Image of the Texas State Capitol courtesy of adpal3180 via Flickr

One of Tim Flynn’s first duties as the first full-time nurse for the Texas State Capitol was to give then-Governor Ann Richards a flu shot. He was nervous enough that he forgot to bring a band-aid, which led Gov. Richards to warn him that he better not let any blood sully her $300 silk blouse!

He did his job carefully and well and her blouse was safe. His job was safe too evidently, because he’s been the Capitol nurse for the two decades since then, according to this profile of Mr. Flynn in the New York Times.

Through the administrations of Ms. Richards, George W. Bush and Rick Perry, Mr. Flynn has been at the Capitol to dispense flu shots, treat sinus infections, and provide patient education to lawmakers.

Everyone in the Capitol knows him and trusts him. Representative Rick Hardcastle says, “He knows I have bad allergies because he’s seen me before. It’s like going to see your family doctor.”

Even though he loved his job, he did get frustrated that he wasn’t able to write prescriptions or diagnose illnesses. So he decided to go back to school and become a nurse practitioner, graduating from the University of Texas in 2002.

As a state employee, Mr. Flynn does not charge patients. His Capitol clinic operates on a first-come, first-served basis. When children on school trips fall down, they go to him. State employees drop by when they have headaches.

“I love my job,” he said. “After being here 20 years, I know most of the folks that work here. I know their medical histories, their idiosyncrasies. This is my community. That’s why I call it my Capitol.”

In emergencies, Mr. Flynn is one of the first on the scene, providing life support until paramedics arrive. In 1999, when a Capitol parking guard was found slumped over his desk and suffering from gastrointestinal bleeding, Mr. Flynn treated him for shock before paramedics arrived and saved the man’s life.

Responding to emergencies is the smallest part of his job, Mr. Flynn said. He spends most of his time on procedures like treating strep throat, saving patients a trip to their primary care providers.

His job takes on added importance during the biennial legislative sessions, when lawmakers convene for 140 days at the Capitol.

“When it’s crunch time, I don’t have to call a doctor; I can go down to Tim’s office,” Mr. Hardcastle said. “When you have the flu during the night and you’re working on legislation, you need treatment. His job is vital to what we do.”

Image courtesy of AMagill via Flickr

Debt collection agencies have been embedding debt collectors as employees who run interference in emergency rooms and visit patients’ bedsides to demand payment, among other aggressive tactics.

The Minnesota attorney general, Lori Swanson, revealed that Accretive Health, one of the nation’s largest collectors of medical debts, has been engaging in these tactics. The New York Times notes that this raises concerns that “such practices have become common at hospitals across the country.”

Hospitals are increasingly desperate to recoup payments as their unpaid debts mount. To patients, the debt collectors can blend right in with hospital employees, yet these staff members focus on demanding that patients pay outstanding bills and may even discourage them from seeking emergency care at all. For example, they will sometimes purposely “stall” a visitor to the emergency room in an attempt to get payment before the patient receives any treatment. Their focus is on getting money, not the patient’s health.

Additionally, these workers (who are not actually medical staff) sometimes have access to health information, possibly in violation of Hipaa (the Health Insurance Portability and Accountability Act). Accretive employees may also have broken the law by not clearly stating that they were debt collectors.

As hospitals struggle under a glut of unpaid bills, they are reaching out to companies like Accretive that specialize in collecting medical bills.

Hospitals have long hired outside collection agencies to pursue patients after they have left hospital facilities. But financial pressures are altering the collection landscape so that they are now letting collection firms in the front door, according to Don May, the policy adviser for the American Hospital Association, a trade group.

To achieve promised savings, hospitals turn over the management of their front-line staffing — like patient registration and scheduling — and their back-office collection activities.

Concerns are mounting that the cozy working relationships will undercut patient care and threaten privacy, said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition. “The mission of these companies is in direct opposition to the supposed mission of these hospitals.”

Still, hospitals are in a bind. The more than 5,000 community hospitals in the United States provided $39.3 billion in uncompensated care — predominately unpaid patient debts or charity care — in 2010, up 16 percent from 2007, the hospital association estimated.

Accretive is one of the few companies specializing in hospital debt collection that is publicly traded. Last year, it reported $29.2 million in profit, up 130 percent from a year earlier.

Late last month, Fairview Health Services, a Minnesota hospital group that Accretive provided services to, announced it was canceling its contract with Accretive for back-office debt collection. After Accretive informed investors, its stock plunged 19 percent in a day. On Tuesday, the company’s shares closed at $18.49, down 2.7 percent.

Accretive says that it trains its staff to focus on getting payment through “revenue cycle operations.” Accretive fostered a pressurized collection environment that included mandatory daily meetings at the hospitals in Minnesota, according to employees and the newly released documents. Employees with high collection tallies were rewarded with gift cards. Those who fell behind were threatened with termination.

“We’ve started firing people that aren’t getting with the program,” a member of Accretive’s staff wrote in an e-mail to his bosses in September 2010.

Collection activities extended from obstetrics to the emergency room. In July 2010, an Accretive manager told staff members at Fairview that they should “get cracking on labor and delivery,” since there is a “good chunk to be collected there,” according to company e-mails.

Employees were told to stall patients entering the emergency room until they had agreed to pay a previous balance, according to the documents. Employees in the emergency room, for example, were told to ask incoming patients first for a credit card payment. If that failed, employees were told to say, “If you have your checkbook in your car I will be happy to wait for you,” internal documents show.

Employees at Accretive’s client hospitals ask patients to make “point of service” payments before they receive treatment. Until she went to Fairview for her son Maxx’s ear tube surgery in November, Marcia Newton, a stay-at-home mother in Corcoran, Minn., said she had never been asked to pay for care before receiving it. “They were really aggressive about getting that money upfront,” she said in an interview.

Ms. Newton was shocked to learn that the employees were debt collectors. “You really feel hoodwinked,” she said.

While hospital collections at Fairview increased, patient care suffered, the employees said. “Patients are harassed mercilessly,” a hospital employee told Ms. Swanson.

Patients with outstanding balances were closely tracked by Accretive staff members, who listed them on “stop lists,” internal documents show. In March 2011, doctors at Fairview complained that such strong-arm tactics were discouraging patients from seeking lifesaving treatments, but Accretive officials dismissed the complaints as “country club talk,” the documents show.

Ms. Swanson said that the hounding of patients violated the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to provide emergency health care regardless of citizenship, legal status or ability to pay.

In the January lawsuit, Ms. Swanson said that by giving its collectors access to health records, Accretive violated the Health Insurance Portability and Accountability Act, known as Hipaa (pronounced HIP-ah). For example, an Accretive collection employee had access to records that showed a patient had bipolar disorder, Parkinson’s disease and a host of other conditions.

In addition, she said, the company broke state collections laws by failing to identify themselves as debt collectors when dealing with patients.

Late Tuesday afternoon, Accretive announced it won a contract to provide “revenue cycle operations” for Catholic Health East, which has hospitals in 11 states.

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Dr. Otis Brawley is concerned how health care is currently consumed. He’s written a book called “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America” that examines and explains these concerns.

Tara Parker Pope of the NYT’s Well blog spoke to him about his book and how broken he considers the United States health care system to be. He states that “failure is in the system” — that no horror stories (and he has some doozies, like a woman with untreated breast cancer who brings in her breast for re-attachment after it falls off) should be dismissed as an aberration.

He doesn’t just blame hospitals, health care workers, or insurance companies though. He also thinks that patients demand overtreatment, and that this contributes to the bloat and inefficiency of the current health care system.

He says he decided to write the book after listening to the debate over the Affordable Care Act. He says, “The talk should not be about rationing health care but about rational health care. So much of what we do in health care is irrational.” When asked to describe an example of irrational health care, he says:

A.
There was a man with colon cancer who went to a wonderful hospital with a wonderful reputation. He got surgery and was referred to a medical oncologist who has a wonderful reputation as a doctor to the rich and famous in Atlanta. That medical oncologist started giving him chemotherapy and two other expensive drugs. When this man lost his insurance, the oncologist basically dropped him, and the guy ended up being seen by me at the county hospital. A doctor who is training with me to be an oncologist immediately realizes that this guy is getting a chemotherapy regimen for colon cancer that we stopped using about 15 years ago. His medical oncologist was practicing the best medicine of the late 1980s, but we were in 2006. The other drugs he was being prescribed were totally unnecessary. But the doctor could get a substantial markup and make a substantial amount of money by selling them. The oncologist had known just enough to be greedy and prescribe drugs he can make money off of, but he didn’t know enough to prescribe the chemotherapy that would have given the patient a much better chance of surviving his cancer.

I’ve seen that so many times, where doctors really have failed to evolve and failed to learn as the profession and the scientific evidence have changed over time.

Q.
But in reading the book, you don’t just blame doctors for being greedy. You blame patients for being gluttonous. Can you explain?

A.
Another patient of mine had early colon cancer. Three doctors had told her she should not get chemotherapy. She decided she wanted it, and she went doctor-shopping until she found a doctor who would give it to her. Her insurance had no way to object to her getting this inappropriate chemotherapy because privacy laws prevent disclosing the stage of the disease to the insurance company. She was referred to me by a relative who was concerned about what she was doing. She readily admitted that she had three different medical opinions that said she should not get chemotherapy, but she wanted chemotherapy. So a doctor made $10,000 off that six months of chemotherapy, and she got an increased risk of leukemia for the rest of her life, not to mention losing her hair and everything else, with no scientific evidence that the treatment reduced her risk of the colon cancer coming back.

I blame patients, I blame doctors, I blame hospitals, I blame drug companies, I blame insurance companies. Our health care system is messed up because the system is designed to fail, and everybody is responsible for health care failing as it is now.

Q.
The story about the woman whose breast fell off was horrible. What were you trying to tell us with that example?

A.
We so frequently talk about breast cancer almost as if it’s a boutique disease or trendy. I feel some people have forgotten how terrible this disease can be. This lady – I saw a lot of things in her background that were lessons for society about what we need to do if we want to defeat breast cancer. When she realized she had something growing in her breast, she had insurance, but logistics having to do with her job and child care and a little bit of denial kept her from going to the doctor and getting this thing diagnosed and treated when it was likely curable. Later on, when she wanted to see a doctor, she couldn’t because her insurance had gotten so expensive that she had to drop it. If she had come in when she first found this thing 9 or 10 years earlier, I probably could have cured it, and it would have cost about a tenth of what we spent when she was uninsured and receiving free care from the hospital. She lived for about two years after I met her. That’s a failure of medicine to educate people.

Q.
In the book, you talk about a conversation with a hospital marketing executive who talks about drumming up business with free prostate cancer screenings at a mall health fair. How did that affect you?

A.
That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does, and then I see a lady whose breast is falling off who couldn’t afford to see a doctor when she wanted to see one.

Q.
Is there any hope that things might improve someday?

A.
I am trying to get folks, through this book, to talk a little more about rational use of health care and realize that we are actually hurting people with overtreatment. Health care needs to be consumed in a wiser way that is much more concerned about allegiance to the science. We need to be more concerned about the welfare of our patients. There was a recent report, the 45 tests we do too much, that I was thrilled to see. People are starting to realize that we need to be a little wiser in our use of health care.

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These days, your social life is never farther than your desktop, laptop or phone. Through a variety of devices and social platforms, not only can you stay in touch with all your friends from college, but also the ones from high school, grade school, Sunday school and your gym.

Unfortunately all of this intermingling of social spheres often leads to an information seep, where what you plan for only some people to see is in fact seen by many others. Information that was meant only for family, say, can often be easily seen by acquaintances, coworkers, or clients. Once you’ve shared information online, it can be disseminated across the globe with a quick click of a button or sometimes, simply doing nothing. No matter what the privacy settings are on your social media account, if a friend’s settings do not carry the same restrictions, there’s no telling who has access to your information.

All of this presents two big challenges to nurses who use social media. First, patients, family members and co-workers may find information that you’d prefer they not have. Second, even complaining about a tough day at work could put you at risk for violating the Health Insurance Portability and Accountability Act (HIPAA).

For the generation that has grown up with websites such as MySpace, YouTube, Facebook and Twitter, social media has become as ubiquitous as email. So it is easy to lose sight of the fact that sharing work challenges for a limited audience may become global information depending on the discretion of the audience and individual privacy settings. The expression “if you don’t want it all over the internet, don’t put it anywhere on the internet,” holds true for every venture into social media. That includes one-on-one conversations.

When Congress enacted HIPAA in 1996, it did so primarily to enforce an ethical responsibility to protect the privacy of patients and their information. A posting from a nurse on Facebook about a difficult day with the patient in room 213 because she “just couldn’t make him happy,” could result in discipline if not outright dismissal from the job. If a patient, family member or any other private citizen can see the nurse’s employer from her profile and knows the name of the person in room 213 on that day, the patient has been identified. Job loss is a real threat, and what one nurse may think is a harmless complaint about an unnerving day could land her on the unemployment line for violating a Federal mandate.

Hospital and healthcare organizations have adopted internal policies regarding the use of social media and although most of them ban any use of the electronic social venues during work hours, there are professional advantages to using social media. Discussions on research, new technology, practice and professional development can all be accomplished through social media forums. A nurse’s professional online presence may foster network building and lay the groundwork for mentoring relationships. And as this article indicates, smartphones are increasingly being used for things like quickly looking up drug interactions.

Words of caution….
One big disadvantage of maintaining any type of line presence is that you have little control over who can find you. Patients and family members who have read your last name on your badge, might suddenly start following your Twitter feed or send you a friend request on Facebook. The decision to allow this is entirely personal, but blurring the lines of patient-to-nurse care might present challenges with an employer and make future interactions with patient difficult. In the same vein, just as a patient can read public postings, so can an employer. The expression “discretion is the better part of valor” may be a good guide when nurses use social media.

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The future of the Affordable Care Act is uncertain. The Supreme Court has heard arguments about whether or not the ACA is constitutional or not, and will be announcing their decision in June.

Meanwhile, the ACA itself is quite complex. Gina Kolata of the New York Times spoke with Jonathan Oberlander, an expert in the field, about the law and its future.

Mr. Oberlander starts by explaining what the ACA is, exactly. He calls it “a series of policies and regulations and subsidies and mandates.” He explains that that’s the reason it’s so complex — it has many different parts to it. Rather that starting from scratch, it is building on an “incoherent” medical system, and trying to patch the holes.

That’s not to say that he thinks that the ACA itself is also incoherent — he says that if it is implemented, it would be the biggest thing since Medicaid and Medicare in 1965, and that “it brings us closer to the ideal that all Americans should have access to care regardless of income or health status.”

Can the act be carried out without requiring almost everyone to buy health insurance?

That would be a serious wound, but it would not be fatal. There are many parts of the act, including the expansion of Medicaid, that could be implemented and that have little to do with the mandate. But without the mandate, the Affordable Care Act would cover fewer people and would not be as effective. And it will raise questions about the stability of the health insurance exchanges.

My guess is that if the whole law is thrown out we will see a return to incrementalism, doing small things like expanding Medicaid by a little bit or giving very modest tax credits to some uninsured. Or we will see federalism — turning things over to the states. Or doing nothing, which has been our default for much of the past century.

How you can have health insurance exchanges without a mandate? Wouldn’t the healthy shun them until they become sick, forcing the exchanges to charge prohibitive rates?

There are other things that you can do, but chances are Congress won’t do them. You can tell the insurers that they can charge a penalty to people who do not sign up at first and try to enroll later. It could be like what happens with Medicare prescription drug coverage — if you try to sign up after you are eligible, you pay a higher premium for the rest of your life.

So if the mandate is thrown out, what about other kinds of insurance? Medicare is deducted from my paycheck, right?

One of the things that even the conservative justices said is that tax-financed national health insurance is permissible. That’s why Medicare is O.K. It is a tax, and Congress has the authority to raise revenue. The mandate would require people to purchase private insurance.

In fairness to the Obama administration, at the time the Affordable Care Act was proposed there was an overwhelming legal consensus that the mandate was constitutional. The idea has been around for decades — it was originally a conservative Republican idea as an alternative to national health insurance — and few had raised serious constitutional issues.

If the law stands more or less intact, when will we see some big changes? So far, what has happened seems less than transformative.

June will be the big earthquake. (That is when the Supreme Court will announce its decision.) The next big month is November, with the election. If the law survives those two big challenges, legal and political, the big year is 2014. That is when most of the major changes go into effect.

States will be required to expand Medicaid. All Americans making up to 138 percent of the poverty line — that’s about $15,000 today for an individual — will be eligible for Medicaid. Historically, Medicaid has been linked to demography. It is not enough to be poor. In most states you have to be a pregnant woman, a child, elderly or disabled to be eligible. The A.C.A. will change that.

In addition, insurance subsidies will be made available to help the uninsured and some workers in small businesses buy private insurance through insurance exchanges. Small businesses can buy insurance there, too.

Insurers will be prohibited from denying coverage or charging higher premiums to persons with pre-existing conditions. And most Americans will be required to obtain — and larger businesses will be required to offer — health insurance or pay a penalty.

Doesn’t the Affordable Care Act contain a lot of proposals to get costs under control, like comparative effectiveness studies and reimbursing doctors based on their performance? Will such ideas help contain the cost of medical care?

Most of these ideas are wishful thinking. The evidence is either mixed or just not there that these reforms will rein in spending. They are a sort of faith-based cost control. Other options are more painful, and at the moment there may not be any method for controlling spending that is politically feasible.

The A.C.A.’s capacity to produce reliable cost containment has been exaggerated. Its Medicare savings are significant — it will save an estimated $500 billion in the next decade by slowing payments to hospitals and private insurance plans that contract with Medicare. Outside of Medicare, the cost containment is less impressive.

Do you foresee big changes in the near future — politically difficult decisions that will rein in costs?

I’m a Red Sox fan, so I believe in miracles. But in the short term, the answer is no. We will build on our existing system — it’s what we have, and it is too difficult to move away from it. Two or three decades from now, nobody knows.