever, that tells me, ‘No, it’s probably not the flu; we should be thinking about something else going on,’” Killeen says by way of example. “But absent other contradictory physical exam findings, then I would say we would treat [with antivirals].”

A Word (Or Two) Of Advice
For clinicians who have seen no abatement of flu season, or whose regions were late starters, here is some advice from your colleagues:

• Get your flu shot if you haven’t already. “Its efficacy varies, but in healthy adults you’re getting between 60% and 80% immunity,” O’Rourke notes.

• Wash your hands. “The quick alcohol hand rubs are great, but in flu season, I love soap and water,” says O’Rourke.

• Protect yourself and your other patients. Wear a mask. Ask patients with suspected cases of flu to do the same. If possible, do what Barry and his colleagues do: “We have anybody who has flu-like symptoms come in a separate entrance to our office, so we don’t have them in our main waiting area.”

• Stay home if you’re sick. This isn’t quite the no-brainer it seems. “[Clinicians] will come to work when they’re deathly ill, because they don’t want to burden their colleagues, they don’t want to miss out, and there’s a certain pressure for us to be the ‘soldiers’ who carry on,” O’Rourke observes. “If we’re sick, we’re not doing anybody any favors by coming to work. I think the better part of valor is to stay home and take care of yourself. We can’t be good caregivers to others if we can’t care for ourselves.”

In a flu season that has been described in superlative terms (eg, Worst In Years), Massachusetts has perhaps been the poster child for just how widespread, virulent, and debilitating the virus has been. While the state reported a slight decline in flu activity in mid-January, Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP, who practices in the ICU and urgent care/emergency department settings of Good Samaritan Medical Center in Brockton, says, “We’re still seeing a lot of people who are very, very ill.”

Her description of the situation in Massachusetts will be familiar to clinicians in many of the 48 states that have reported widespread flu activity: “Emergency departments across the state are still packed. For the past three or four weeks, our ICU has been at full capacity every single day, and so has every other hospital in Massachusetts. There are just no beds to be had anywhere.”

The CDC’s FluView (www.cdc.gov/flu/weekly) for the week ending January 19 paints a national picture of epidemic proportions. About 26% of specimens tested by reporting laboratories were positive for influenza. The proportion of reported deaths attributable to pneumonia and influenza (9.8%) was above the epidemic threshold. Eight pediatric deaths were reported (although not all occurred during that particular week; there have been 37 pediatric deaths reported since flu season began). The cumulative rate (from October 1, 2012, to January 19, 2013) of laboratory-confirmed influenza-associated hospitalizations was 22.2 per 100,000 population; almost half of cases involved adults 65 and older.

In Massachusetts alone, about 11,000 people have already tested positive for flu. And as O’Rourke points out, “Those are just the folks who have shown up and been tested. There may be many more who are at home, just weathering it.”

All in all, it would be an understatement to say it’s been a pretty bad year for the flu.

Is It Really the Flu?
The CDC data focus on confirmed cases of influenza. But as O’Rourke notes, there are individuals who may not seek care (or, ironically, do not feel well enough to do so), as well as those who present too late in the course of illness for a flu test.

The CDC, though, also reports an increase in outpatient visits for influenza-like illness, which is defined as a temperature of at least 100°F, cough, and/or sore throat. While this description focuses on quantifiable symptoms, it does little to convey the malaise caused by the flu. When lifting your hand to pick up a glass of water on the bedside table seems like an insurmountable task, or standing upright long enough to shower becomes an unnecessary extravagance, you know you’re sick!

One of the confounding factors of this flu season has been the confluence of circulating viruses and infections. Besides influenza (three strains, no less), there have been outbreaks of norovirus and cases of mononucleosis, as well as the usual assortment of upper respiratory infections.

The distinguishing feature of flu, clinicians in the field say, tends to be fever. “If a child comes in with a high fever—101°F to 103°F—that child is more likely to have flu,” says Patrick E. Killeen, MS, PA-C, who practices at Danbury Hospital in Connecticut and holds academic posts in the Yale University School of Medicine’s Department of Pediatrics and the Quinnipiac University School of Health Sciences. “Whereas with RSV [respiratory syncytial virus] or rhinovirus, they have very similar symptomatology and x-ray findings, but they don’t have the high fever.”

Killeen and his colleagues have also observed that “children with the flu are more likely to develop secondary bacterial pneumonias. They’ve been sick for three or four days, they come into the hospital, and then their chest x-rays are showing significant infiltrate and they have high white counts.”

In the outpatient setting, Christopher M. Barry, PA-C, says a good history and physical examination can provide a lot of information. He echoes Killeen’s assessment that a quick-onset, high fever is often the first sign. But looking further, “We tend to see a person who just looks really sick. They often have a lot of nasal discharge, and sometimes the eyes have almost a glassy appearance. That gives us a little bit of a clue as well.”

At Jeffers, Mann, and Artman Pediatric and Adolescent Medicine in North Carolina, where Barry practices, they are fortunate to have access to a rapid antigen detection flu test. “We get a result back usually within five to 10 minutes,” he says. “So if there’s a suspicion, we typically run the test.”

At the other end of the age spectrum, O’Rourke has noticed that elderly patients tend to minimize their symptoms (as a general rule; this is not specific to flu). Many are appearing at urgent care centers and emergency departments when they’re already very ill.

“A lot of them are coming in with viral pneumonia,” she reports. “It quickly develops in them. They come in and they’re short of breath, they have really bad oxygenation, and they require a day or two in the ICU.”

Another observation that O’Rourke has made, and which has been noted extensively in national news broadcasts, is that “it’s a lingering illness this year; people are sick for a week, two weeks. Even though they may start to feel better, they’re still washed out, coughing, with chest symptoms that they need to pay attention to.”

To Treat Or Not To Treat
In some areas of the country (including Boston, where a state of emergency was declared), practicing clinicians have been so overwhelmed with patients that some have abandoned flu testing and decide to initiate antiviral treatment without a validated diagnosis. As Killeen says, “If it looks like flu and acts like flu, then people are going to treat it with [oseltamivir].”

With older patients, O’Rourke says, “I’m going to err on the side of giving it to them as opposed to not, because they are so vulnerable. A lot of them have comorbid conditions, such as diabetes or COPD, which puts them at greater risk. Any folks with chronic illnesses—asthma, HIV—you want to be more aggressive with their management.”

However, there may be patients for whom the gastrointestinal side effects of the medication do not sufficiently outweigh the benefits of a slightly reduced course of flu. “In many situations—and especially if we haven’t started treatment within the first 48 hours—we don’t necessarily recommend using an antiviral medication,” says Barry. “Even if we’ve caught it within 48 hours, if the child is otherwise healthy with no major underlying heart or lung issues, often I’ll leave it up to the parents.”

Barry has also learned to emphasize what antiviral medication can and cannot do in discussions with patients and families. “We try to make parents aware that it’s not a magic bullet,” he says. “It won’t cure the flu, boom, right there on the spot.”

While Killeen also supports the appropriate use of antiviral medications, he notes that there are some patients for whom clinicians will want to be more cautious about prescribing them. “A sickle cell patient, for example—if that person comes in with the flu, you have to think about other encapsulated organisms, like pneumococcus, that could be potentially detrimental to the patient, pending their vaccination status,” he says.

Clinicians have to rely on their clinical judgment when they don’t have the time or resources to confirm a flu diagnosis with a test. “If a pediatric patient comes in with petechiae and fever, that tells me, ‘No, it’s probably not the flu; we should be thinking about something else going on,’” Killeen says by way of example. “But absent other contradictory physical exam findings, then I would say we would treat [with antivirals].”

A Word (Or Two) Of Advice
For clinicians who have seen no abatement of flu season, or whose regions were late starters, here is some advice from your colleagues:

• Get your flu shot if you haven’t already. “Its efficacy varies, but in healthy adults you’re getting between 60% and 80% immunity,” O’Rourke notes.

• Wash your hands. “The quick alcohol hand rubs are great, but in flu season, I love soap and water,” says O’Rourke.

• Protect yourself and your other patients. Wear a mask. Ask patients with suspected cases of flu to do the same. If possible, do what Barry and his colleagues do: “We have anybody who has flu-like symptoms come in a separate entrance to our office, so we don’t have them in our main waiting area.”

• Stay home if you’re sick. This isn’t quite the no-brainer it seems. “[Clinicians] will come to work when they’re deathly ill, because they don’t want to burden their colleagues, they don’t want to miss out, and there’s a certain pressure for us to be the ‘soldiers’ who carry on,” O’Rourke observes. “If we’re sick, we’re not doing anybody any favors by coming to work. I think the better part of valor is to stay home and take care of yourself. We can’t be good caregivers to others if we can’t care for ourselves.”

In a flu season that has been described in superlative terms (eg, Worst In Years), Massachusetts has perhaps been the poster child for just how widespread, virulent, and debilitating the virus has been. While the state reported a slight decline in flu activity in mid-January, Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP, who practices in the ICU and urgent care/emergency department settings of Good Samaritan Medical Center in Brockton, says, “We’re still seeing a lot of people who are very, very ill.”

Her description of the situation in Massachusetts will be familiar to clinicians in many of the 48 states that have reported widespread flu activity: “Emergency departments across the state are still packed. For the past three or four weeks, our ICU has been at full capacity every single day, and so has every other hospital in Massachusetts. There are just no beds to be had anywhere.”

The CDC’s FluView (www.cdc.gov/flu/weekly) for the week ending January 19 paints a national picture of epidemic proportions. About 26% of specimens tested by reporting laboratories were positive for influenza. The proportion of reported deaths attributable to pneumonia and influenza (9.8%) was above the epidemic threshold. Eight pediatric deaths were reported (although not all occurred during that particular week; there have been 37 pediatric deaths reported since flu season began). The cumulative rate (from October 1, 2012, to January 19, 2013) of laboratory-confirmed influenza-associated hospitalizations was 22.2 per 100,000 population; almost half of cases involved adults 65 and older.

In Massachusetts alone, about 11,000 people have already tested positive for flu. And as O’Rourke points out, “Those are just the folks who have shown up and been tested. There may be many more who are at home, just weathering it.”

All in all, it would be an understatement to say it’s been a pretty bad year for the flu.

Is It Really the Flu?
The CDC data focus on confirmed cases of influenza. But as O’Rourke notes, there are individuals who may not seek care (or, ironically, do not feel well enough to do so), as well as those who present too late in the course of illness for a flu test.

The CDC, though, also reports an increase in outpatient visits for influenza-like illness, which is defined as a temperature of at least 100°F, cough, and/or sore throat. While this description focuses on quantifiable symptoms, it does little to convey the malaise caused by the flu. When lifting your hand to pick up a glass of water on the bedside table seems like an insurmountable task, or standing upright long enough to shower becomes an unnecessary extravagance, you know you’re sick!

One of the confounding factors of this flu season has been the confluence of circulating viruses and infections. Besides influenza (three strains, no less), there have been outbreaks of norovirus and cases of mononucleosis, as well as the usual assortment of upper respiratory infections.

The distinguishing feature of flu, clinicians in the field say, tends to be fever. “If a child comes in with a high fever—101°F to 103°F—that child is more likely to have flu,” says Patrick E. Killeen, MS, PA-C, who practices at Danbury Hospital in Connecticut and holds academic posts in the Yale University School of Medicine’s Department of Pediatrics and the Quinnipiac University School of Health Sciences. “Whereas with RSV [respiratory syncytial virus] or rhinovirus, they have very similar symptomatology and x-ray findings, but they don’t have the high fever.”

Killeen and his colleagues have also observed that “children with the flu are more likely to develop secondary bacterial pneumonias. They’ve been sick for three or four days, they come into the hospital, and then their chest x-rays are showing significant infiltrate and they have high white counts.”

In the outpatient setting, Christopher M. Barry, PA-C, says a good history and physical examination can provide a lot of information. He echoes Killeen’s assessment that a quick-onset, high fever is often the first sign. But looking further, “We tend to see a person who just looks really sick. They often have a lot of nasal discharge, and sometimes the eyes have almost a glassy appearance. That gives us a little bit of a clue as well.”

At Jeffers, Mann, and Artman Pediatric and Adolescent Medicine in North Carolina, where Barry practices, they are fortunate to have access to a rapid antigen detection flu test. “We get a result back usually within five to 10 minutes,” he says. “So if there’s a suspicion, we typically run the test.”

At the other end of the age spectrum, O’Rourke has noticed that elderly patients tend to minimize their symptoms (as a general rule; this is not specific to flu). Many are appearing at urgent care centers and emergency departments when they’re already very ill.

“A lot of them are coming in with viral pneumonia,” she reports. “It quickly develops in them. They come in and they’re short of breath, they have really bad oxygenation, and they require a day or two in the ICU.”

Another observation that O’Rourke has made, and which has been noted extensively in national news broadcasts, is that “it’s a lingering illness this year; people are sick for a week, two weeks. Even though they may start to feel better, they’re still washed out, coughing, with chest symptoms that they need to pay attention to.”

To Treat Or Not To Treat
In some areas of the country (including Boston, where a state of emergency was declared), practicing clinicians have been so overwhelmed with patients that some have abandoned flu testing and decide to initiate antiviral treatment without a validated diagnosis. As Killeen says, “If it looks like flu and acts like flu, then people are going to treat it with [oseltamivir].”

With older patients, O’Rourke says, “I’m going to err on the side of giving it to them as opposed to not, because they are so vulnerable. A lot of them have comorbid conditions, such as diabetes or COPD, which puts them at greater risk. Any folks with chronic illnesses—asthma, HIV—you want to be more aggressive with their management.”

However, there may be patients for whom the gastrointestinal side effects of the medication do not sufficiently outweigh the benefits of a slightly reduced course of flu. “In many situations—and especially if we haven’t started treatment within the first 48 hours—we don’t necessarily recommend using an antiviral medication,” says Barry. “Even if we’ve caught it within 48 hours, if the child is otherwise healthy with no major underlying heart or lung issues, often I’ll leave it up to the parents.”

Barry has also learned to emphasize what antiviral medication can and cannot do in discussions with patients and families. “We try to make parents aware that it’s not a magic bullet,” he says. “It won’t cure the flu, boom, right there on the spot.”

While Killeen also supports the appropriate use of antiviral medications, he notes that there are some patients for whom clinicians will want to be more cautious about prescribing them. “A sickle cell patient, for example—if that person comes in with the flu, you have to think about other encapsulated organisms, like pneumococcus, that could be potentially detrimental to the patient, pending their vaccination status,” he says.

Clinicians have to rely on their clinical judgment when they don’t have the time or resources to confirm a flu diagnosis with a test. “If a pediatric patient comes in with petechiae and fever, that tells me, ‘No, it’s probably not the flu; we should be thinking about something else going on,’” Killeen says by way of example. “But absent other contradictory physical exam findings, then I would say we would treat [with antivirals].”

A Word (Or Two) Of Advice
For clinicians who have seen no abatement of flu season, or whose regions were late starters, here is some advice from your colleagues:

• Get your flu shot if you haven’t already. “Its efficacy varies, but in healthy adults you’re getting between 60% and 80% immunity,” O’Rourke notes.

• Wash your hands. “The quick alcohol hand rubs are great, but in flu season, I love soap and water,” says O’Rourke.

• Protect yourself and your other patients. Wear a mask. Ask patients with suspected cases of flu to do the same. If possible, do what Barry and his colleagues do: “We have anybody who has flu-like symptoms come in a separate entrance to our office, so we don’t have them in our main waiting area.”

• Stay home if you’re sick. This isn’t quite the no-brainer it seems. “[Clinicians] will come to work when they’re deathly ill, because they don’t want to burden their colleagues, they don’t want to miss out, and there’s a certain pressure for us to be the ‘soldiers’ who carry on,” O’Rourke observes. “If we’re sick, we’re not doing anybody any favors by coming to work. I think the better part of valor is to stay home and take care of yourself. We can’t be good caregivers to others if we can’t care for ourselves.”

Assuming the ancient Mayans were wrong about that whole “end of the world” scenario, 2013 has dawned by the time you’re reading this. And a new year brings a new, unified voice for nurse practitioners: the American Association of Nurse Practitioners (AANP). But the leadership of the “new” organization—the result of a merger between the American Academy of Nurse Practitioners and the American College of Nurse Practitioners (ACNP)—hopes you won’t notice much of a change from its previous incarnations.

“NPs will see a new name, but they’ll see the same people from the two organizations still working very hard to assist them and focus on their practice,” says Angela K. Golden, DNP, FNP-C, FAANP, President of both the old and the new AANP. “Both organizations were member-focused, and that clearly will remain our guiding principle.”

“We are able, essentially, to join forces, combine the talent of both staff and members, and move forward with a renewed purpose toward advancing the cause of NPs,” says David Hebert, who served as CEO of ACNP and will retain that role within the new AANP. “Certainly, the profession will continue to vigorously advocate to practice fully within its scope, and we will continue to be very assertive on that front.”

HERE’S THE DEAL ...
On November 19, 2012, AANP and ACNP announced their plans to consolidate effective January 1, 2013. The new organization has approximately 40,000 members, making it the largest professional membership organization in the United States representing NPs of all specialties.

Golden will serve out the first year of her two-year term as President; then, at AANP’s annual meeting in Las Vegas this June, she will be joined by Co-President Kenneth P. Miller, PhD, RN, CFNP, FAAN, who was the President-Elect of ACNP. The executive committee of the new organization also includes Past President Penny Kaye Jensen, DNP, APRN, FNP-C, FAANP; Treasurer Joyce M. Knestrick, PhD, FNP, FAANP; Recording Secretary Cindy Cooke, MSN, FNP, NP-C, FAANP; and Members at Large Cathy R. Arvidson, PhD, FNP-BC, FAANP, and Cynthia J. Edwards-Tuttle, MSN, FNP, BC.

The boards of both AANP and ACNP obviously had to approve the merger, and a bylaw change was sent to the membership for a vote. Golden says the response from NPs, both members and nonmembers, has been “overwhelmingly positive.” In fact, the move has been applauded by those outside the profession as well.

“I recently had the opportunity to speak at a PA meeting,” Golden reports, “and they were all saying, ‘This is so exciting for NPs.’ So I think lots of organizations recognize the value of having one voice.”

During her term as President of AANP, Jensen was often asked by colleagues, NP students, and other stakeholders, “Why are there two organizations for NPs?”

“There was never a good explanation,” Jensen says. “The merger will provide unity in terms of our messages, goals, strategies, and resources. NPs must speak with a unified voice and encourage our health care system to embrace us fully as highly skilled, educated, and qualified.”

That’s the entire point of the merger: strengthening the voice of NPs on the national stage as well as within each state. The consensus is that this is an exciting moment for NPs, particularly in light of the Institute of Medicine’s Future of Nursing report and the impending implementation of aspects of the Patient Protection and Affordable Care Act (PPACA) that will result in an additional 32 million Americans having health insurance and needing access to health care providers. NPs have been working aggressively to improve and align state practice acts and update archaic language in laws that prevent them from practicing to the full extent of their education and training.

“It is more important than ever that NPs are involved in key discussions at both the state and national level,” Jensen says. “Two of the most important places to do this are the insurance exchange and medical home arenas. A presence in each of these venues will be critical to NP involvement in the future of health care in the nation.”

“This is just one more way that we can concentrate on getting ‘all hands on deck,’ getting everybody ready for NPs to come forward and be one of the primary providers of primary care,” says Golden. “There are other NP organizations that we will still, very clearly, collaborate with, but to have one organization representing all NPs shows solidarity.”

WHAT TO EXPECT
A strategic planning session will be held early this year, at which the board of AANP will outline its vision for 2013 and beyond. “At that point,” Hebert says, “we will have a discussion about utilization of resources, the creation of new services to be provided to the membership, and to really set forth what we plan to do for the future.”

In some ways, the mission of the new organization will simply be a continuation of the work that both AANP and ACNP were already doing. Of course, AANP provided full services to members and had established a research division, as well as education and continuing education components, while ACNP focused primarily on health policy and their own annual meeting. But Golden says the merger went smoothly in part because the two organizations had a similar focus to their policy initiatives.

“I think what [the merger] is really going to do is provide us with a stronger base to do the things that we were planning to do anyway,” she says. “Both organizations were looking at the home health and hospice issue and getting old laws updated across the United States, and helping our group members and our state affiliates to work on the language in their states so that there is full access to NPs for our patients.”

As much as things will remain the same, Hebert anticipates additions and improvements to what the new AANP can offer its members. “My sense is that once the board has its strategic planning session, members will see some new services,” he notes. There will also be a rebranding campaign to introduce the new “look” to the organization, which includes a new logo.

And there will be an opportunity for members to have their own voices heard by the organization. “I think we’re going to want to take some time to find out from the members what new services they want,” Hebert adds. (He sounds unfazed by how refreshing this concept is.) “The board and the staff will have ideas about what else we can do to improve member services, but we certainly want to reach out to the membership. You do your best to try and think of what a member wants, but nothing beats just talking to them.”

WORKING TOGETHER BENEFITS ALL
All parties agree that the merger was the right move at the right time. Golden knows from speaking with prior leaders of AANP that the conversation had often been started but never proceeded. Hebert acknowledges that both organizations had heard the question of “Why isn’t there one group for NPs?” before; after all, the nurse anesthetists and the nurse-midwives each have an umbrella group to represent them.

“I think sometimes things occur when they’re supposed to,” Golden says. “That sounds a bit metaphysical, but I think in this case, Jill Olmstead and Penny Kaye Jensen, who were the presidents of ACNP and AANP when this conversation began, both acknowledged how valuable this could be and got both boards involved in the discussion.”

In January 2012, Jensen, Olmstead, Hebert, ACNP Immediate Past President Janet Selway, DNSc, CRNP, and AANP Interim CEO Janice DeMartino met “to discuss the possibility of the two organizations working together to promote the NP profession and create a legislative agenda that would ensure NPs a seat at the table with the expected changes brought by the implementation of PPACA,” Jensen says.

That meeting was followed by additional discussions that eventually led to the merger proposal in July 2012. “Both boards were very thoughtful throughout the process and should be given credit for working diligently to make the merger a reality,” Jensen says. 

She gives much of the credit to DeMartino, who she says “worked tirelessly to ensure AANP made the needed changes to ensure a bright future and was able to open doors that had never been opened in the past. She is a visionary, and I cannot thank her enough for serving as interim CEO for the past 13 months and working closely with the board to make the vision of a successful merger a reality.”

The consolidation process has already demonstrated that the leaders and staff of the two organizations can work together effectively and efficiently, to the benefit of all NPs. “We’ve been working very hard over the past six months, pending the formal ratification by both organizations, to make sure that if in fact [the merger] occurred, we would be ready to ensure a seamless transition,” Hebert says.

Golden describes the negotiation process as “pretty easy and painless,” as well as “collegial.” “We all just said, ‘This is our end goal; how do we get there?’ Both organizations had ideas, but they were pretty close together. We were both focused on members. It’s just like NPs focusing on patient care—when you keep your focus where it’s supposed to be, the details kind of come along.”

Golden laughs when it is suggested that NPs should forget about marching on Congress and instead take over the legislative body, acknowledging, “Maybe we could give them an example of how to work together.” More important to her is for all NPs to get involved to advance the cause and enhance their ability to provide quality patient care, because, as she says, “We can’t do it alone.”     

“There is strength in numbers,” Jensen says. “The NP profession has gained visibility and momentum over the past two years. We are well positioned for the future, and I am ecstatic that we will now be able to relay our message to key stakeholders with one unified voice.”                                

Assuming the ancient Mayans were wrong about that whole “end of the world” scenario, 2013 has dawned by the time you’re reading this. And a new year brings a new, unified voice for nurse practitioners: the American Association of Nurse Practitioners (AANP). But the leadership of the “new” organization—the result of a merger between the American Academy of Nurse Practitioners and the American College of Nurse Practitioners (ACNP)—hopes you won’t notice much of a change from its previous incarnations.

“NPs will see a new name, but they’ll see the same people from the two organizations still working very hard to assist them and focus on their practice,” says Angela K. Golden, DNP, FNP-C, FAANP, President of both the old and the new AANP. “Both organizations were member-focused, and that clearly will remain our guiding principle.”

“We are able, essentially, to join forces, combine the talent of both staff and members, and move forward with a renewed purpose toward advancing the cause of NPs,” says David Hebert, who served as CEO of ACNP and will retain that role within the new AANP. “Certainly, the profession will continue to vigorously advocate to practice fully within its scope, and we will continue to be very assertive on that front.”

HERE’S THE DEAL ...
On November 19, 2012, AANP and ACNP announced their plans to consolidate effective January 1, 2013. The new organization has approximately 40,000 members, making it the largest professional membership organization in the United States representing NPs of all specialties.

Golden will serve out the first year of her two-year term as President; then, at AANP’s annual meeting in Las Vegas this June, she will be joined by Co-President Kenneth P. Miller, PhD, RN, CFNP, FAAN, who was the President-Elect of ACNP. The executive committee of the new organization also includes Past President Penny Kaye Jensen, DNP, APRN, FNP-C, FAANP; Treasurer Joyce M. Knestrick, PhD, FNP, FAANP; Recording Secretary Cindy Cooke, MSN, FNP, NP-C, FAANP; and Members at Large Cathy R. Arvidson, PhD, FNP-BC, FAANP, and Cynthia J. Edwards-Tuttle, MSN, FNP, BC.

The boards of both AANP and ACNP obviously had to approve the merger, and a bylaw change was sent to the membership for a vote. Golden says the response from NPs, both members and nonmembers, has been “overwhelmingly positive.” In fact, the move has been applauded by those outside the profession as well.

“I recently had the opportunity to speak at a PA meeting,” Golden reports, “and they were all saying, ‘This is so exciting for NPs.’ So I think lots of organizations recognize the value of having one voice.”

During her term as President of AANP, Jensen was often asked by colleagues, NP students, and other stakeholders, “Why are there two organizations for NPs?”

“There was never a good explanation,” Jensen says. “The merger will provide unity in terms of our messages, goals, strategies, and resources. NPs must speak with a unified voice and encourage our health care system to embrace us fully as highly skilled, educated, and qualified.”

That’s the entire point of the merger: strengthening the voice of NPs on the national stage as well as within each state. The consensus is that this is an exciting moment for NPs, particularly in light of the Institute of Medicine’s Future of Nursing report and the impending implementation of aspects of the Patient Protection and Affordable Care Act (PPACA) that will result in an additional 32 million Americans having health insurance and needing access to health care providers. NPs have been working aggressively to improve and align state practice acts and update archaic language in laws that prevent them from practicing to the full extent of their education and training.

“It is more important than ever that NPs are involved in key discussions at both the state and national level,” Jensen says. “Two of the most important places to do this are the insurance exchange and medical home arenas. A presence in each of these venues will be critical to NP involvement in the future of health care in the nation.”

“This is just one more way that we can concentrate on getting ‘all hands on deck,’ getting everybody ready for NPs to come forward and be one of the primary providers of primary care,” says Golden. “There are other NP organizations that we will still, very clearly, collaborate with, but to have one organization representing all NPs shows solidarity.”

WHAT TO EXPECT
A strategic planning session will be held early this year, at which the board of AANP will outline its vision for 2013 and beyond. “At that point,” Hebert says, “we will have a discussion about utilization of resources, the creation of new services to be provided to the membership, and to really set forth what we plan to do for the future.”

In some ways, the mission of the new organization will simply be a continuation of the work that both AANP and ACNP were already doing. Of course, AANP provided full services to members and had established a research division, as well as education and continuing education components, while ACNP focused primarily on health policy and their own annual meeting. But Golden says the merger went smoothly in part because the two organizations had a similar focus to their policy initiatives.

“I think what [the merger] is really going to do is provide us with a stronger base to do the things that we were planning to do anyway,” she says. “Both organizations were looking at the home health and hospice issue and getting old laws updated across the United States, and helping our group members and our state affiliates to work on the language in their states so that there is full access to NPs for our patients.”

As much as things will remain the same, Hebert anticipates additions and improvements to what the new AANP can offer its members. “My sense is that once the board has its strategic planning session, members will see some new services,” he notes. There will also be a rebranding campaign to introduce the new “look” to the organization, which includes a new logo.

And there will be an opportunity for members to have their own voices heard by the organization. “I think we’re going to want to take some time to find out from the members what new services they want,” Hebert adds. (He sounds unfazed by how refreshing this concept is.) “The board and the staff will have ideas about what else we can do to improve member services, but we certainly want to reach out to the membership. You do your best to try and think of what a member wants, but nothing beats just talking to them.”

WORKING TOGETHER BENEFITS ALL
All parties agree that the merger was the right move at the right time. Golden knows from speaking with prior leaders of AANP that the conversation had often been started but never proceeded. Hebert acknowledges that both organizations had heard the question of “Why isn’t there one group for NPs?” before; after all, the nurse anesthetists and the nurse-midwives each have an umbrella group to represent them.

“I think sometimes things occur when they’re supposed to,” Golden says. “That sounds a bit metaphysical, but I think in this case, Jill Olmstead and Penny Kaye Jensen, who were the presidents of ACNP and AANP when this conversation began, both acknowledged how valuable this could be and got both boards involved in the discussion.”

In January 2012, Jensen, Olmstead, Hebert, ACNP Immediate Past President Janet Selway, DNSc, CRNP, and AANP Interim CEO Janice DeMartino met “to discuss the possibility of the two organizations working together to promote the NP profession and create a legislative agenda that would ensure NPs a seat at the table with the expected changes brought by the implementation of PPACA,” Jensen says.

That meeting was followed by additional discussions that eventually led to the merger proposal in July 2012. “Both boards were very thoughtful throughout the process and should be given credit for working diligently to make the merger a reality,” Jensen says. 

She gives much of the credit to DeMartino, who she says “worked tirelessly to ensure AANP made the needed changes to ensure a bright future and was able to open doors that had never been opened in the past. She is a visionary, and I cannot thank her enough for serving as interim CEO for the past 13 months and working closely with the board to make the vision of a successful merger a reality.”

The consolidation process has already demonstrated that the leaders and staff of the two organizations can work together effectively and efficiently, to the benefit of all NPs. “We’ve been working very hard over the past six months, pending the formal ratification by both organizations, to make sure that if in fact [the merger] occurred, we would be ready to ensure a seamless transition,” Hebert says.

Golden describes the negotiation process as “pretty easy and painless,” as well as “collegial.” “We all just said, ‘This is our end goal; how do we get there?’ Both organizations had ideas, but they were pretty close together. We were both focused on members. It’s just like NPs focusing on patient care—when you keep your focus where it’s supposed to be, the details kind of come along.”

Golden laughs when it is suggested that NPs should forget about marching on Congress and instead take over the legislative body, acknowledging, “Maybe we could give them an example of how to work together.” More important to her is for all NPs to get involved to advance the cause and enhance their ability to provide quality patient care, because, as she says, “We can’t do it alone.”     

“There is strength in numbers,” Jensen says. “The NP profession has gained visibility and momentum over the past two years. We are well positioned for the future, and I am ecstatic that we will now be able to relay our message to key stakeholders with one unified voice.”                                

Assuming the ancient Mayans were wrong about that whole “end of the world” scenario, 2013 has dawned by the time you’re reading this. And a new year brings a new, unified voice for nurse practitioners: the American Association of Nurse Practitioners (AANP). But the leadership of the “new” organization—the result of a merger between the American Academy of Nurse Practitioners and the American College of Nurse Practitioners (ACNP)—hopes you won’t notice much of a change from its previous incarnations.

“NPs will see a new name, but they’ll see the same people from the two organizations still working very hard to assist them and focus on their practice,” says Angela K. Golden, DNP, FNP-C, FAANP, President of both the old and the new AANP. “Both organizations were member-focused, and that clearly will remain our guiding principle.”

“We are able, essentially, to join forces, combine the talent of both staff and members, and move forward with a renewed purpose toward advancing the cause of NPs,” says David Hebert, who served as CEO of ACNP and will retain that role within the new AANP. “Certainly, the profession will continue to vigorously advocate to practice fully within its scope, and we will continue to be very assertive on that front.”

HERE’S THE DEAL ...
On November 19, 2012, AANP and ACNP announced their plans to consolidate effective January 1, 2013. The new organization has approximately 40,000 members, making it the largest professional membership organization in the United States representing NPs of all specialties.

Golden will serve out the first year of her two-year term as President; then, at AANP’s annual meeting in Las Vegas this June, she will be joined by Co-President Kenneth P. Miller, PhD, RN, CFNP, FAAN, who was the President-Elect of ACNP. The executive committee of the new organization also includes Past President Penny Kaye Jensen, DNP, APRN, FNP-C, FAANP; Treasurer Joyce M. Knestrick, PhD, FNP, FAANP; Recording Secretary Cindy Cooke, MSN, FNP, NP-C, FAANP; and Members at Large Cathy R. Arvidson, PhD, FNP-BC, FAANP, and Cynthia J. Edwards-Tuttle, MSN, FNP, BC.

The boards of both AANP and ACNP obviously had to approve the merger, and a bylaw change was sent to the membership for a vote. Golden says the response from NPs, both members and nonmembers, has been “overwhelmingly positive.” In fact, the move has been applauded by those outside the profession as well.

“I recently had the opportunity to speak at a PA meeting,” Golden reports, “and they were all saying, ‘This is so exciting for NPs.’ So I think lots of organizations recognize the value of having one voice.”

During her term as President of AANP, Jensen was often asked by colleagues, NP students, and other stakeholders, “Why are there two organizations for NPs?”

“There was never a good explanation,” Jensen says. “The merger will provide unity in terms of our messages, goals, strategies, and resources. NPs must speak with a unified voice and encourage our health care system to embrace us fully as highly skilled, educated, and qualified.”

That’s the entire point of the merger: strengthening the voice of NPs on the national stage as well as within each state. The consensus is that this is an exciting moment for NPs, particularly in light of the Institute of Medicine’s Future of Nursing report and the impending implementation of aspects of the Patient Protection and Affordable Care Act (PPACA) that will result in an additional 32 million Americans having health insurance and needing access to health care providers. NPs have been working aggressively to improve and align state practice acts and update archaic language in laws that prevent them from practicing to the full extent of their education and training.

“It is more important than ever that NPs are involved in key discussions at both the state and national level,” Jensen says. “Two of the most important places to do this are the insurance exchange and medical home arenas. A presence in each of these venues will be critical to NP involvement in the future of health care in the nation.”

“This is just one more way that we can concentrate on getting ‘all hands on deck,’ getting everybody ready for NPs to come forward and be one of the primary providers of primary care,” says Golden. “There are other NP organizations that we will still, very clearly, collaborate with, but to have one organization representing all NPs shows solidarity.”

WHAT TO EXPECT
A strategic planning session will be held early this year, at which the board of AANP will outline its vision for 2013 and beyond. “At that point,” Hebert says, “we will have a discussion about utilization of resources, the creation of new services to be provided to the membership, and to really set forth what we plan to do for the future.”

In some ways, the mission of the new organization will simply be a continuation of the work that both AANP and ACNP were already doing. Of course, AANP provided full services to members and had established a research division, as well as education and continuing education components, while ACNP focused primarily on health policy and their own annual meeting. But Golden says the merger went smoothly in part because the two organizations had a similar focus to their policy initiatives.

“I think what [the merger] is really going to do is provide us with a stronger base to do the things that we were planning to do anyway,” she says. “Both organizations were looking at the home health and hospice issue and getting old laws updated across the United States, and helping our group members and our state affiliates to work on the language in their states so that there is full access to NPs for our patients.”

As much as things will remain the same, Hebert anticipates additions and improvements to what the new AANP can offer its members. “My sense is that once the board has its strategic planning session, members will see some new services,” he notes. There will also be a rebranding campaign to introduce the new “look” to the organization, which includes a new logo.

And there will be an opportunity for members to have their own voices heard by the organization. “I think we’re going to want to take some time to find out from the members what new services they want,” Hebert adds. (He sounds unfazed by how refreshing this concept is.) “The board and the staff will have ideas about what else we can do to improve member services, but we certainly want to reach out to the membership. You do your best to try and think of what a member wants, but nothing beats just talking to them.”

WORKING TOGETHER BENEFITS ALL
All parties agree that the merger was the right move at the right time. Golden knows from speaking with prior leaders of AANP that the conversation had often been started but never proceeded. Hebert acknowledges that both organizations had heard the question of “Why isn’t there one group for NPs?” before; after all, the nurse anesthetists and the nurse-midwives each have an umbrella group to represent them.

“I think sometimes things occur when they’re supposed to,” Golden says. “That sounds a bit metaphysical, but I think in this case, Jill Olmstead and Penny Kaye Jensen, who were the presidents of ACNP and AANP when this conversation began, both acknowledged how valuable this could be and got both boards involved in the discussion.”

In January 2012, Jensen, Olmstead, Hebert, ACNP Immediate Past President Janet Selway, DNSc, CRNP, and AANP Interim CEO Janice DeMartino met “to discuss the possibility of the two organizations working together to promote the NP profession and create a legislative agenda that would ensure NPs a seat at the table with the expected changes brought by the implementation of PPACA,” Jensen says.

That meeting was followed by additional discussions that eventually led to the merger proposal in July 2012. “Both boards were very thoughtful throughout the process and should be given credit for working diligently to make the merger a reality,” Jensen says. 

She gives much of the credit to DeMartino, who she says “worked tirelessly to ensure AANP made the needed changes to ensure a bright future and was able to open doors that had never been opened in the past. She is a visionary, and I cannot thank her enough for serving as interim CEO for the past 13 months and working closely with the board to make the vision of a successful merger a reality.”

The consolidation process has already demonstrated that the leaders and staff of the two organizations can work together effectively and efficiently, to the benefit of all NPs. “We’ve been working very hard over the past six months, pending the formal ratification by both organizations, to make sure that if in fact [the merger] occurred, we would be ready to ensure a seamless transition,” Hebert says.

Golden describes the negotiation process as “pretty easy and painless,” as well as “collegial.” “We all just said, ‘This is our end goal; how do we get there?’ Both organizations had ideas, but they were pretty close together. We were both focused on members. It’s just like NPs focusing on patient care—when you keep your focus where it’s supposed to be, the details kind of come along.”

Golden laughs when it is suggested that NPs should forget about marching on Congress and instead take over the legislative body, acknowledging, “Maybe we could give them an example of how to work together.” More important to her is for all NPs to get involved to advance the cause and enhance their ability to provide quality patient care, because, as she says, “We can’t do it alone.”     

“There is strength in numbers,” Jensen says. “The NP profession has gained visibility and momentum over the past two years. We are well positioned for the future, and I am ecstatic that we will now be able to relay our message to key stakeholders with one unified voice.”                                

Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.

Q: With which of the following statements do you agree?

a) I’m safe, because I’ve never intentionally committed fraud.

b) Mistakes made by the billing department are their problem, not mine.

c) A fraud investigation is only costly if you’re found guilty.

If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.

YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.

How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.

While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.

“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”

Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”

But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”

Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”

Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.

HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.

“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.

Q: With which of the following statements do you agree?

a) I’m safe, because I’ve never intentionally committed fraud.

b) Mistakes made by the billing department are their problem, not mine.

c) A fraud investigation is only costly if you’re found guilty.

If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.

YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.

How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.

While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.

“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”

Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”

But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”

Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”

Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.

HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.

“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.

Q: With which of the following statements do you agree?

a) I’m safe, because I’ve never intentionally committed fraud.

b) Mistakes made by the billing department are their problem, not mine.

c) A fraud investigation is only costly if you’re found guilty.

If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.

YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.

How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.

While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.

“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”

Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”

But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”

Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”

Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.

HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.

“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:

“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”

Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.

The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.

NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.

That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.

“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”

Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”

The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.

Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.

“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”

“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”

The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”

Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.

For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”

In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”

THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.

“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”

Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.

“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”

PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”

Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.

“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”

The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?

“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”

How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)

TRULY SPECIALIZED

KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.

Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”

The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.

“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”

Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”

Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.

“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”

Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.

Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.

“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”

Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.

“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”

All of this is daunting—but there will come a time when it is no longer optional.

PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).

Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).

Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”

To be blunt: People have filed lawsuits for less.

Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.

“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”

Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”

The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.

“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”

And you’d better do it before Baker joins the geriatric set!

Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:

“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”

Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.

The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.

NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.

That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.

“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”

Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”

The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.

Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.

“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”

“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”

The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”

Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.

For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”

In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”

THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.

“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”

Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.

“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”

PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”

Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.

“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”

The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?

“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”

How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)

TRULY SPECIALIZED

KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.

Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”

The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.

“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”

Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”

Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.

“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”

Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.

Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.

“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”

Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.

“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”

All of this is daunting—but there will come a time when it is no longer optional.

PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).

Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).

Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”

To be blunt: People have filed lawsuits for less.

Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.

“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”

Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”

The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.

“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”

And you’d better do it before Baker joins the geriatric set!

Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:

“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”

Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.

The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.

NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.

That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.

“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”

Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”

The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.

Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.

“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”

“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”

The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”

Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.

For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”

In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”

THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.

“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”

Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.

“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”

PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”

Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.

“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”

The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?

“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”

How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)

TRULY SPECIALIZED

KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.

Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”

The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.

“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”

Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”

Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.

“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”

Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.

Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.

“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”

Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.

“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”

All of this is daunting—but there will come a time when it is no longer optional.

PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).

Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).

Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”

To be blunt: People have filed lawsuits for less.

Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.

“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”

Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”

The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.

“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”

And you’d better do it before Baker joins the geriatric set!

Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).

More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.

While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.

“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”

WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.

But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.

How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.

“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”

Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.

“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”

By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.

“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”

Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.

“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”

BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.

Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.

But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)

“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”

Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”

The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”

In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.

“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”

Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.

“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”

Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).

More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.

While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.

“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”

WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.

But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.

How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.

“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”

Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.

“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”

By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.

“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”

Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.

“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”

BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.

Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.

But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)

“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”

Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”

The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”

In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.

“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”

Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.

“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”

Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).

More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.

While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.

“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”

WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.

But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.

How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.

“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”

Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.

“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”

By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.

“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”

Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.

“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”

BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.

Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.

But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)

“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”

Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”

The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”

In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.

“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”

Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.

“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.” 

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

Providing patients and families with reliable information is helpful, Barry says. If they need or want to review the material and have a discussion at home, they are welcome to come back with questions. “That’s the key: In a busy day it’s sometimes hard to do, but it’s important to spend the time to counsel patients and parents about vaccines,” Barry says, “so they know that you’re really giving all the time and attention they need.”

Given the publicity that ACIP’s recommendation has already received, there will undoubtedly be more discussions about HPV vaccine between clinicians and adolescent patients (and their parents). Clinicians need to be prepared to answer questions about why boys can benefit from a vaccine that protects against a virus that causes, most notably, cervical cancer.

“They may say, ‘Well, my son doesn’t have a cervix,’” Barry says, “so there might need to be additional discussions just to clarify the exact reasons for giving the vaccine to males.”

Whether the concern is cervical cancer, anal cancer, cancers of the head and neck, or any of the other variations caused by HPV, the bottom line for clinicians is that the HPV vaccine is a powerful tool at their disposal that can help to prevent serious illness.

“You get a shot and you can potentially prevent your child from getting cancer,” Barry says. “That’s the main point I try to make. I just look at it as caring for the children.”

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.” 

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

Providing patients and families with reliable information is helpful, Barry says. If they need or want to review the material and have a discussion at home, they are welcome to come back with questions. “That’s the key: In a busy day it’s sometimes hard to do, but it’s important to spend the time to counsel patients and parents about vaccines,” Barry says, “so they know that you’re really giving all the time and attention they need.”

Given the publicity that ACIP’s recommendation has already received, there will undoubtedly be more discussions about HPV vaccine between clinicians and adolescent patients (and their parents). Clinicians need to be prepared to answer questions about why boys can benefit from a vaccine that protects against a virus that causes, most notably, cervical cancer.

“They may say, ‘Well, my son doesn’t have a cervix,’” Barry says, “so there might need to be additional discussions just to clarify the exact reasons for giving the vaccine to males.”

Whether the concern is cervical cancer, anal cancer, cancers of the head and neck, or any of the other variations caused by HPV, the bottom line for clinicians is that the HPV vaccine is a powerful tool at their disposal that can help to prevent serious illness.

“You get a shot and you can potentially prevent your child from getting cancer,” Barry says. “That’s the main point I try to make. I just look at it as caring for the children.”

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.” 

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

Providing patients and families with reliable information is helpful, Barry says. If they need or want to review the material and have a discussion at home, they are welcome to come back with questions. “That’s the key: In a busy day it’s sometimes hard to do, but it’s important to spend the time to counsel patients and parents about vaccines,” Barry says, “so they know that you’re really giving all the time and attention they need.”

Given the publicity that ACIP’s recommendation has already received, there will undoubtedly be more discussions about HPV vaccine between clinicians and adolescent patients (and their parents). Clinicians need to be prepared to answer questions about why boys can benefit from a vaccine that protects against a virus that causes, most notably, cervical cancer.

“They may say, ‘Well, my son doesn’t have a cervix,’” Barry says, “so there might need to be additional discussions just to clarify the exact reasons for giving the vaccine to males.”

Whether the concern is cervical cancer, anal cancer, cancers of the head and neck, or any of the other variations caused by HPV, the bottom line for clinicians is that the HPV vaccine is a powerful tool at their disposal that can help to prevent serious illness.

“You get a shot and you can potentially prevent your child from getting cancer,” Barry says. “That’s the main point I try to make. I just look at it as caring for the children.”

When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”

While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.

“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”

READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.

“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”

The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.

Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.

“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”

The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”

Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.

“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.

“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”

SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.

“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”

Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.

Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.

At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.

“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.

While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”

To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”

Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.

THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?

“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”

“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”

“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”

For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”

Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.

Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”

On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”

There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)

“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”

Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.

“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”

“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”

When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”

While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.

“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”

READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.

“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”

The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.

Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.

“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”

The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”

Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.

“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.

“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”

SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.

“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”

Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.

Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.

At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.

“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.

While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”

To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”

Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.

THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?

“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”

“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”

“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”

For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”

Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.

Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”

On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”

There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)

“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”

Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.

“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”

“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”

When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”

While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.

“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”

READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.

“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”

The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.

Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.

“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”

The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”

Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.

“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.

“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”

SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.

“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”

Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.

Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.

At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.

“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.

While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”

To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”

Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.

THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?

“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”

“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”

“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”

For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”

Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.

Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”

On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”

There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)

“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”

Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.

“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”

“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”

This year, New York became the second state to enact a law requiring health care providers to provide information on end-of-life options to terminally ill patients. California was the first; the Right to Know End-of-Life Options Act has been in effect there since January 1, 2009. New York’s Palliative Care Information Act took effect on February 9, 2011.

What do these laws mean, to whom do they apply—and in a larger context, is it possible to legislate one of the most difficult and intimate conversations a health care provider can have with a patient?

It’s the Law, But What Does That Mean?
First, the facts about these laws:

California’s Right to Know End-of-Life Options Act states that “when a health care provider … makes a diagnosis that a patient has a terminal illness, the health care provider shall, upon the patient’s request, provide the patient with comprehensive information and counseling regarding legal end-of-life options … and provide for the referral or transfer of a patient ... if the patient’s health care provider does not wish to comply with the patient’s request for information on end-of-life options.”

The law defines a “health care provider” as an attending physician or surgeon. However, it is further stipulated that the phrase “also means a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols.”

New York’s Palliative Care Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including … prognosis, risk and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management.”

The state Department of Health further clarifies that physicians and NPs are subject to the requirements of the law. PAs and other health care professionals may also, consistent with their scope of practice, provide information about these services but are not required to do so.

It is unclear how much of a difference these laws will make. In California, there has not been a noticeable flurry of concern or activity in response to the law; some clinicians haven’t even registered its existence on their radar. In a state facing an ongoing and major fiscal crisis, enforcing this type of law probably is not going to be a top priority.

New York’s law was passed despite protests from the medical society, which felt that parties that would be directly impacted by the law were not sufficiently consulted on its import and implementation. In May, two physicians from Maimonides Medical Center in Brooklyn wrote in the New England Journal of Medicine that “Physicians and health care organizations are struggling to understand what the law requires.”

Whether such laws are enforceable or effective in and of themselves, they do serve another purpose. They remind us of a largely unmet need in patient care: the need for an open and honest discussion about the end of life.

Shattering Hospice Myths
Medicine is about healing. Some­one becomes sick, and the clinician strives to make him or her well again. But there are devastating diseases about which we don’t know everything, and for many of them, a full-blown cure is not yet available. Even where life can be prolonged, death is never completely vanquished. Everyone knows that, but it is not easy to accept.

“Because most people die in old age, these issues get a lot of attention in the geriatric medicine arena—but this is across the life­span,” says Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey. “Many people spend a lot of money in their last months of life because we are a very interventionist medical society. And we still believe that we can cure and save everybody.”

“It’s true that we can always do something more,” says Karen Ayers, ACNP, who works with Hospice of Humboldt in California. “But is it futile? Is it going to work? Or is it just going to flog somebody? That’s really the question.”

Americans have already proven that they are not ready for a discussion of the financial aspects of treatment for terminal illnesses and other chronic, life-shortening conditions. (Recall the “death panels” propaganda?) But the larger issue is how individual patients would prefer to die, if “in my sleep, at a very old age” is not possible.

Some are inclined to fight until the last moment; if two rounds of chemo didn’t do the job, well, let’s try a third. Others would prefer to be as comfortable as possible for the remaining days/weeks/months of their lives. Most do not want to spend the end of their lives hooked up to machines in a hospital.

The question is whether patients know that they have choices and really understand what the options are. There are often misperceptions that when a clinician brings up end-of-life care, it is because he or she has “given up on” the patient.

“People think when you talk about end-of-life care that means ‘We’re going to give you morphine until you go into oblivion, and then you die,’” says Debbie Miller-Saultz, DNP, FNP-BC, of the Department of Pain Medicine and Palliative Care at Beth-Israel Medical Center in New York City. “And people think the morphine is causing someone to die faster. But all of those myths are really quelled when you talk to people who have palliative care, because they are offered services in a way that is timely and that provides much more support. People aren’t distressed or living in pain.”

 By way of evidence, Miller-Saultz cites a study published last August in the New England Journal of Medicine (2010;363:733-742). Researchers at Massachusetts General Hospital randomized patients with metastatic non–small cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone.

Patients who received early palliative care showed significant improvements in quality of life and mood, compared to their counterparts. Furthermore, while fewer patients in the palliative care group underwent aggressive end-of-life care (eg, chemotherapy within 14 days of death), median survival was higher for them than for patients in the oncologic care–only group (11.6 months vs 8.9 months).

Temel and colleagues said their results “offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.”

A Tough Talk to Have
Despite such positive findings, hospice remains an underutilized resource; the average length of stay is less than two weeks. “The reality is, the hospice literature shows that people get into hospice too late,” says Segal-Gidan.

In New York State, the average length of stay in hospice is 11 days. “People have end-of-life issues and disease longer than 11 days,” says Miller-Saultz. “So that’s a big part of the problem.”

Clearly, this is part of the impetus for legislative efforts such as those in California and New York. The implication of these laws is that, left to their own devices, clinicians are not providing terminally ill patients with essential information about the services available to them. Physicians in particular have often been criticized by advocates of palliative care and hospice for pushing aggressive treatments and dismissing the other options as “not real medicine.”

Nurses’ training may make them more receptive to alternatives. “We’re not schooled to ‘cure,’ that everything you do is driven to cure,” Miller-Saultz says. “You palliate. You do pain and symptom management. To me, it’s really no different from what we do anyway.”

That may change as medical schools try to incorporate more on end-of-life care into their curricula. But knowing you need to have these conversations—and in some cases being mandated to have them—does not make the discussion any easier.

Ayers considers herself fortunate to live and work in a relatively isolated area of California, centered around Eureka. The medical/nursing professionals are used to working together and do a lot of community outreach. When the local St. Joseph’s Hospital surveyed patients and providers, for example, they discovered that patients felt they weren’t getting information about the end of their lives, and clinicians said the hospital was not the right setting to deliver that information.

“It was just too late, it was too chaotic, and the patients were too upset,” Ayers explains. “It wasn’t the right time to be having that conversation.”

From this finding came the Physician Communication Initiative (it was named before the NPs got involved). The group held a series of dinners at a physician’s house “to talk about these issues, what is tough about it, how do you do it, how do you work it into the conversation,” Ayers says, “and how can we do it better.”

The Only Certainty Is …
While not everyone lives in that kind of community, Ayers suggests clinicians in other areas reach out to local medical and nursing groups, hospice services, or other community groups that may have an interest in educating people about what palliative care and end-of-life services are available locally. Major organizations also have resources on their Web sites that may help clinicians prepare for conversations with patients (see box).

A lot depends on context. Segal-Gidan works with patients who have Alzheimer’s disease, dementia, or other neurologic problems. “I’m able to bring up end-of-life care in the context of, say, ‘You’ve had a stroke, and you’re more likely to have another one. We hope not, but if so, let’s talk about what you would want to happen,’” she says. “When people are elderly and they have multiple chronic illnesses or a degenerative disease, people realize they’re coming to the end of their life. And in some ways, these discussions are more likely to happen.”

Timing is another question. The New York law, for example, requires that information on palliative and end-of-life options be provided to patients whose life expectancy does not exceed six months. Can that really be predicted with any certainty?

“We can identify the person with Alzheimer’s disease or multiple sclerosis or cancer,” Segal-Gidan says, “but we can’t identify very well when they’re six months before death. And then it may be too late.” This is another likely reason why so many people spend so little time in hospice programs before they die.

It may make sense to encourage patients to consider the choices they would make sooner rather than later. But even if a plan of care has been established or an advanced directive has been completed, nothing is set in stone. People can change their minds; death is an emotional issue and even those who are capable of frank discussion in the abstract may feel differently when it becomes reality.

In their editorial, the doctors from Maimonides Medical Center described an elderly patient with gastrointestinal and lung cancer for whom a satisfactory care plan had been developed—or so they thought. When the patient’s condition started to decline, his daughter found that she no longer agreed with the plan.

“She had previously accepted the fact of her father’s impending death as a theoretical matter,” the doctors wrote, “but when she came face to face with the troubling reality of his deteriorating condition, her thoughts and feelings had changed.”

How patients will respond to treatment, how long they will survive, and how they will choose to end their lives—there is so much uncertainty. Yet who might have pressing need for these services typically is not part of it. As Segal-Gidan said, it is possible to identify patients with terminal illnesses or degenerative conditions (although the diagnosis sometimes comes much too late in the process). But what of the 32- or 45-year-old who survives a car accident but has a traumatic brain injury and can no longer problem-solve, process, or plan? Who will make the decisions for that person? Did he or she ever discuss with a spouse or parent what he or she would want?

“It’s when death occurs at younger ages, more suddenly or unexpectedly, or even after the course of an illness, that I think it doesn’t really get a lot of attention,” Segal-Gidan says. “The grief gets a lot of attention, but all of the things around it—preparing for it, acknowledging it as a possibility—aren’t talked about.”

It isn’t possible to predict death and it certainly isn’t possible to avoid it forever. If there is one thing that frustrates humans, it is that we do not have all the answers.

This year, New York became the second state to enact a law requiring health care providers to provide information on end-of-life options to terminally ill patients. California was the first; the Right to Know End-of-Life Options Act has been in effect there since January 1, 2009. New York’s Palliative Care Information Act took effect on February 9, 2011.

What do these laws mean, to whom do they apply—and in a larger context, is it possible to legislate one of the most difficult and intimate conversations a health care provider can have with a patient?

It’s the Law, But What Does That Mean?
First, the facts about these laws:

California’s Right to Know End-of-Life Options Act states that “when a health care provider … makes a diagnosis that a patient has a terminal illness, the health care provider shall, upon the patient’s request, provide the patient with comprehensive information and counseling regarding legal end-of-life options … and provide for the referral or transfer of a patient ... if the patient’s health care provider does not wish to comply with the patient’s request for information on end-of-life options.”

The law defines a “health care provider” as an attending physician or surgeon. However, it is further stipulated that the phrase “also means a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols.”

New York’s Palliative Care Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including … prognosis, risk and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management.”

The state Department of Health further clarifies that physicians and NPs are subject to the requirements of the law. PAs and other health care professionals may also, consistent with their scope of practice, provide information about these services but are not required to do so.

It is unclear how much of a difference these laws will make. In California, there has not been a noticeable flurry of concern or activity in response to the law; some clinicians haven’t even registered its existence on their radar. In a state facing an ongoing and major fiscal crisis, enforcing this type of law probably is not going to be a top priority.

New York’s law was passed despite protests from the medical society, which felt that parties that would be directly impacted by the law were not sufficiently consulted on its import and implementation. In May, two physicians from Maimonides Medical Center in Brooklyn wrote in the New England Journal of Medicine that “Physicians and health care organizations are struggling to understand what the law requires.”

Whether such laws are enforceable or effective in and of themselves, they do serve another purpose. They remind us of a largely unmet need in patient care: the need for an open and honest discussion about the end of life.

Shattering Hospice Myths
Medicine is about healing. Some­one becomes sick, and the clinician strives to make him or her well again. But there are devastating diseases about which we don’t know everything, and for many of them, a full-blown cure is not yet available. Even where life can be prolonged, death is never completely vanquished. Everyone knows that, but it is not easy to accept.

“Because most people die in old age, these issues get a lot of attention in the geriatric medicine arena—but this is across the life­span,” says Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey. “Many people spend a lot of money in their last months of life because we are a very interventionist medical society. And we still believe that we can cure and save everybody.”

“It’s true that we can always do something more,” says Karen Ayers, ACNP, who works with Hospice of Humboldt in California. “But is it futile? Is it going to work? Or is it just going to flog somebody? That’s really the question.”

Americans have already proven that they are not ready for a discussion of the financial aspects of treatment for terminal illnesses and other chronic, life-shortening conditions. (Recall the “death panels” propaganda?) But the larger issue is how individual patients would prefer to die, if “in my sleep, at a very old age” is not possible.

Some are inclined to fight until the last moment; if two rounds of chemo didn’t do the job, well, let’s try a third. Others would prefer to be as comfortable as possible for the remaining days/weeks/months of their lives. Most do not want to spend the end of their lives hooked up to machines in a hospital.

The question is whether patients know that they have choices and really understand what the options are. There are often misperceptions that when a clinician brings up end-of-life care, it is because he or she has “given up on” the patient.

“People think when you talk about end-of-life care that means ‘We’re going to give you morphine until you go into oblivion, and then you die,’” says Debbie Miller-Saultz, DNP, FNP-BC, of the Department of Pain Medicine and Palliative Care at Beth-Israel Medical Center in New York City. “And people think the morphine is causing someone to die faster. But all of those myths are really quelled when you talk to people who have palliative care, because they are offered services in a way that is timely and that provides much more support. People aren’t distressed or living in pain.”

 By way of evidence, Miller-Saultz cites a study published last August in the New England Journal of Medicine (2010;363:733-742). Researchers at Massachusetts General Hospital randomized patients with metastatic non–small cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone.

Patients who received early palliative care showed significant improvements in quality of life and mood, compared to their counterparts. Furthermore, while fewer patients in the palliative care group underwent aggressive end-of-life care (eg, chemotherapy within 14 days of death), median survival was higher for them than for patients in the oncologic care–only group (11.6 months vs 8.9 months).

Temel and colleagues said their results “offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.”

A Tough Talk to Have
Despite such positive findings, hospice remains an underutilized resource; the average length of stay is less than two weeks. “The reality is, the hospice literature shows that people get into hospice too late,” says Segal-Gidan.

In New York State, the average length of stay in hospice is 11 days. “People have end-of-life issues and disease longer than 11 days,” says Miller-Saultz. “So that’s a big part of the problem.”

Clearly, this is part of the impetus for legislative efforts such as those in California and New York. The implication of these laws is that, left to their own devices, clinicians are not providing terminally ill patients with essential information about the services available to them. Physicians in particular have often been criticized by advocates of palliative care and hospice for pushing aggressive treatments and dismissing the other options as “not real medicine.”

Nurses’ training may make them more receptive to alternatives. “We’re not schooled to ‘cure,’ that everything you do is driven to cure,” Miller-Saultz says. “You palliate. You do pain and symptom management. To me, it’s really no different from what we do anyway.”

That may change as medical schools try to incorporate more on end-of-life care into their curricula. But knowing you need to have these conversations—and in some cases being mandated to have them—does not make the discussion any easier.

Ayers considers herself fortunate to live and work in a relatively isolated area of California, centered around Eureka. The medical/nursing professionals are used to working together and do a lot of community outreach. When the local St. Joseph’s Hospital surveyed patients and providers, for example, they discovered that patients felt they weren’t getting information about the end of their lives, and clinicians said the hospital was not the right setting to deliver that information.

“It was just too late, it was too chaotic, and the patients were too upset,” Ayers explains. “It wasn’t the right time to be having that conversation.”

From this finding came the Physician Communication Initiative (it was named before the NPs got involved). The group held a series of dinners at a physician’s house “to talk about these issues, what is tough about it, how do you do it, how do you work it into the conversation,” Ayers says, “and how can we do it better.”

The Only Certainty Is …
While not everyone lives in that kind of community, Ayers suggests clinicians in other areas reach out to local medical and nursing groups, hospice services, or other community groups that may have an interest in educating people about what palliative care and end-of-life services are available locally. Major organizations also have resources on their Web sites that may help clinicians prepare for conversations with patients (see box).

A lot depends on context. Segal-Gidan works with patients who have Alzheimer’s disease, dementia, or other neurologic problems. “I’m able to bring up end-of-life care in the context of, say, ‘You’ve had a stroke, and you’re more likely to have another one. We hope not, but if so, let’s talk about what you would want to happen,’” she says. “When people are elderly and they have multiple chronic illnesses or a degenerative disease, people realize they’re coming to the end of their life. And in some ways, these discussions are more likely to happen.”

Timing is another question. The New York law, for example, requires that information on palliative and end-of-life options be provided to patients whose life expectancy does not exceed six months. Can that really be predicted with any certainty?

“We can identify the person with Alzheimer’s disease or multiple sclerosis or cancer,” Segal-Gidan says, “but we can’t identify very well when they’re six months before death. And then it may be too late.” This is another likely reason why so many people spend so little time in hospice programs before they die.

It may make sense to encourage patients to consider the choices they would make sooner rather than later. But even if a plan of care has been established or an advanced directive has been completed, nothing is set in stone. People can change their minds; death is an emotional issue and even those who are capable of frank discussion in the abstract may feel differently when it becomes reality.

In their editorial, the doctors from Maimonides Medical Center described an elderly patient with gastrointestinal and lung cancer for whom a satisfactory care plan had been developed—or so they thought. When the patient’s condition started to decline, his daughter found that she no longer agreed with the plan.

“She had previously accepted the fact of her father’s impending death as a theoretical matter,” the doctors wrote, “but when she came face to face with the troubling reality of his deteriorating condition, her thoughts and feelings had changed.”

How patients will respond to treatment, how long they will survive, and how they will choose to end their lives—there is so much uncertainty. Yet who might have pressing need for these services typically is not part of it. As Segal-Gidan said, it is possible to identify patients with terminal illnesses or degenerative conditions (although the diagnosis sometimes comes much too late in the process). But what of the 32- or 45-year-old who survives a car accident but has a traumatic brain injury and can no longer problem-solve, process, or plan? Who will make the decisions for that person? Did he or she ever discuss with a spouse or parent what he or she would want?

“It’s when death occurs at younger ages, more suddenly or unexpectedly, or even after the course of an illness, that I think it doesn’t really get a lot of attention,” Segal-Gidan says. “The grief gets a lot of attention, but all of the things around it—preparing for it, acknowledging it as a possibility—aren’t talked about.”

It isn’t possible to predict death and it certainly isn’t possible to avoid it forever. If there is one thing that frustrates humans, it is that we do not have all the answers.

This year, New York became the second state to enact a law requiring health care providers to provide information on end-of-life options to terminally ill patients. California was the first; the Right to Know End-of-Life Options Act has been in effect there since January 1, 2009. New York’s Palliative Care Information Act took effect on February 9, 2011.

What do these laws mean, to whom do they apply—and in a larger context, is it possible to legislate one of the most difficult and intimate conversations a health care provider can have with a patient?

It’s the Law, But What Does That Mean?
First, the facts about these laws:

California’s Right to Know End-of-Life Options Act states that “when a health care provider … makes a diagnosis that a patient has a terminal illness, the health care provider shall, upon the patient’s request, provide the patient with comprehensive information and counseling regarding legal end-of-life options … and provide for the referral or transfer of a patient ... if the patient’s health care provider does not wish to comply with the patient’s request for information on end-of-life options.”

The law defines a “health care provider” as an attending physician or surgeon. However, it is further stipulated that the phrase “also means a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols.”

New York’s Palliative Care Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including … prognosis, risk and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management.”

The state Department of Health further clarifies that physicians and NPs are subject to the requirements of the law. PAs and other health care professionals may also, consistent with their scope of practice, provide information about these services but are not required to do so.

It is unclear how much of a difference these laws will make. In California, there has not been a noticeable flurry of concern or activity in response to the law; some clinicians haven’t even registered its existence on their radar. In a state facing an ongoing and major fiscal crisis, enforcing this type of law probably is not going to be a top priority.

New York’s law was passed despite protests from the medical society, which felt that parties that would be directly impacted by the law were not sufficiently consulted on its import and implementation. In May, two physicians from Maimonides Medical Center in Brooklyn wrote in the New England Journal of Medicine that “Physicians and health care organizations are struggling to understand what the law requires.”

Whether such laws are enforceable or effective in and of themselves, they do serve another purpose. They remind us of a largely unmet need in patient care: the need for an open and honest discussion about the end of life.

Shattering Hospice Myths
Medicine is about healing. Some­one becomes sick, and the clinician strives to make him or her well again. But there are devastating diseases about which we don’t know everything, and for many of them, a full-blown cure is not yet available. Even where life can be prolonged, death is never completely vanquished. Everyone knows that, but it is not easy to accept.

“Because most people die in old age, these issues get a lot of attention in the geriatric medicine arena—but this is across the life­span,” says Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey. “Many people spend a lot of money in their last months of life because we are a very interventionist medical society. And we still believe that we can cure and save everybody.”

“It’s true that we can always do something more,” says Karen Ayers, ACNP, who works with Hospice of Humboldt in California. “But is it futile? Is it going to work? Or is it just going to flog somebody? That’s really the question.”

Americans have already proven that they are not ready for a discussion of the financial aspects of treatment for terminal illnesses and other chronic, life-shortening conditions. (Recall the “death panels” propaganda?) But the larger issue is how individual patients would prefer to die, if “in my sleep, at a very old age” is not possible.

Some are inclined to fight until the last moment; if two rounds of chemo didn’t do the job, well, let’s try a third. Others would prefer to be as comfortable as possible for the remaining days/weeks/months of their lives. Most do not want to spend the end of their lives hooked up to machines in a hospital.

The question is whether patients know that they have choices and really understand what the options are. There are often misperceptions that when a clinician brings up end-of-life care, it is because he or she has “given up on” the patient.

“People think when you talk about end-of-life care that means ‘We’re going to give you morphine until you go into oblivion, and then you die,’” says Debbie Miller-Saultz, DNP, FNP-BC, of the Department of Pain Medicine and Palliative Care at Beth-Israel Medical Center in New York City. “And people think the morphine is causing someone to die faster. But all of those myths are really quelled when you talk to people who have palliative care, because they are offered services in a way that is timely and that provides much more support. People aren’t distressed or living in pain.”

 By way of evidence, Miller-Saultz cites a study published last August in the New England Journal of Medicine (2010;363:733-742). Researchers at Massachusetts General Hospital randomized patients with metastatic non–small cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone.

Patients who received early palliative care showed significant improvements in quality of life and mood, compared to their counterparts. Furthermore, while fewer patients in the palliative care group underwent aggressive end-of-life care (eg, chemotherapy within 14 days of death), median survival was higher for them than for patients in the oncologic care–only group (11.6 months vs 8.9 months).

Temel and colleagues said their results “offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.”

A Tough Talk to Have
Despite such positive findings, hospice remains an underutilized resource; the average length of stay is less than two weeks. “The reality is, the hospice literature shows that people get into hospice too late,” says Segal-Gidan.

In New York State, the average length of stay in hospice is 11 days. “People have end-of-life issues and disease longer than 11 days,” says Miller-Saultz. “So that’s a big part of the problem.”

Clearly, this is part of the impetus for legislative efforts such as those in California and New York. The implication of these laws is that, left to their own devices, clinicians are not providing terminally ill patients with essential information about the services available to them. Physicians in particular have often been criticized by advocates of palliative care and hospice for pushing aggressive treatments and dismissing the other options as “not real medicine.”

Nurses’ training may make them more receptive to alternatives. “We’re not schooled to ‘cure,’ that everything you do is driven to cure,” Miller-Saultz says. “You palliate. You do pain and symptom management. To me, it’s really no different from what we do anyway.”

That may change as medical schools try to incorporate more on end-of-life care into their curricula. But knowing you need to have these conversations—and in some cases being mandated to have them—does not make the discussion any easier.

Ayers considers herself fortunate to live and work in a relatively isolated area of California, centered around Eureka. The medical/nursing professionals are used to working together and do a lot of community outreach. When the local St. Joseph’s Hospital surveyed patients and providers, for example, they discovered that patients felt they weren’t getting information about the end of their lives, and clinicians said the hospital was not the right setting to deliver that information.

“It was just too late, it was too chaotic, and the patients were too upset,” Ayers explains. “It wasn’t the right time to be having that conversation.”

From this finding came the Physician Communication Initiative (it was named before the NPs got involved). The group held a series of dinners at a physician’s house “to talk about these issues, what is tough about it, how do you do it, how do you work it into the conversation,” Ayers says, “and how can we do it better.”

The Only Certainty Is …
While not everyone lives in that kind of community, Ayers suggests clinicians in other areas reach out to local medical and nursing groups, hospice services, or other community groups that may have an interest in educating people about what palliative care and end-of-life services are available locally. Major organizations also have resources on their Web sites that may help clinicians prepare for conversations with patients (see box).

A lot depends on context. Segal-Gidan works with patients who have Alzheimer’s disease, dementia, or other neurologic problems. “I’m able to bring up end-of-life care in the context of, say, ‘You’ve had a stroke, and you’re more likely to have another one. We hope not, but if so, let’s talk about what you would want to happen,’” she says. “When people are elderly and they have multiple chronic illnesses or a degenerative disease, people realize they’re coming to the end of their life. And in some ways, these discussions are more likely to happen.”

Timing is another question. The New York law, for example, requires that information on palliative and end-of-life options be provided to patients whose life expectancy does not exceed six months. Can that really be predicted with any certainty?

“We can identify the person with Alzheimer’s disease or multiple sclerosis or cancer,” Segal-Gidan says, “but we can’t identify very well when they’re six months before death. And then it may be too late.” This is another likely reason why so many people spend so little time in hospice programs before they die.

It may make sense to encourage patients to consider the choices they would make sooner rather than later. But even if a plan of care has been established or an advanced directive has been completed, nothing is set in stone. People can change their minds; death is an emotional issue and even those who are capable of frank discussion in the abstract may feel differently when it becomes reality.

In their editorial, the doctors from Maimonides Medical Center described an elderly patient with gastrointestinal and lung cancer for whom a satisfactory care plan had been developed—or so they thought. When the patient’s condition started to decline, his daughter found that she no longer agreed with the plan.

“She had previously accepted the fact of her father’s impending death as a theoretical matter,” the doctors wrote, “but when she came face to face with the troubling reality of his deteriorating condition, her thoughts and feelings had changed.”

How patients will respond to treatment, how long they will survive, and how they will choose to end their lives—there is so much uncertainty. Yet who might have pressing need for these services typically is not part of it. As Segal-Gidan said, it is possible to identify patients with terminal illnesses or degenerative conditions (although the diagnosis sometimes comes much too late in the process). But what of the 32- or 45-year-old who survives a car accident but has a traumatic brain injury and can no longer problem-solve, process, or plan? Who will make the decisions for that person? Did he or she ever discuss with a spouse or parent what he or she would want?

“It’s when death occurs at younger ages, more suddenly or unexpectedly, or even after the course of an illness, that I think it doesn’t really get a lot of attention,” Segal-Gidan says. “The grief gets a lot of attention, but all of the things around it—preparing for it, acknowledging it as a possibility—aren’t talked about.”

It isn’t possible to predict death and it certainly isn’t possible to avoid it forever. If there is one thing that frustrates humans, it is that we do not have all the answers.