[ksilty]

Originally Posted by Jolie

Perhaps not in so many words, but if continuing to pay for futile health care services to rescue clients who decline to follow treatment regimens that would stabilize their conditions is not "enabling," then what is it?

THe non-compliant are not running up the big bills. Non-compliance means no doctor visits and no medications. As someone who monitors claims data on a regular basis, I can tell you that it is only when I step in and am successful at resolving an A1c of 12.0, that the bills go up. One hospitalization for an amputation is often cheaper than the on-going care to prevent comorbidities. This is just a generalization, of course, but the "facts" we hear are always misleading. If I could move my diabetic patients to the point where they are controling their glucose levels through diet and exercise, we would truely save money. But I have to spend some money to get to that point.

[ksilty]

Originally Posted by Jolie

1. Inpatient, residential treatment at weight-loss facilities for morbidly obese clients who are documented to have family members bring in food or who order food from late-night delivery services. (As documented on TLC and Discovery Health programs.)

2. Continuing treatment for complications

3. Repeated emergent treatment for complications of heart disease .

Most payers do not pay for inpatient weight reduction, and rightfully so. #s 2 and 3 would benefit from a hard-working, ****** case manager like me. I have been trying something new lately that has given me some success. When I sit down with a new patient, we map out a Plan of Care, prioritizing goals. If I sense a patient is going to be stubbornly non-compliant, I make Advanced Directives and a will their first priority. I encourage them to make realistic choices, reminding them that anything other than DNR status wouldn't be realistic since they are killing themselves anyway. I am always respectful and soft spoken as I explain this, then we move on to my "real" goals. It has worked for several of my worst cases......

[Noryn]

Originally Posted by ksilty

THe non-compliant are not running up the big bills. Non-compliance means no doctor visits and no medications. As someone who monitors claims data on a regular basis, I can tell you that it is only when I step in and am successful at resolving an A1c of 12.0, that the bills go up. One hospitalization for an amputation is often cheaper than the on-going care to prevent comorbidities. This is just a generalization, of course, but the "facts" we hear are always misleading. If I could move my diabetic patients to the point where they are controling their glucose levels through diet and exercise, we would truely save money. But I have to spend some money to get to that point.

Why then do we on average pay more per citizen for healthcare than other countries yet have worse outcomes? Prevention and maintenance are much cheaper in the long run. If it was only one amputation I would agree with you but most often with diabetics it is treatment of the ulcers, multiple amputations and dealing with other things such as renal failure, etc.

But we are penny wise and pound foolish. We save 500-2000 a year for 20 years but then end up paying 50,000-100,000+ a year to treat complications in their later years. So I really think preventative and maintenance care are cost effective.

[Noryn]

Daggonit. Tweety took away my edit button!

So here is my personal experience. I had an ingrown toenail. Had to get antibiotics 2 times. Finally I decided just to get it removed but my insurance wouldnt pay for it. I talked to the insurance (which is considered one of the best in my state) and asked about why they wouldnt pay for it. They told me it was not covered but upon asking them--get this--"The insurance would continue to pay for doctor's visit and antibiotics for the ingrown toenail." They would also even pay for IV antibiotics for 6 weeks if I got osteomyelitis from it.

I am lucky, I was able to afford to pay for it but there are many people out there that can't just up and pay for a procedure like that. Again penny wise and pound foolish.

[Jolie]

Originally Posted by ksilty

THe non-compliant are not running up the big bills. Non-compliance means no doctor visits and no medications. As someone who monitors claims data on a regular basis, I can tell you that it is only when I step in and am successful at resolving an A1c of 12.0, that the bills go up. One hospitalization for an amputation is often cheaper than the on-going care to prevent comorbidities. This is just a generalization, of course, but the "facts" we hear are always misleading. If I could move my diabetic patients to the point where they are controling their glucose levels through diet and exercise, we would truely save money. But I have to spend some money to get to that point.

I respectfully disagree that non-compliance = no bills. Please read the examples I gave in my response to ingelein. They included 1.) Morbidly obese patients receiving inpatient care at great expense to taxpayers, who at the same time have food brought into the facility for them. 2.) My aunt who refuses to comply with daily diabetes care, yet repeatedly calls 911 and takes an ambulance ride to the ER for episodes of hypoglycemia, has had numerous expenses related to care of non-healing wounds and injuries and 3.) My overweight, sedentary, non-compliant diabetic neighbor who died after his fourth CABG operation.

I understand your point that initial care and management of chronic diseases is expensive, more so than "doing nothing." But I find it hard to believe that auntie's repeated trips to the ER and various specialists are a bargain compared to daily diabetes care, or that my neighbor's 4 open heart surgeries were less expensive than routine management of the chronic conditions he chose to neglect (until he suffered chest pain, that is.)

[HM2Viking]

I agree that daily evidence based care should be the standard to strive for. Unfortunately, medical calvinism doesn't work. Frankly, I think that psychiatric issues are under diagnosed and under treated in the chronically ill. I still think that the French (and VA) models of care for the chronically ill have the most merit.

[ksilty]

Originally Posted by Noryn

Why then do we on average pay more per citizen for healthcare than other countries yet have worse outcomes? Prevention and maintenance are much cheaper in the long run. If it was only one amputation I would agree with you but most often with diabetics it is treatment of the ulcers, multiple amputations and dealing with other things such as renal failure, etc.

I have patients who would have gone to the ER for gangrene, and perhaps the ulcer, but would ignore the other comorbidities until it kills them. I once had a patient who had every comorbidity known to diabetics, including a bleeding leg wound. He also had AIDS, so I had to try to track him down on the streets of Baltimore to persuade him to go to wound treatment. He should have been high cost, but he wasn't, because he wasn't compliant with care.

[ksilty]

Originally Posted by Jolie

I understand your point that initial care and management of chronic diseases is expensive, more so than "doing nothing." But I find it hard to believe that auntie's repeated trips to the ER and various specialists are a bargain compared to daily diabetes care, or that my neighbor's 4 open heart surgeries were less expensive than routine management of the chronic conditions he chose to neglect (until he suffered chest pain, that is.)

That wasn't the point I was trying to make. Folks like your aunt are high cost, and need intervention for non-compliance. Docs don't have time, so she needs case management. But I have many patients who won't go to the doc and ER, even though they know they have diabetes. I have visited patients who had black feet, and I have piled them in my car and taken them to the ER. They lose a foot, go home, and the cycle begins again. Refuse wound care, PT and IV abx. Only claim on the record is a 4-day stay for the amputation. Sounds extreme, but it is not uncommon with my rural population.

[Jolie]

I'd be happy to have you round her up. She utilizes the services of a PCP, and endocrinologist, the ER and other specialists, yet has no intention of doing anything other than seek relief when her complications cause her pain or inconvenience.

[Nurse4years]

Universal Health Care or not-supported by hardworking taxpayers or not-noncompliant or not---we all must live our own lives.
What good is life if it isn't enjoyed?
Who are we to tell the non-compliant how to live their lives? or that they are wrong? If this is their life-so be it.
And-not everyone needs therapy, just because they think differently than health care workers.
I am very offended that people place non-comliance into a mentally unhealthy catogory. Who are we to decide what makes a person's life worthy to them.
Life, liberty and the pursuit of happiness. So, if it doesn't make you happy to financially support health care for everyone, including the "non-compliant", well, don't know what you will do. You already pay for local schools, roads, government costs, etc..
This isn't meant toward anyone in particular, but having read these threads, I wanted to voice my opinion about non-compliance.
I have witnessed many a health care professional offend patients with their insistance that the patients be compliant. Educate, inform, then leave them alone. That is called treating others as I want to be treated. (I never chase down AMAs either-unless their are other circumstances)
Now, getting off my soap box and back to Universal Health Care, how many banana splits a week will be allowed? I may have to start stockpiling.
Life is too darn short.