10 Questions: Elizabeth Madigan, PhD, RN


1. What's the biggest barrier to practicing medicine today?

In the U.S., we still have a system that makes care coordination difficult. Almost everyone has a story about an older friend or relative who sees multiple providers, but, for example, there is no communication between that patient's cardiologist and rheumatologist. The electronic health record has helped [when] the providers are in the same healthcare system. Across healthcare systems, we are not there yet.

I come from the home healthcare world. In that setting, we routinely may be unable to access electronic healthcare information for all the systems through which a patient receives care. As a result, home healthcare nurses cannot easily and seamlessly share their observations with other providers. We're making progress on this front, and I am optimistic that this barrier will be greatly reduced in the next five years.

2. What's the most important healthcare issue that nobody is talking about?

The aging of the healthcare provider workforce. Throughout the nursing community, we are well aware of the growing nursing shortage. For nurses, but also physicians, physical therapists, and other disciplines, the retirement projections are scary. With the aging of the American population and the growth in chronic non-communicable diseases, we will need more providers than we have now. There are not enough younger people entering these professions to replace the retiring members. This is not just an American issue; many other countries have the same concerns, Japan being one of them.

Rural/Urban Disparity in Cancer Mortality


Rural Americans develop cancer less often than their metropolitan counterparts but are more likely to die of the disease, according to a first-of-its-kind report from the CDC.

From 2006 to 2015, cancer mortality in rural areas decreased by 1% a year as compared with a 1.6% annual decline in urban areas. The percentages translated into cancer-associated death rates of 180 per 100,000 persons in rural areas versus 158 per 100,000 in urban areas.

Rural areas had a lower cancer incidence over the 10-year period that ended in 2013, 442 cases versus 457 cases per 100,000 in urban areas. Overall, cancer incidence decreased about 1% per year in rural and metropolitan areas, as reported in Morbidity and Mortality Weekly Report.

"Differences between nonmetropolitan and metropolitan counties in cancer incidence might reflect differences in risk factors such as cigarette smoking, obesity, and physical inactivity, whereas differences in cancer death rates might reflect disparities in access to healthcare and timely diagnosis and treatment," S. Jane Henley, PhD, of the CDC National Center for Chronic Disease Prevention and Health Promotion, and coauthors concluded.

Poor Patient Care at Many Nursing Homes Despite Stricter Oversight

This will only get worse if Medicaid is cut....


In 2012, Parkview Healthcare Center’s history of safety violations led California regulators to issue an ultimatum reserved for the most dangerous nursing homes.

The state’s public health department designated Parkview, a Bakersfield, Calif., nursing home, a “special focus facility,” requiring it to either fix lapses in care while under increased inspections or be stripped of federal funding by Medicare and Medicaid — a financial deprivation few homes can survive. After 15 months of scrutiny, the regulators deemed Parkview improved and released it from extra oversight.

But a few months later, Elaine Fisher, a 74-year-old who had lost the use of her legs after a stroke, slid out of her wheelchair at Parkview. Afterward, the nursing home promised to place a nonskid pad on her chair but did not, inspectors later found. Twice more, Ms. Fisher slipped from her wheelchair, fracturing her hip the final time.

The violation drew a $10,000 penalty for Parkview, one of 10 fines totaling $126,300 incurred by the nursing home since the special focus status was lifted in 2014.

While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to an analysis of federal health inspection data. Of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.

These nursing homes are in 46 states. Some gave patients the wrong medications, failed to protect them from violent or bullying residents and staff members, or neglected to tell families or physicians about injuries, inspection records show. Years after regulators conferred clean bills of health, levels of registered nurses tend to remain lower than at other facilities.

Yet, despite recurrences of patient harm, nursing homes are rarely denied Medicare and Medicaid reimbursement. Consequences can be dire for patients like Ms. Fisher.

Beyond “To Close Or Not To Close” Rural Hospitals


About 60 million Americans live in rural areas. And almost every health statistic shows they’re falling behind their fellow Americans who live in urban areas. Rural residents are less likely to have health insurance coverage through a jobhave lower incomes, and have higher rates of death from heart disease and stroke.

However, there’s not only a health gap widening between urban and rural areas. There’s also a growing gap between the way systems of health work in different areas of the country.

As reported in a recent study commissioned by the Episcopal Health Foundation (EHF), seventeen rural hospitals in Texas have closed since 2010. After EHF released the report this May, two more rural hospitals—East Texas Medical Center Trinity in Trinity, Texas, and Timberlands Healthcare in Crockett, Texas—announced their closures. At EHF, we have followed with great interest the changes and challenges in rural health care, and particularly the impact on rural communities when their hospitals close.

We believe the financial pressures experienced by rural hospitals are likely to continue. As a philanthropy serving both rural and urban communities, EHF wanted to understand in this study how rural communities threatened by hospital closures could ensure that a reliable system of health care services would be accessible to residents, should their hospital close.

We knew this was a complicated problem that required critical analysis to develop practical solutions. We were fortunate to partner with a great team at the Rural and Community Health Institute (RCHI) at Texas A&M University. The team is led by Nancy Dickey, a visionary rural health leader, researcher, and former American Medical Association president.

The recently released report from Dickey and her team is titled What’s Next? Practical Suggestions for Rural Communities Facing a Hospital Closure. It’s a powerful narrative on the opportunities for rural communities to optimize their health care delivery systems in the face of hospital closures.

Remove the 20 visit behavioral health maximum limitation

Policy Subject: Outpatient Behavioral Health Visits

Affected Programs: Medicaid, Healthy Michigan Plan

Distribution: Practitioners, Outpatient Hospitals, Federally Qualified Health Centers, Local
Health Departments, Rural Health Clinics, Community Mental Health Services Programs,
Prepaid Inpatient Health Plans, Medicaid Health Plans, Tribal Health Centers

Policy Summary: In order to provide greater access to care for behavioral health services,
the Michigan Department of Health and Human Services (MDHHS) will remove the 20 visit
maximum limitation for outpatient behavioral health services. The restriction is lifted for both
fee-for-service and Medicaid Health Plan beneficiaries effective for dates of service on or
after October 1, 2017.

Purpose: To provide greater access to care for behavioral health services.

The entire policy proposal is below the header I posted.

Have Employer Coverage? GOP Proposals Will Affect You Too (Part 2)

Employer-based insurance will also be degraded by the current House and Senate health bills...


As Senate Republican leaders continue to craft their bill to repeal and replace the Affordable Care Act (ACA), most attention has been focused on the number of individuals who would lose coverage if the legislation is enacted. To be sure, the ACA coverage expansions—through Medicaid and subsidized Marketplace plans—have been a lifeline for millions of people, particularly those who are low income, and have reduced the number of individuals without coverage to record lows. But the legislation that passed the House and the bill now under consideration in the Senate could also affect the more than 150 million people with employer-sponsored insurance (ESI) who gained federally guaranteed protections against catastrophic costs.

Earlier this year, I wrote about ACA reforms that apply to employer-based plans. At the time, we didn’t know yet what GOP repeal plans would retain of the ACA and what would be lost. Now, with the bills under discussion, we know more about what’s at risk for those with job-based plans.

What Protections Can People With ESI Hope To Retain?

Both the House-passed American Health Care Act (AHCA) and the Senate’s Better Care Reconciliation Act (BCRA) leave untouched the requirement that job-based plans cover recommended preventive services without cost-sharing, the prohibition on excluding coverage for pre-existing conditions, and the right to appeal your plan’s denial of care to an independent expert reviewer. The bills also retain the requirement that plans that cover dependents must make that coverage available until they turn 26. However, this latter protection could become illusory. Both bills repeal the requirement that large employers offer coverage to employees and their dependents. Thus, the right to keep a child on a parent’s plan until they turn 26 can only be exercised by those with employers willing to continue offering dependent coverage.

What Are The Risks For People With ESI Who Have Pre-Existing Conditions?

Now let’s look at what might be lost. The biggest risks are for employees with pre-existing and chronic conditions because they can no longer count on comprehensive benefits and the ACA’s protections against catastrophic costs that are tied to those benefits. Both the House and Senate bills allow states to waive the essential health benefits (EHB), the ACA requirement that individual and small employer plans cover 10 categories of services, including services often excluded from coverage prior to the ACA. For people who work for small businesses (fewer than 50 workers), a waiver from EHB would mean skimpier coverage that may exclude key services such as prescription drugs, maternity care, or mental health treatment.

The Takeaway: Oh, What a Tangled Web They Weave


Despite his best efforts, Senate Majority Leader McConnell couldn't coax a ‘yes’ vote out of 50 of his 52-member caucus before the July Fourth recess. The path forward for McConnell and the Senate Republicans seems to revolve around trying to move in two directions at once – more money for the more centrist party members coupled with more insurance deregulation for the far-right -- while continuing to mislead the public about the true content of the bill.

Here's a closer look at why the Senate bill stalled and what steps are being taken to revive it, along with some notable bits and pieces from the recent debate.

Why McConnell couldn't get to ‘yes’ before the Fourth

The push for a vote before the Fourth ran aground on a combination of internal Senate dynamics and external forces. As far as internal dynamics go, roughly three groups of senators blocked the path to a Senate vote. One group, typified by senators Heller and Collins, expressed concerns about the damage the legislation would do to the health care system in their states; Other senators, Such as Ron Johnson from Wisconsin, were unhappy with the process and wanted more time to evaluate the bill. Finally, senators like Ted Cruz and Rand Paul did not believe that the bill did enough to roll back the ACA or to undermine the Medicaid program. Key external forces were also critical in giving senators pause. Especially important were the popular mobilization against the bill, as well as the rising tide of stakeholder opposition. Absent these external forces, there is little doubt that the Senate would have swallowed its doubts and voted.

Use of Fentanyl Patches in Nursing Homes Persists After FDA Warning


Despite FDA warnings regarding the risk for adverse effects from administering long-acting opioids to patients who had not developed opioid tolerance through prior usage, the initiation of potent long-acting fentanyl patches (Duragesic, Janssen) without first receiving an opioid analgesic persists for these residents (J Am Geriatr Soc 2016;64:1772-1778).

Of 12,278 long-stay Medicare-enrolled nursing home residents who were prescribed long-acting opioids within 30 days of admission in 2011, 9.4% had not received an opioid analgesic in the previous 60 days, according to the study.

“Our conclusion is that opioid-naive initiation of long-acting opioids is a rare occurrence in nursing homes, and there has been a decrease in this practice since it was first described in the mid-2000s,” said Camilla B. Pimentel, MPH, PhD, a postdoctoral associate at the University of Massachusetts Medical School, in Worcester, and the lead author of the study. “However, opioid-naive initiation of fentanyl patches persists despite FDA safety communications and other national efforts to increase awareness of safe use of opioids.

Cuts threaten rural hospitals 'hanging on by their fingernails'

Michigan is doing reasonably well in regard to rural hospital closings at least until Medicaid Expansion disappears...


One Monday in 2013, Dr. Alluri Raju learned that the only hospital in rural Richland, Georgia, would close on Wednesday. But there were still patients in hospital beds and surgeries scheduled for Wednesday.

Raju pleaded with the hospital's owner to keep it open a few more days.

Ultimately, the hospital closed that Friday, leaving the rural town without a hospital for miles. Raju, who had been the hospital's chief of staff, is now the only doctor left in the town a two-hour drive south of Atlanta.

Nationwide, about 80 rural hospitals have closed since 2010, according to the Chartis Center for Rural Health.Another 673 rural hospitals are in danger of shutting their doors. Many providers worry that the newly proposed health care legislation -- and in particular its proposed cuts to Medicaid -- could push a number of hospitals over the edge.

"These hospitals are hanging on by their fingernails," said Maggie Elehwany, vice president of government affairs for the National Rural Health Association, a nonprofit health research and advocacy group. "If you leave this legislation as is, it's a death sentence for individuals in rural America."

The hippocampus underlies the link between slowed walking and mental decline


The connection between slowed walking speed and declining mental acuity appears to arise in the right hippocampus, a finger-shaped region buried deep in the brain at ear-level, according to a 14-year study conducted by scientists at the University of Pittsburgh Graduate School of Public Health.

The finding, published in Neurology, the medical journal of the American Academy of Neurology, indicates that older patients may benefit if their doctors regularly measure their walking speed and watch for changes over time, which could be early signs of cognitive decline and warrant referral to a specialist for diagnostic testing.

"Prevention and early treatment may hold the key to reducing the global burden of dementia, but the current screening approaches are too invasive and costly to be widely used," said lead author Andrea Rosso, Ph.D., M.P.H., assistant professor in Pitt Public Health's Department of Epidemiology. "Our study required only a stopwatch, tape and an 18-foot-long hallway, along with about five minutes of time once every year or so."

Rosso and her colleagues assessed 175 older adults ages 70 to 79 when they enrolled in the Health, Aging and Body Composition (Health ABC) study in Pittsburgh or Memphis, Tennessee. At the beginning of the study, the participants were all in good mental health and had normal brain scans. Multiple times over 14 years, the participants walked an 18-foot stretch of hallway at what they deemed a normal walking pace while a research assistant timed them. At the conclusion of the study, the participants were tested again for their mental acuity and received brain scans.

As previous studies have shown, slowing in the participants' gait, or walking speed, was associated with cognitive impairment. However, Rosso's research determined that participants with a slowing gait and cognitive decline also experienced shrinkage of their right hippocampus, an area of the brain important to both memory and spatial orientation. It was the only area of the brain where the researchers found a shrinking volume to be related to both gait slowing and cognitive impairment.

Rosso's study also found gait slowing over an extended period of time to be a stronger predictor of cognitive decline than simply slowing at a single time point, which is what other, similar research evaluated. All the participants slowed over time, but those who slowed by 0.1 seconds more per year than their peers were 47 percent more likely to develop cognitive impairment. The finding held even when the researchers took into account slowing due to muscle weakness, knee pain and diseases, including diabetesheart disease and hypertension.

"A fraction of a second is subtle, but over 14 years, or even less, you would notice," said Rosso, also an assistant professor in Pitt's Clinical and Translational Science Institute. "People should not just write off these changes in walking speed. It may not just be that grandma's getting slow - it could be an early indicator of something more serious."