Ordering aspirin tied into a part of ER MD salary ??

nursej22, MSN, RN · Aug 21, 2011

So I get that you have a distrust/skepticism about insurance. Private insurance needs to make a profit to satisfy shareholders; Medicare/Medicaid is mandated to be fiscally responsible. Both are big, impersonal bureaucracies.

But people can always pay out of pocket if insurance won't pay.

Just to play the devil's advocate, who should make sure that docs are delivering the best, most up to date care? Do patients just trust that they are getting is going to help? Should there be any standards of care? And who should enforce them?

MassED, BSN, RN · Aug 21, 2011

So I get that you have a distrust/skepticism about insurance. Private insurance needs to make a profit to satisfy shareholders; Medicare/Medicaid is mandated to be fiscally responsible. Both are big, impersonal bureaucracies.
But people can always pay out of pocket if insurance won't pay.
Just to play the devil's advocate, who should make sure that docs are delivering the best, most up to date care? Do patients just trust that they are getting is going to help? Should there be any standards of care? And who should enforce them?

I know that there are national patient safety goals - Joint commission enforces these. I know that there's a tie between hospital accreditation and medicare payments. If a hospital fails a Joint Commission site visit, I'm pretty sure their medicare coverage/payments would be yanked. I think most insurance companies must follow medicare requiremetns. I think it's all pretty confusing, actually.

"Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable." http://www.jointcommission.org/assets/1/18/Standards1.PDF

SO I guess my next logical question would be... who controls Joint Commission? Who are the professionals who set our standards? Are they appointed by the government, hired, elected...? Are they tied to insurance companies?

I'm completely jumping down the wormhole here....

MassED, BSN, RN · Aug 22, 2011

ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhh...................... too much to get into..... it's hard enough to get through 12 hours in the ER!!!

Bottoms up!

ReggaeRN · Sep 5, 2011

What mostly everyone else said. I don't know about aspirin being tied to the DOCs salaries, but if we in the ER don't meet certain goals (percentages) for core measures, such as Aspirin on Arrival for anyone with cardiac chest pain, we lose out on part of our year-end bonus. Which is incentive for me to say to the doc, "By the way, I ordered Aspirin already." :)

murphyle, BSN, RN · Sep 5, 2011

ASA for any chest pain patient is part of core measures, which drives insurance reimbursement (i.e. you get more money if all the core measures are met, and less if they aren't). Some insurers are now taking core measures one step further, as in denying reimbursement for the patient's ENTIRE HOSPITAL STAY if ASA isn't given and documented in at least half a dozen places. (Yes, you read that right - a $55,000 cardiac intervention can become charity care, or put your patient in the poorhouse, all for want of a $0.01 aspirin tablet. They're also comprehensively denying reimbursement on core measures for pneumonia, most of it tied to blood cultures. This caused a massive RN-vs-MD fight in our EC a few months back, but that's another story...) ASA for core measures purposes can't be the patient's home ASA (how do you know they didn't take acetaminophen or ibuprofen and say "aspirin" by mistake?), and nor can it be EMS ASA (there's no place to document that it was given in our charting system, and EMS paper documentation doesn't count for hospital reimbursement purposes).

This is sometimes taken to ridiculous extremes, as when the Cath Lab says that our (Emergency Center) ASA given in Resus doesn't count because it allegedly doesn't meet THEIR core measures goals, and then the same thing happens on the floor for THEIR core measures. End result: a chest pain patient can get as much as 1325 mg of ASA before everyone's happy in core-measures-land. (Took 325 at home, given another 325 by EMS, given another in EC, given a fourth in Cath Lab, and a fifth when they got to the floor, which will be continued for the rest of their stay.) Of course, when the patient develops GI issues from all that aspirin, it'll be considered "iatrogenic" and "preventable," and so that care won't be reimbursed either...

Sigh. Who's running the asylum again?

MassED, BSN, RN · Sep 6, 2011

What mostly everyone else said. I don't know about aspirin being tied to the DOCs salaries, but if we in the ER don't meet certain goals (percentages) for core measures, such as Aspirin on Arrival for anyone with cardiac chest pain, we lose out on part of our year-end bonus. Which is incentive for me to say to the doc, "By the way, I ordered Aspirin already." :)

I don't know about that.... more likely, perhaps management won't get their bonus, but our bonuses (if we get one this year) is varied and depends on participation in committees, mostly, not if you administer meds that are ordered. We, as nurses, are expected to administer meds as ordered. Period.

Since we are not physicians and don't prescribe, and therefore can't determine protocol orders, any compliance or money tied to that doesn't direct come back to us. If it does, it's pittance.

I understand insurance and their expectations for reimbursement.