Waiting for NCLEX.

Good news: I graduated! Along with the smartest, finest looking group of nurses this side of anywhere. We are all pretty sure we’re going to fix health care. Be on the lookout.

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Bad news: I hurt my back moving boxes and carrying around my 45 pound child.

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Good news: It’s you and me laptop stuck in a supine position!

I’ve been meaning to blog you this: my short piece of writing was published as an editorial in the Washington Post and then recorded for airing on local NPR affiliate WVTF. I AM LIKE FAMOUS. In all seriousness I am very humbled at how a wee handful of words caused a number of wonderful people to go out on a limb for me and support what I’ve done. My school values writing and reflection as a part of creating resiliency in nurses. My clinical faculty encouraged me to submit my writing. And a very awesome former journalist current writer went out of her way to help get my piece published. You people get a round of applause.

Now that I’m 95% RN I’m waiting for the boards to make it official. I’ve been transcripted, fingerprinted, background checked, notarized, certified by mail, and written many checks. So now I anxiously thumb through NCLEX licensing exam study guides as I wait for the Board of Nursing to approve me for an opportunity to sit for the big test. I secretly love it.

Emergency Landing.

Almost a month and no posts?! My rants have been diverted into papers for a phenomenal policy course I am taking this semester and my links to articles aren’t making it past a retweet.

So here’s my word picture for you: I am emergency landing an Airbus A320 containing all of my adult life on the Hudson River. We hope to hit the water and begin evacuation in late April. And yes, in this metaphor I am Captain Sully and when I nail this I will get to go back in time and sit on the stage for the first inauguration of President Barack Obama.

School is boiling me alive by degree, I’m selling my house, separating from my husband, searching for a first job, squeezing in an MRI here and a trip to NIH there, and hoping it all settles out in time to give my beautiful kid a fun summer break of swimming pools and tee ball before starting kindergarten at a (please God let it be halfway decent) school. See how I used the capital “G” there? That’s right people, there are no no-job-no-home-no-partner having atheists trying to finish nursing school. We’s back on speaking terms, me and Gosh and Jeepers.

But seriously, forgive me my absence. I’ll post some of my writing from class as it applies. Please let it be my belly that hits the water.

EDIT:
My mom has informed me that this metaphor makes no sense. What I’m trying to say is there was a whole series of things I was depending on to bring the end of my career as a student in for a safe landing: a stable household (selling house), a stable income and health insurance (partner leaving and I ain’t got a job), and a plan for school, friends, and recreation for my kid. So let’s think of that stuff as the runway, the landing gear, various instruments… without it I’m depending on my wits, experience, not passing out, and I guess the Hudson would be my parent’s basement.

A complete novice refutes the statements of a qualified professional

Why I oppose payment reform- Alan Weil, Health Affairs Blog

Interesting article but I’ve got counterpoints ’cause I’m a student with more opinions than I have a right to and am cocksure enough to comment on statements made by the editor-in-chief of Health Affairs.

Summaries of his points are in bold. Please read his article regarding opposing payment reform in health care to get his full and well considered arguments.

The current workforce is unprepared for a model that doesn’t reward for filling beds, doing tests:

  • There are tremendous rewards for innovation in the field of health care right now! These folks have seen the model they came up in become more and more of a frustration to them and their patients. Everywhere I look, from floor staff to executives, the feeling is very get on the train folks, we’re heading to the future. Alternately: retire, find a different gig, or learn to cope with the new requirements. People are learning to become successful and you better believe that new leaders are prepared for these challenges.

Any money saved will move its way to the top (health systems, hospitals) and workers on the front lines won’t see any benefit:

  • Maybe. Based on the ones I’ve spoken to I don’t think dietitians, social workers, and community health workers are expecting a huge raise. But many hospitals are dramatically understaffed in these positions to the point that they are unable to perform the core competencies of their roles. As these workers bring forward evidence showing the financial benefit to hospitals of having, say, a full time dietitian to improve nutrition and reduce pressure ulcer rates, hospitals will have a financial reason to staff these professionals.

There is no current evidence to suggest that payment reform will achieve the goals we need it to achieve, and there is some evidence to the contrary.

  • Okay, your evidence is good here, but early days! There is evidence showing smaller programs put into place are already saving money such as reduced re-admissions with heart failure transitional care (article unfortunately not open access, DOI: 10.1097/JCN.0b013e31827db560).

The original rationale offered for payment reform doesn’t match the current objectives.

  • I think it does match that original rationale (to pay for quality rather than quantity of care). Health systems do not have an incentive to stop a practice for which they are getting reimbursed. We know patient falls are bad thing for a patient, but more days in the hospital to recover from your now necessary hip surgery is money in the hospital’s pocket. Why would you spend money reducing falls to stop yourself from making money? When hospitals are told they won’t be getting paid for the consequences of that fall innovations in care happen and adverse event rates go down. Of course we need metrics to quantify success and failure, and because these rule changes are rolled out in a way that intends to give health systems time to introduce new measures without sinking the rusty old tub. And certainly hospitals with higher acuity patients are getting the shaft, hence even more complex models to try to even the playing field.
Payment reform poses a risk for the growing understanding of the importance of patient-centered care (What is an appropriate value formula when patients differ in their goals for recovery).
  • The value formula is simple: “Patient, are you satisfied that you have reached your stated goal of x?” If your 95 year old patient states his goal is successfully completing the Marine Corps Marathon pain-free then you’ve got to use your negotiating skills to get him back on this planet. The point is to set patient centered appropriate goals before undertaking invasive or potentially harmful interventions.

Where the strength comes from.

This week has been crushing. Just crushing. I’ve been looking for something to settle the outrage. It’s the stuff needed by everyone who practices moral distress for a living. The things that get you by when 5 out of six patients in the ICU are bodies begging to be let die. When you feel helpless, without recourse, exhausted. When the news is just so bad.

Breathless diatribes to friends and family members do not work. Also, they are not appreciated.

Trolling twitter is an exercise in futility and will prevent you from sleeping at night. Not recommended.

So after alienating all people IRL and on the internet, I went to the books. My college roommate gave me a Maya Angelou book of poetry for my 20th birthday and I am forever grateful. (Although that night the only thing I was was debauched, later I was grateful. What a cool roommate). Angelou was given a diet of abuse and society’s garbage and still grew into a sterling woman, poet, author, activist. I mean a true gift to the human race. I could listen to her forever, but this excerpt from a Fresh Air interview where she talks about discovering the universality of poetry and recites a Shakespearean sonnet (spur of the moment, from memory) knocks. me. back.

*Listen to the entire Maya Angelou interview

This is what is doing it for me today.

A seat at the table. Psst this is a feminist issue.

I spent all day yesterday and half of today at the hospital, then the other half of today writing a paper about my profession, then came home and watched this 26 min documentary about the future of nursing. I am so thoroughly in brainwashed/in love (that’s the same thing, right?).

I’m on board with all of this nurses are the answer messaging. But the very last line hits a sour note:

“Wake up public, you vote us most trusted profession but we need your support to be all that we need to be.”

THUMBS DOWN. Don’t spend twenty minutes talking about how we are natural fixers of problems then lob the biggest one we have, our fractured image, into the lap of the public.

Wake up faculty. Teach young nurses that it is absolutely their professional obligation to speak up for their patients. Not just in the hospital. Take that noise to the press, the internet, the state house.

Wake up nurses. That trust we get from the public is sacred. Earn it by being conscientious, whip-smart, and brave. And be public about it.

Heath Insurance 101, for those who have.

For my nursing school people, basic health insurance components/jargon demystified. Also, I wrote you a vocab list and a little story, too. <3

Premium: monthly cost (often split between individual and employer OR fed gov’t subsidy (ACA Healthcare Marketplace, Medicare) OR state gov’t (Medicaid).

Copay: Set amount of $ you have to pay to see a doc/receive a service.

Coinsurince: % of bill you owe.

Deductible: $ you pay before insurance kicks in (depending on plan, you may have to meet a deductible before insurance will cover anything, or before your insurance will cover specific services, or you may not have a deductible at all).

Out of pocket max: The most $ you’ll have to pay in 1 year (insurance agrees to cover all expenses after it’s met).

Formulary: list of Rx drugs covered by your insurance usually split into “tiers” that determine how much you pay. Tier 1=generics, cheapies, 2=expensive generics, brand names, 3=expensive brand names, 4=specialty or brand new (crazy expensive).

Provider network: “In network”=hospitals, health systems, and doctors your insurance has bargained with for lower prices. HMO/EPO insurance will not pay anything towards care out-of-network. PPO pays much less for out-of-network.

Referral: Required by some insurance plans, a referral comes from your primary care doctor and recommends that you see a specialist.

Re-enrollment: period of time when you must sign up for a new insurance plan or verify that you are sticking with your current plan. Happens yearly, often in late November.

STORYTIME
You’re biking in the school arboretum which you weren’t even supposed be doing in the first place and you fall and break your arm. But, intelligent child that you are you’ve remembered to sign up for health insurance and pay your $200 a month premium so this injury won’t sink your financial battleship. You go to the ED at an in-network hospital and pay a $100 copay at registration. You have x-rays and get a soft cast and the doc gives you 2 Percocet and an Rx for some Percocet for the road. You fill your Rx at the pharmacy and lucky you Percocet comes in generic and is on tier 1 of the formulary so you’re only out $7 for the pills. Man you sleep like a baby. Your health insurance plan doesn’t require a referral from your primary care doc so first thing in the morning you go to the orthopedist and pay your $35 specialist copay as you register. The doc examines your arm, puts on a hard cast and says see ya in 6 weeks.

Four weeks later you’re scratching your arm with a coat hanger and the bills are rolling in. You have a $200 deductible for physicians’ services, diagnostics, or treatments, so you have to pay the full $200 bill for the Emergency Services Physician’s Group (this pays your ED doc for his time). That satisfies your deductible. Bills from the hospital system arrive and you pay a 20% coinsurance on the x-rays, the soft cast, and the meds they gave you in the hospital. Next comes the bill from the private practice orthopedist who bless his heart is also in-network. You pay 20% coinsurance on the amount he charged for setting and casting your arm.

You’ve paid about $500 towards your out-of-pocket maximum for the year. If you’re going to have a catastrophic injury or illness, it would be cheapest for you to do it now and not wait for re-enrollment to come around!