EMS and insurance companies - page 2

Does anyone out there besides me feel that insurance companies are getting too deepl involved in healthcare decision making. I'm referring to the recent decision by Kaiser Permanente to have their... Read More

  1. by   nursedude
    Judith and all others,

    Heres one with a twist. It completely contradicts what you said Judith:

    "the other reality is that it is effectively the hmo's (not employers) which are making what in essence are medical decisions ..."

    What about a situation where the employer was also the HMO and was also a hospital???

    Check this out...
    http://www.upmc.edu/upmchealthplan /

    UPMC= University of Pittsburgh Medical Center
    This hospital(s) started its own HMO(they own Tri-State Network). So now you have a HOSPITAL(employer) that is also an HMO. Guess what insurance they give thier employees? Thats right, the employees are insured by the employers HMO. So, you work at a hospital, the hospital is your employer your employer is the HMO.

    In this instance IT IS THE EMPLOYER THAT MAKES THE MEDICAL DECISIONS...

    Wild, isn't it? Or is it scary?
  2. by   nursedude
    Chubby,

    I left there because I could not live with myself...

    From every point of view it was agreat job-401K, FULL/UNLIMITED tuition reimbursement, great salary, cushy job, free coffee/doughnuts etc, etc, etc.

    I could not live with myself anymore. I had senior vice presidents calling me, I had steelworkers calling me, I had parents of dying children calling me, I had patients dying of cancer calling me... They all wanted to know the same thing... ??? Why won't you pay my claim????

    Some(most) were ligitimate claims. Some were stupid. I tried to do my best as a case manager there. If it made sense - I would approve it. If it didn't make sense, I would send it to a Physician for review. I think I did a really good job there. The reason I couldn't live with myself anymore?

    What bothered me was this: There were docs and nurses who had the "I am God" attitude and what I say goes!!! There was a lot of that there. It was a power thing and sometimes a money thing. I couldn't believe I was a part of something so big that was guiding some peoples destinies and deciding their futures yet at the same time driven by self serving power and money hungry crazies!!!

    I could get more specific but I'll save you the details and simply tell you that I have never been a part of something so "evil" for a lack of better terms.

    The thing I must point out here is that most of this power lust was displayed by MEDICAL PROFESSIONALS. I dont disagree - there is a big problem with litigation and people wanting to sue their doctor etc, but what I saw was doctors and nurses turning on patients and other docs and nurses for their own gain...It was easy there - you hardly ever saw any patients.
  3. by   judith
    Nurse dude:
    couldn't agree more about the "evil"...what's that phrase about "power corrupts, and absolute power corrupts absolutely?".
    Glad to hear you couldn't live with it. I've left a couple jobs over moral issues, so can only applaud your decision.

    I'd love to think my take on the insurance/healthcare mess were the only right one,(don't we all like to be right?) but of course it's an enormously complex issue, only compounded by the greed factor of all those who are making cash on the deal.

    My point re: our individual resposibilities remains. While my employer offers HMO coverage, Istill have the option of buying an indemnity plan w/ high deductable through employer or individually, which, in fact I've done. This is not a choice that everyone can make comfortably or perhaps affordably. I guess would like more of us to recognize the real costs involved in buying "insurance". Medical care can't come for free, nor could the system continue to function with no constraints, as someone mentioned in a different but related thread.
  4. by   judith
    another thought: regardless of the basis for decision making about medical treatment, whether by algorhythm or MD standards, the fact remains that as a legal entity, an HMO cannot at present be held accountable for those medical decisions in the same way that an individual practioner is.
    Just a thought.
  5. by   suellen e.
    Dear Nursedude, Judith, and others, Thank you for your helpful insights to this mess of a health care system we have. Your last comment Judith about the liability issue is very interesting, although hopefully will be changing soon, as consumers continue fighting back and HMO's become increasingly legally liable for some of their medical decisions. In the family practice where I work, a physician is paid $5 a month to provide whatever medical services are needed during a month for the patient. This is typical, I know. There was a patient who needed suturing of a laceration last week, and this is not enough to pay for the packet of sutures used! Not to mention the cost of sterilizing the suture set, staff to assist, other office overhead. If the cost of medical care is so expensive, how can a HMO have the gall to pay a doctor so little? Is it really greed? Are we living what we read about in the fairy tales to our kids? The greedy kings robbing as many poor people as possible? If this is what is going on, why is it taking us so long to make laws to outlaw this? The $937 million annual CEO profits could pay a few medical bills. I still feel not absolutely certain about how HMOs operate.
  6. by   bluesboyj
    Good news! California law was just enacted to make it possible to sue HMOs for refusing to pay for treatment, etc. Basically, if you feel you received sub-standard care, you can sue. I agree we all know healthcare costs must be contained, but I have a problem with someone with a high school education sitting at a computer denying care while the CEO gets millions of $ to keep the stockholders happy and you can bet there's not one of them who have hmo for insurance. WE've gone too far the other way. I've seen first hand what happens when a doctor knows a patient needs a CT scan or some other diagnostic test but if it's done the hmo will deny payment so it comes out of the md's pocket. It's PROFIT driven and as I still believe it has PUT A MONETARY VALUE ON HUMAN LIFE!!!!!!!

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    If Ya' Don't Love The Blues, Ya' Got A Hole In Your Soul
  7. by   suellen e.
    Dear Bluesboyj, Have you actually known of or seen the cost of a HMO denied CT scan come from the MD's pocket? I haven't personally seen or known of this. But I have seen a MD paying his staff out of his personal savings to make ends meet. This is kuku.
  8. by   nursedude
    I know this isn't a popular opinion but What do you think is going to happen next?

    HMM, lets see. First, people paid for health-care as "self pay". Then along came commercial insurance and then technology and oh yeah, lawyers. So ever since all that happened medicine got too expensive. Now I am not a brain scientist, but since we all can now sue HMO's how long do you think they will be around?

    Then what will happen? I think that being able to sue HMO's will end an era of the best medical treatment this country has ever known. Then we'll all end up with government sponsored medical care. Then who will we sue???
  9. by   nursedude
    And again, I feel that I must point out again that HMO's (those evil money hungry care denying tyrants) Cannot and do not exist without DOCTORS AND NURSES who are paid $$$$$$ to make medical decisions/policies/guidelines. Yes, can you believe it? doctors and nurses......

    I know that HMO's are not anyones favorite, but when all the HMO's go bankrupt who will be paying for the humungous cost of medical care?
  10. by   suellen e.
    I agree with you nursedude, that it is not good news that citizens may be able to sue HMO's if the the Senate and President ok it too. The HMOs will go broke fast. HMOs are going broke now, but the multiple lawsuits are sure to increase the velocity of the process. The thing is that nobody has been able to come up with a solution of how to pay for expensive healthcare. This is a worldwide problem. In countries where there is much less expensive and lower quality care than in the USA, the governments are having trouble paying for it. I say that we continue to deliver quality healthcare at home but lower our spending. How?? No sonograms to verify the sex of infants. Maybe a $150.00 urine culture isn't necessary in many cases of UTI. Of course there are lots more dollar saving ideas if we would just put our heads together and look for ways to save. The changes won't happen overnight, it might take twenty years. What do you think?
  11. by   bluesboyj
    Yes I have known a couple of nurses who get headaches so debilitating that they suffer vision changes to the point of temporary blindness yet CT scans are denied as not "medically necessary." And suellen e., you just don't get it if you think it's sad that HMOs can be sued for non treatment. It's called MALPRACTICE and it's done to keep the CEOs making millions of $$. I don't believe for a moment that HMOs are going broke and if they are, it's their own fault because they would rather wait for a patient to get extremely ill to pay for their care rather than pay for preventitive care because preventitive care costs a little more in the short run but saves money in the long run but all they care about is the "now" aspect. There is a lawyer in Ca. who sued his late sister's HMO because they refused to pay for a bone marrow transplant for her battle against cancer because transplants are "experimental." Bone marrow transplants have been done to long are are to effective to be called experimental. He won a big settlement and the HMOs are scared of him which I think is great. If you had a loved one die because of HMO greed, you wouldn't think suing them is such a bad idea. It's time for universal coverage and to get rid of money grubbing HMOs.

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    If Ya' Don't Love The Blues, Ya' Got A Hole In Your Soul
  12. by   mn nurse
    It's fashionable to slam HMOs, but often, it isn't the insurance company denying care. On a self-insured plan, it's the employer. In a capitated clinic, it's the clinic. Most hospitals, at least in my area of the country, are paid either on a DRG-based system or a per diem. If care is not covered in the hospital, it's the hospital that's decided they're not going to spend the money. The insurance company doesn't care; it's costing them the same either way.

    Then there are the nurses who know little about reimbursement and care even less. The supplies wasted, the items ordered for convenience. The doctors who send patients to multiple specialists and order a battery of expensive tests, not because they feel the patient's condition warrants it, but because they want to avoid confrontation and the threat of litigation. The patients who don't know (or understand) their certificate of coverage, neglect their health until a problem becomes critical, or use E.R. as a convenience. Add the advanced technology that allows us to keep people alive longer and sicker, and it's easy to see why health care costs are out of control.

    I don't think managed care is perfect, but in the old days, we'd be paid with blankets and chickens. As for universal coverage, it would be administered by the same fine people who brought us Medicare and Medicaid.

    I once worked for a clinic that was able to get a major health plan's blessing to develop a CHF program. In the pilot program, we searched for 25 of our sickest, most labile, most hospitalized CHFers and threw every service we had at them. Everyone got at least one home visit, and continued getting them until the home environment was adapted for their disease: making sure they took their meds right, had appropriate foods in their cupboards, set up ways to accomplish their ADLs that didn't overtax their physical capabilities, etc. Then we put them all through a specially developed outpatient cardiac rehab program for 8 weeks. Then we brought them into the clinic to be checked weekly until they were completely stabilized and educated well enough to manage their own disease. In addition, every patient had 24 hour phone access to an RN. We had NO hospitalizations and an annualized savings of over $800,000. All of the patients rated their symptoms better and their quality of life better. None of them would have gotten any of this if they hadn't been members of an HMO.

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