NEWS FLASH
Houston Business Journal Features Vickie and the LNC Profession
Attorneys who read the Houston Business Journal now know more about the legal nurse consulting profession. This popular business weekly interviewed Vickie L. Milazzo, RN, MSN, JD, for their quarterly special focus on healthcare, citing her as the pioneer of this field.
In the article, Denise Heath-Graham, RN, CLNC, praised the LNC training she received through Medical-Legal Consulting Institute (MLCI): "The training positioned me for success and provided the encouragement and support I needed to actually get out there and do it."
"With fees ranging from $60 to $150 an hour," Vickie says, "legal nurse consulting is more lucrative than the typical nursing job." Jennifer Fougerousse, RN, CLNC, of League City, reports that she is now making more money working part-time as a legal nurse consultant than she did working part-time in the hospital.
Jennifer says she considers the training in legal terminology and understanding "the attorney's viewpoint" to be among the most valuable parts of the MLCI home-study course she took. "I don't feel I've lost any of my nursing knowledge. I've gained more than I ever could have in a hospital setting," says the Certified Legal Nurse ConsultantCM.
Vickie and Her Grads Featured in "Legal Eagles" Article
"Put nursing, law and business together and what do you get?" asks Minority Nurse magazine. Their answer is, "The exciting field of legal nurse consulting!"
In her recent interview with Minority Nurse about the legal nurse consulting profession, Vickie L. Milazzo, RN, MSN, JD, shared, "The door is wide open, whether nurses want to work for employers or independently...There's no limit. You can take it wherever you want to go."
Graduates of the CLNC® Certification Program also commented for the "Legal Eagles" article, stating that "the education and mentoring they received through Medical-Legal Consulting Institute gave them the tools to get started in the field." Click below for the article from the Summer 2001 issue of Minority Nurse, the career and education resource for the minority nursing profession: http://www.minoritynurse.com/features/nurse_emp/07-09-01c.html
CLNC® SUCCESS STORY
Vickie Gave Me the Confidence to Forge My New Career
by Bridget D. King, RN, BSN, RNFA, CNOR, CLNC
As a nurse for more than 20 years, my experience includes OR, ICU, and home-health. Because of a recent life change, it was time for my career to change too. A friend recommended that I try Vickie's CLNC® Certification Program.
I purchased the home-study version and began listening to the tapes. Excited about the possibilities, I decided to attend Vickie's 6-Day CLNC® Live Certification Program.
With business cards and my letter of introduction ready to go — I brought them to the seminar for a quick review by Vickie. I left the live seminar, ready, willing, and able to forge my new career as a legal nurse consultant.
Vickie taught us so much valuable information about starting a business. She taught us how important it was to get out there and market our services. Her program has given me the confidence to start my own practice. I began advertizing my services on a website for trial lawyers. Boom — my consulting practice started! Now, most of my business comes from word of mouth referrals. The majority of my cases are for personal injury attorneys.
Vickie is a wonderful person! I can't say enough about her or her CLNC® Certification Program. I continually reread the material and I receive the free Legal Nurse Consulting Ezine. I recently purchased the 20 Medical-Related Case Reports and they help me every time I write up a case report.
My goal is to quit the hospital and practice full-time as a legal nurse consultant. I will reach my goal!
Bridget D. King, RN, BSN, RNFA, CNOR, CLNC, owns Elite Consulting in California.
BEST PRACTICES FOR MANAGED CARE
Changes in Managed Care Have Implications for LNCs
by Maureen Jones, FNP, CLNC
The not-so-distant thunder you hear is reform taking place in the healthcare system. Every day the news contains more stories about collapsing health plans, shrinking pharmacy benefits coverage, withdrawals from Medicare managed care and health plan litigation. After a decade of proliferating managed care, patients, physicians and health groups have said "ENOUGH!"
ERISA Protection of HMOs Questioned by States
The Employee Retirement Income Security Act (ERISA) of 1974 preempted state laws referring to employee benefit plans such as health insurance. The ERISA has long been used to prevent patients from suing HMOs in state courts. In 1995, the Supreme Court emphasized that states may exercise their police powers over healthcare and insurance.
In 1997, Texas became the first state to allow consumers to sue HMOs for medical malpractice. In June 2000, the Fifth US Circuit Court of Appeals upheld the Texas law, stating it did not violate ERISA. This ruling further established that the right to sue pertains to treatment, not coverage decisions; health plans may be sued for negligent care but not for denial of a medical service. Within the first year of the Texas law, 591 patients asked the Texas Department of Insurance to independently review decisions made by managed care organizations (MCOs). Approximately half these decisions were upheld and the other half overturned. While reviewers of these cases acknowledge it is not unusual to ask for additional data, some plans did not involve specialists in their decisions to deny care.
State, Patient and Physician Allegations Against MCOs Abound
Within the last year there has been a flurry of legal action against health plans, specifically MCOs. In addition to patients, these suits are being filed by physician groups, state attorneys general and insurance commissioners.
Accusations by state attorneys general and physician groups against large MCOs include:
Breach of contract
Violations of trade practice and insurance acts
Control over medical decisions
Failure to pay physicians in a timely manner
System-wide administrative lapses contributing to communication breakdowns
Accusations against MCOs in plaintiff class-action lawsuits include:
Breaching the express terms of the healthcare plan by determining the "medical necessity" of proposed care using standards inconsistent or in conflict with generally accepted standards;
Imposing unfair contract terms, denying and delaying payments for medically necessary treatments, and underpaying physicians;
Failing to update, use and reconcile eligibility and financial data, resulting in millions of dollars in damages;
Violating state prompt payment laws;
Failing to comply with laws requiring companies to provide patients with health plan information.
MCO Cost Control Measures May Reduce Quality of Care
MCOs control their costs by using a variety of strategies, including limiting patient referrals to specialists and reducing utilization rates for various medical procedures. Do these restrictive guidelines adversely affect clinical outcomes for patients?
Cardiac Care
At the 70th annual scientific session of the American Heart Association, Paul Casale, MD, presented his study of nearly 4,000 patients under age 65 with acute myocardial infarction (AMI).1 Comparing clinical outcomes by type of insurance (fee-for-service versus HMO), Casale reported in-hospital mortality was significantly higher for HMO patients. Fee-for-service patients received more clinical procedures including cardiac catheterization and angioplasty. He concluded that enrollment in an HMO is an independent predictor of in-hospital mortality for patients presenting with AMI.
Every et al. reported in the Journal of the American College of Cardiology2 that HMO hospitals use fewer procedures and average longer stays to treat patients with AMI. Even after on-site facilities became available, the number of procedures in the HMO group did not increase significantly. While more conservative treatment involves a longer hospital stay, the shorter stay in the fee-for-service group may have been based on knowledge of the patient's coronary system obtained from cardiac procedures.
Recently, Erickson et al. reported in JAMA3 on a study of 60,000 patients undergoing coronary artery by-pass graft surgery and comparing insurance plans. The authors stated that managed care plans sent cardiac surgery patients to medical centers with higher mortality rates than traditional insurance plans. The authors concluded that managed care contracts with hospitals were based on lower costs rather than on patient outcomes. They agreed that the incentive should be for hospitals to compete on a quality of care basis instead.
Stroke
Brown et al. reported in JAMA4 on the outcomes of stroke patients in Medicare HMOs versus fee-for-service plans. HMO patients were sent to nursing homes more regularly and were less likely to be discharged to rehabilitation facilities following the acute event. A similar study from Harvard5 found that patients enrolled in an HMO were discharged sooner than conventional Medicare patients. The authors recommended further study of the ultimate outcome of such care.
Hyperlipidemia
Elevated cholesterol (hyperlipidemia) is a known risk factor for cardiac diseases. A recent study by Lai et al.6 looked at cholesterol treatment practices in an HMO primary care setting. Based on the standards of the National Cholesterol Education Program (NCEP), less than one-sixth of the HMO patients requiring treatment for elevated cholesterol received such treatment. The authors suggest that some financial incentives and types of reimbursement may influence HMO physicians to limit their services to patients largely on the basis of cost.
Elderly and At-Risk Patients
The Medical Outcomes Study published in JAMA7 was a four-year observational study by Ware et al. comparing chronically ill patients treated in fee-for-service and HMO systems in three large urban areas. The authors concluded that elderly patients from HMOs in all three areas were more likely to have poor physical health outcomes. This study also found that physically limited patients and those in poverty were at greater risk for decline in an HMO system.
Breast Cancer
In evaluating the trends in malpractice awards for patients with breast cancer, Mitnick et al.8 found that the most common complaint was delay in diagnosis. The patients' average age at diagnosis was 44 years and the average delay in diagnosis was 14 months. HMOs were cited for denying six-month follow-up, providing improper treatment, and failing to refer patients to a specialist for biopsy. Because of the basic tenet of cost containment in HMOs, there may be a disincentive to perform fine-needle aspirations or ultrasounds and referrals may not be offered or may occur too late to benefit the patient.
Asthma
In a recent report Standford et al.9 evaluated rates of hospitalization for asthma based on insurance status. Hospitalization for asthma can be avoided if effective ambulatory care is provided. Yet hospitalization and emergency care accounts for 60% of the estimated $5 billion spent on asthma care each year in the US. While the cost of emergency care for HMO patients and fee-for-service patients was the same, hospital stays were significantly shorter for HMO patients. The HMO patients had significantly lower asthma medication costs. The authors conclude that while restricted formularies and drug choices lower pharmacy costs in managed care, this may in fact lead to higher costs in other departments such as emergency departments and inpatient care.
Suicide
Suicide is the eighth leading cause of death for Americans. A study by Hall and Platt10 addressed how managed care barriers to treatment may dramatically affect patient outcome. Several MCOs developed criteria for suicidal patients to qualify for psychiatric admissions, including:
The patient had to have a specific suicide plan.
The patient had to have acute suicidal ideation or ruminations.
The patient had to have a prior history of suicide attempts.
In testing these criteria, the authors studied 100 patients presenting to the emergency department after a serious suicide attempt. The vast majority of these patients attempted suicide impulsively, with 84% having no preexisting plan and 90% giving no warning of their intentions. Although 83% of the patients had contact with a healthcare provider within a month before their suicide attempt, the majority said they had not been asked about their emotional state or if they were suicidal at the time. The authors conclude that using incorrect or outmoded qualifying criteria can have dangerous outcomes for suicidal patients.
Implications for Legal Nurse Consultants
Legal nurse consultants must be cognizant of recent changes in managed care. More changes will be forthcoming as health plans and insurers negotiate contracts for MCOs. We will undoubtedly see a proliferation of class action suits against MCOs.
As LNCs we must continue to evaluate the care given in MCOs and in comparable fee-for-service systems. We must be able not just to evaluate the Standard of Care for a specific diagnosis, but to compare how that standard is met in various healthcare systems. Today's LNC must stay current on these issues now being addressed in the medical and nursing literature.
References
Casale, Paul. "In-Hospital Mortality is Higher in AMI Patients Enrolled in an HMO." Presentation at the 70th Annual Scientific Session of the American Heart Association, November 9, 1997. http://www.harp.org/4-casale.htm
Every, N., Fihn, S., Maynard, et al. "Resource Utilization in Treatment of Acute Myocardial Infarction: Staff Model Health Maintenance Organization Versus Fee-For-Service Hospitals." Journal of the American College of Cardiology, 1995; 26: 401-6.
Erickson, L.C., Torchiana, D.F., et al. "The Relationship Between Managed Care Insurance and Use of Lower Mortality Hospitals for CABG Surgery." JAMA, 2000; 283: 1976-82.
Brown, R.C., Retchin, S.M., Yeh, S.C. "Outcomes of Stroke Patients in Medicare Fee-for-Service and Managed Care." JAMA, 1997; 278: 119-24.
Kanter, M., Glynn, R.J. and Avorn, J. "Variability in Length of Hospitalization for Stroke: Role of Managed Care in an Elderly Population." Archives Neurology, 1996 Sep; 53 (9): 875-80.
Lai, L., Poblet, M. and Bello, C. "Are Patients With Hyperlipidemia Being Treated? Investigations of Cholesterol Treatment Practices in an HMO Primary Care Setting." Southern Medical Journal, 2000; 93 (3): 283-6.
Ware, J., Baylis, M. et al. "Differences in 4-Year Health Outcomes for Elderly and Poor, Chronically Ill Patients Treated in HMO and Fee-For-Service Systems." JAMA, 1996; 276: 1039-47.
Mitnick, J., Vasquez, M. et al. "Malpractice Litigation Involving Patients With Carcinoma of the Breast." Journal American College of Surgery, 1995; 181(4): 315-2.1
Standford, R., Okamoto, L. and McLaughlin, T. "Rates of Hospitalization for Asthma by Insurance Status."
Hall, R.C. and Platt, D.E. "Suicide Risk Assessment: A Review of Risk Factors for Suicide in 100 Patients Who Made Severe Suicide Attempts. Evaluation of Suicide Risk in a Time of Managed Care." Psychosomatics, 1999; 40:18-27.
Maureen Jones, FNP, CLNC, has practiced as a nurse practitioner for nearly 20 years in family practice, internal medicine, and emergency care. She is the owner of Century Consulting, LLC, in Oregon.
