On Point: Room with a View - by James E. Hill, Jr., MEd, PA-C Emeritus, DFAAPA
I have been clinically retired as a practicing PA for several years now after a 42-year career as a PA, mostly in emergency medicine. During that time, a number of patient experiences have remained with me, mostly for the life lessons they taught me. There is one, though, which has haunted me for over 10 years, and I’ve finally decided to banish those demons by sharing the story.
In emergency medicine, the practice environment is a closed system. There are no windows and the doors lead to other areas of the ED or the hospital. In wintertime, while working a day shift, it was dark when I left for work and dark when I finished my shift to drive home. The florescent lights on the ceilings are our synthetic sunshine.
One winter’s shift I arrived to discover that the Spanish interpreter we usually used to help us with our Hispanic patients had called in sick, and there was not a backup interpreter available. My first patient was a 12-year-old Hispanic girl who was presenting with 2 weeks of nausea. She spoke English fluently, but her mother did not speak English. I had a dilemma since there were no staff in the ED who spoke Spanish that day.
I decided to speak to the 12 year old since she was intelligent and appeared mature for her age. I did ask her to share my questions with her mother, and her answers with her mother---English to Spanish to English. A history of present illness revealed no associated symptoms---just intermittent nausea throughout the day for 2 weeks. She also told me she had not started having menstrual periods yet and had no boyfriends.
Her physical examination was normal---no signs of dehydration, no icterus, no abdominal discomfort. The decision was then made to obtain some laboratory studies (blood and urine) as a screening assessment. Just before sending these to the lab for analysis, my “6th sense” told me to add a urine pregnancy test. All the labs came back normal except for one---a positive pregnancy test.
I returned to the room to speak to my patient about her lab results. She swore to me, quite adamantly, that the test had to be a mistake as she had no boyfriend and had never had sex. I was determined to uncover the truth, and we continued our discussion for over an hour---her denials and my persistent assertions that it was important to face the truth for her health. Ultimately, she started to cry, then told me that her stepfather had been sexually abusing her for several years, finally progressing to penetration in the past few months. She begged me not to tell her mother, saying that he was the only one who worked in the family and that she, her younger brother and her mother would have no place to live if he was arrested. I convinced her to tell her mother what she had told me. And, I told both of them I had to report this to the police and to the social worker as what the stepfather was doing was harmful to both of them, as well as a crime.
The mother had difficulty accepting the diagnosis and the facts behind the pregnancy. The police arrived as well as a social worker, and the stepfather was arrested in the waiting room. All I could think to say to the 12 year old girl that she would come to realize later this was the only way to heal and move toward a healthy life.
I then returned to seeing other patients after being tied up with one patient for over 2 hours. As is common in emergency medicine, her follow-up was lost to me. At the end of my shift, I drove home in darkness, thinking about this child and the terrible events bringing her to the emergency department, wondering what would happen to her and her pregnancy, wondering if she and her family would survive the betrayal of trust from her step-father and his path through the criminal justice system, wondering if she would grow wiser in the coming years. It was then I had an epiphany. The emergency department may have no windows, but it is truly a room with a view. It allows us to see people in their worst times, caused by events not of their choosing in most cases, and it allows us as PAs to be part of their lives for a sliver of time when dealing with the results of those events. I’m happy to settle for that.
On Point: CMS needs to include measures for social drivers of health
This op-ed was shared on April 29, 2022, on STAT
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Yet even with an ongoing pandemic that has painfully brought these issues to the fore, no measures of social drivers of health exist in any federal quality and payment programs, and these factors are still not accounted for in CMS’s “risk adjustment” calculations — how healthy (or sick) a patient is and, therefore, how much their physician should be paid to care for them.
The Physicians Foundation, whose directors are appointed by 21 state and county medical societies, responded to CMS’s annual invitation for new Medicare measures by putting forward the first two SDOH measures ever proposed. These focus on the percentage of patients who are asked about food insecurity, housing instability, inadequate transportation, interpersonal safety, and difficulties paying for electricity and other utilities; and the percentage of patients who are positive for each of these needs. Even though CMS has declared it a priority to “develop and implement measures that reflect social and economic determinants,” these two measures are the only ones related to social drivers of health and are the only patient-level equity measures in this review cycle.
To truly move the needle to improve health outcomes for vulnerable Americans and give physicians the quality measures they want and need, CMS must act now to incorporate these two measures. Last week, CMS took a crucial first step by proposing these measures for the Hospital Inpatient Quality Reporting Program, which sets rules for Medicare payments to hospitals. Next, it will consider the same measures for the Merit-based Incentive Payment System.
Many stakeholders have emphasized the particular importance of the percentage of patients who screen positive for social needs. The rate itself should not be rewarded or penalized, recognizing that it would be influenced by the community in which a practice exists and its patient population. Yet this measure is essential to make visible and address factors that contribute to health disparities and support improvement activities. In addition, this measure would enable CMS to account for patient-level social drivers of health in risk adjustment, providing a more complete picture of the impact of these factors on health care costs, outcomes and disparities.
Both measures are essential to fulfill CMS’s commitment to health equity — articulated in its recently released health equity strategy pillar and its vision for the Centers for Medicare and Medicaid Innovation and its associated health equity initiatives, all of which cite the importance of routinely and in standard ways “collecting self-reported demographic and social-needs data.”
Over time, these measures of social drivers of health can and will be improved with the benefit of the input of physicians and patients across the country and the data generated by these measures. Yet we also recognize that, given the profound challenges that Covid-19 has wreaked on patients, physicians, and the U.S. health care system at large — and the commitment to equity and the reduction in health disparities that CMS and health care institutions across the country have declared — that time is of the essence in enacting these historic measures of social drivers of health.
Michael Darrouzet is the chief executive officer of the Texas Medical Association. Jennifer Lawrence Hanscom is the chief executive officer of the Washington State Medical Association. Chip Baggett is the chief executive officer of the North Carolina Medical Society. All are board members of The Physicians Foundation, a nonprofit seeking to advance the work of practicing physicians and help them facilitate the delivery of high-quality health care to patients.
Joint Legislative Oversight Committee - Medicaid and NC Health Choice
The Joint Legislative Oversight Committee on Medicaid and NC Health Choice met on January 12, 2020.
View the metting agenda here. Watch the replay of the meeting here.
NC DHHS Secretary, Dr. Mandy Cohen, MD, provided the Committee an overview of the COVID-19 vaccine distribution process.
North Carolina Healthcare Association Vaccine Rollout
Leah Burns, Vice President of Government Relations for the NC Healthcare Association provided an update on the vaccine distribution process from the hospital's perspective. She explained the steps to the process of vaccinate the 1A population and the 75+ population. She shared that flexbility, the CVMS operability, and rural popuations are current challenges. She suggested that working with primary care providers and retail pharamcies could help with vaccinating more individuals more rapidly.
Dave Richard and Jay Ludlam from the Department of Health and Human Services shared a brief update about the NC Medicaid Transformation.
Day 1 Goal for Transformation: Patients get the care they need, and providers get paid.
Identified Medicaid Transformation Challenges:
- COVID-19
- Provider Contracting
- Legislative Changes
- State Budget
Transparent Communication & Engagement with Partners:
- Beneficiaries
- Providers
- Counties
- Health Plans
Proactive Comunication
- DHHS remains committed to transparency and frequent updates to the legislature and the general public.
Contracting During COVID-19
- Contracting during the pandemic has made it challenging for providers & health systems to focus on contracting.
- Plans are currently focused on open enrollment and contracting with primary care physicians and health systems.
- NC Medicaid is convening workgroups between prepaid health plans and certain provider groups to understand and resolve issues that may be standing in the way of contracting.
Coronavirus Relief Fund Update
House Select Committee on Community Relations, Law Enforcement and Justice
The House Select Committee on Community Relations, Law Enforcement and Justice met on December 14, 2020.
Listen to the entire audio here.
The Committee approved a draft report to be presented to the NCGA.
- Create additional statwide law enforcement training require and provide additional educational and training resources
- Create requirements for law enforcement agencies to report disciplinary actions, resignations, and terminations
- Create whistlblower protection for officers that report misconduct
- Provide law enforcement with additional resources encountering mental health issues in the field
- Provide law enforcement with additional resources to recieve mental health treatment
- Increase availability of specialty courts
- Ban the use of chokeholds
- Require law enforcement to report use of force incidents
- Mandate the duty to intervene and the duty to report miscondcut
- Fund pilot program for student law enforcment career exploration
- Establish a system to allow infividuals to recieve notification of court dates
NC Child Fatality Task Force Intentional Death Prevention Committee
The NC Child Fatality Task Force Intentional Death Prevention Committee met on December 14, 2020 from 1:30-3:30.
Agenda Items
- Student Mental Health and Child Abuse Neglect Reporting
- Infant Safe Surrender
- Updates from NC Division of Social Services
View all of the sildes for this meeting here.
Joint Legislative Program Evaluation Oversight Committee
The Joint Legislative Program Evaluation Oversight Committee met on Decenber 14, 2020.
- Report Release Better Coordination with Nonprofit Volunteer Organizations During Preparedness Can Improve Disaster Recovery
- DOT Internal Audit: Highway Division Contract Pre-Award Process
- Bill Draft for Consideration
- Teacher Diversity/PED Reccomendations
- Directs the State Board of Education to develop an alternative plan for teachers to recieve a continuing professional license
- Directs NC Teaching Fellows Commission to select at least one minority serving institution to participate in the NC Teaching Fellows Program
- Teacher Diversity/PED Reccomendations
North Carolina Council for Health Care Coverage Second Meeting
The North Carolina Council for Health Care Coverage will meet on Friday, December 18th at 10:ooam.
NCMS CEO, Chip Baggett, JD, and NCMS Board Member, Dr. Merritt Seshul, MD, MBA, FACS are members of this Council.
The meeting will be live streamed on Youtube here.
View the agenda here. View the participant list here.
Future proposed meeting dates:
- Friday, January 8
- Friday, January 22
Joint Legisative Overisight Committee - Education
The Joint Legislative Oversight Committee on Education met on Tuesday, December 1, 2020.
The NC Department of Public Instruction provided an update to the Committee on remote instruction data for 2020.
Here are a few key findings:
- 36% of students are learning all virtual, 59% in person
- 81% of students are attending virtual education regularly
- Less than 1% of students are unaccounted for in NC's public schools with a range reporting from .7% to less than 1%
- 53% of students who qualify for free/reduced lunch are recieving meals
- Public School Units (PSUs) have created focused mental health support and counseling for students on social emotional learning
- Equipment - based on NCGA funding in HB 1043, 100,000 devices for learning were purchased and distributed, there are more requests for devices
- Broadband - every county is still struggling with connectivity, many schools have implements "park and learn" spaces for students to use broadband services
This report provides a summary of all of the Committee meetings this legislative session.
Key reccomendations from the report:
Lunch Periods
- The School Nutrition Associaiton and the CDC recommend students be given at leart 20 minutes for eating lunch after being seated. The Committee encourages local education leaders to work collaboratively to find ways to ensure students have adequate time to eat lunch.
Breakfast
- Only 30% of eleigible students participated in the National School Breakfast Program
- Committee encourages local education leaders to allocate time for breakfast.
Meal Debt
- Total statewide meal debt was $1.9 million for the 2018-19 school year.
- The NCGA allocated $3.9 million for schools ot provide lunches at no cost to students of all grade levels for reduced price meals.
- The NCGA allocated $75 million dollars from federal relief for emergency school nutrition services.
Digital Learning Access
- Committee recommends public school units to report information on student digital learning access to better address this issue.
Computer Science
- Committee reccommends an annual report on computer science implementation.
2020 Voter Tools and Information
We've compiled a list of voter tools and information to help answer some questions you may have about the process this year.
If you have more specific questions, or would like to talk about the candidates on your sample ballot please contact Sue Ann Forrest, Director of Legislative Relations at [email protected].
Did you know you can view your sample ballot before election day? This feature allows you to view the entire list of races and candidates on your ballot from President to Soil and Water Commissioners. You can conduct your own research on candidates!
You can view the following information on this site:
- Check voter registration status
- Sample ballot
- Party affiliation
- Election day polling place
- Voter history (elections you have participated in)
- Absentee ballot information
If you are a registered NC voter, you can use this portal to request an absentee by mail ballot which will be mailed to your home address.
Track the status of your mail-in ballot from printing to acceptance. This is a helpful tool to know where your absentee ballot is during processing.
Do you need to update your voter registration?
- Existing NC Division of Motor vehicle customers can submit their voter registration application online through the DMV.
- Complete a voter registration application. Print and sign the application. Mail the form to your county board of elections.
- The voter registration deadline in NC for the 2020 general election is October 9, 2020. (The county board of elections must receive your application by this date. You can drop off the application at your county board of elections. Eligible voters may register to vote and vote on the same day during the early voting period.)
- In 2020, the early voting period begins Thursday, October 15 and ends Saturday October 31.
- During early voting, voters can cast a ballot at ANY early voting site in their county. (On Election Day, voters must vote at their assigned precinct.)
- Eligible voters may register to vote during the early voting period.
- Find early voting sites and schedules here.
House Select Committee on Community Relations, Law Enforcement & Justice
The House Select Committee on Community Relations, Law Enforcement & Justice met on Monday, September 28, 2020.
NC Association of Chiefs of Police
The Association discussed previous association policing reforms including the following:
- Implemented statewide non-bias based policing training (implicit bias)
- Worked to revise the basic law enforcement program in scenario based reality training
- Worked in bi-partisan legislators to enact the law enforcement video law
- Re-engineered use of force tactics
- Supported Raise the Age legislation
- Created a Police Professionalism Work Group to present reccomendations to address concerns
The Association's foundational principle is that the preservation of life must be at the heart of everything a law enforcment agency does.
They discussed two main goals:
- Create a culture of trust and racial equity in communities
- Preserve life in all use of force
The Association also discussed the goal of enhancing professionalism by creating a culture of excellence by improving policies and procedures as well as improving the wuality of the workforce.
The Sheriff's Association created a working group on Law Enforcement Professionalism. This group discussed training, certifications, accrediation, use of force investigations, data collection, recruitment/retention, and public records.
In October there will be a report released from the Workign Group on where improvements can be made.
NC Police Benevolent Association
The NCPBA discussed some of the top areas of concern for law enforcement officers:
- Mental health
- Response to non-police matters/ordinance violations
- whistleblower protections
- NC Criminal Justice Education and Training Standards Commission
- Procedural Due Process/Uniformity
- Recruitment and Retention
- Office Safety
Overview of Recommendations Recieved
A complete overview was provided of all of the reccomendations recieved for the committee to review thus far.
The group will meet again in October.