EMS and insurance companies

  1. 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 clients call an 800# if they can't decide if they need to call 911. The client gets asked a series of questions at the end of which a person sitting at a computer decides if an ambulance is needed. Kaiser says it is not designed to save money but anyone with any sense knows better esp. those involved with EMS programs. It's only in a few states now but will be nationwide in the spring. Someone with a highschool education sitting at a computer terminal/phone with a book in front of them with these questions is absolutely the LAST PERSON who should be deciding if 911 is needed. It needs to be reinforced that if there is a question of 911 being needed, call it. It is further proof that the only thing insurance companies (HMOs) care about is $$$$ and not the people they are supposed to serve.

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    If Ya' Don't Love The Blues, Ya' Got A Hole In Your Soul
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  2. 24 Comments

  3. by   judith
    Absolutely, the industry (HMO's, indemnity insurance companies) are out to save money at every turn, irregardless of patient welfare. Remember, a "good" HMO is one which pays out the smallest possible proportion of its revenues for patient or provider costs!

    We as nurses need to take the credibility that we still have with the public and work against this in any way we can: educate our friends and relatives; advocate for patient care in every circumstance; write our elected officials; stay current on pending legislation that may impact ever more severely against patient care. There are over 2.5 million of us in this country...if we would only speak up, we could and can be a powerful influence.
    I'm interested in creating grassroots endeavor to educate all of us and our fellow citizens. Any ideas or interest in playing?
  4. by   MollyJ
    I am a little interested in hearing more about this idea. Obviously it is an attempt to reduce the number of clients that come to the ED with non-Emergent problems but I cringe at the idea of an extra layer of bureacracy for someone with chest pain or a benign presenting ectopic pregnancy. I'd love to see their protocols. I quit a case management job, in part, for the reason that I couldn't help but feel that at times I was meant to be the licensced person/gate keeper (read: fall guy) who would limit people's access to to aspects of health care and I didn't like the feeling or the accountability. Still overuse of the ED by insured people doesn't escape your notice in the ED if you work there long enough. ("We're leaving for our ski trip tomorrow and Tommy has a sore throat and sniffles. He's so prone to ear infection. I came to get him some antibiotics.") I hope people who work in these geographical areas where this plan will be implemented will post.
  5. by   CHUBBY
    I heard about the kaiser plan. We'll see how long it lasts before they get sued,because Joe collapsed from his massive MI while he was talking to the insurance rep, especially if the legislature ever gets the ball really rolling with the "prudent layperson" stuff. As it stands now, when a pt. comes to the hospital, the only person "qualified" to do a medical screening (by EMTALA regulations) is a physician.
  6. by   MollyJ
    You know, bluesboyj, I have always worked with enough plain old poor folk that I realized that many people used the ED because they couldn't get in to a doc, didn't want to take the verbal lashing they would get about their outstanding bill that they would never have the resources to do anything about etc and those folks have my sympathy. As a parent, I wouldn't tell my kid that they were just going to have to hurt with that OM because I couldn't pay for the office call. BUT people with a true HMO will (99% of the time) have an assigned doctor. Alot of working folks just have the "Burger King" syndrome when it comes to health care. They want their care at their convenience and don't particularly value continuity of care. I think these folks definitely feed into the ED overload syndrome. This does not mean I think the K-P has the right idea here. But it will be interesting to see what happens. I am sure they have thought about accountability and I bet those High School grad phone answerers will be supervised by some RN---but not me, baby...
    I also think, politically, that the tide has turned against insurance companies and we are seeing them held more and more accountable for procedures they will not okay as it should be. I have heard that law suits are happening in this area. I am not trying to defend hospitals or administrators but I think earning power in health care has shifted signficantly TOWARD insurance agencies and that serves no one except them. Check out the BC/BS office buildings in your cities and states. Good thread.
  7. by   bluesboyj
    Unfortunately, there are forces at work in Congress that would like laws passed that would prevent HMOs from being sued for malpractice over things like this. I agree that the ED is being used for non-emergent things, but with the cost of insurance these days, many working families can't afford medical care and thier only way to receive care is via the ED. This is exactly why there needs to be a universal care plan put in place so everyone can get adequate care but that would cost too much i9n the insurance companies eyes because they can only see the "now" aspect and not the long term savings by keeping people well rather than treating them only when they're ill, if they get treated then. Take teh profit out of the equation and thins will improve greatly.

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    If Ya' Don't Love The Blues, Ya' Got A Hole In Your Soul
  8. by   nursedude
    Pardon me, but FOR CRYING OUT LOUD!!! It is not the insurance companies you dopes!!

    It is the employers who pay the insurance companies/HMO's to save money!!!

    Everything that HMO's/managed care companies do is legal-why/how do you think they exist???

    Read up on the history of Managed care/HMO's. They were started over a Hundred years ago by employers. Currently health insurance is so expensive that most employers turn to HMO's to save them(the employers) money and this includes calling your HMO before seeking treatment? Many employers are self funded-this means that the employer pays the claims and the HMO only administers the Plan.

    Hello, nurses...Wake up!!! don't you see? This is why hospitals have frozen our salaries/cut our wages/insurance- The more of us they cut the more revenue they get!!!

    Nurses, get more educated in managed care! The hospitals see you as an expense and are trying to figure out how to eliminate you!!!

    Bluesboyj, I have been a nurse for 11 years, I have worked for a large BlueCross/Shield and I have worked for a large Managed care company, Currently I work P.T. in a busy city ER and F.T. as a Product support rep for a medical billing/consuting company. IT IS NOT THE HMO'S- IT IS THE EMPLOYER GROUPS THAT PAY THE HMO'S!!! HMO'S ONLY EXIST BECAUSE THE EMPLOYERS PAY THEM TO SAVE MONEY!!!THE "CALL THE HMO BEFORE 911" THING IS PAID FOR BY SOMEONES EMPLOYER LOOKING TO CUT BACK EXPENSIVE ER/AMBULANCE COSTS!!!

    Bluesboyj and all you other nurses ot there- wake up! HMO's are made up of what kind of people? Duh, HMO's employ millions of Nurses and thousands of Doctors!!!! Not to mention a lot of very expensive attorneys. HMO's exist because EMPLOYERS pay them.

    PS, ask yourself this: What kind of insurance do you have? Who pays for the bulk of your insurance premium? AND THEN ASK: Who determines what your plan pays for?

    Nursedude
  9. by   mirn
    ...and, the HMO I was provided by my former employer paid physicians for NOT giving referrals. (ie: fewer referrals, bigger bonus) My employer had NO say in this. I know this because at a time when I needed to see a specialist and was denied BY THE HMO, the HR person at the facility worked with me to get the referral I needed. She was unsuccessful, but the employer tried to get me the needed medical care my HMO refused me.
  10. by   nursedude
    and, the HMO I was provided by my former employer paid physicians for NOT giving referrals.
    OKAY MIRN, THIS IS PART OF THE WAY HMO'S WORK: DOCTORS ARE PAID A CAPITATED RATE IE: X NUMBER OF DOLLARS PER MEMBER/PER MONTH- THATS ALL.(IF THE PCP HAS 1000 HMO MEMBERS-THE PCP GETS $1000/MONTH) THE HMO DOES NOT PAY THE DOCTOR ANY MORE FOR ORDERING TESTS OR ANYTHING. MOST HMO'S HAVE A "REWARD" PROGRAM WHERE THE PCP GETS A MONETARY BONUS AT THE END OF EACH MONTH FOR KEEPING UTILIZATION(OF HEALTHCARE) LOW...THIS IS NOTHING NEW.

    My employer had NO say in this. I know this because at a time when I needed to see a specialist and was denied BY THE HMO, the HR person at the facility worked with me to get the referral I needed. She was unsuccessful, but the employer tried to get me the needed medical care my HMO refused me....MIRN, FIRST OFF YOUR PREVIOUS EMPLOYER DID HAVE A SAY IN THIS- YOUR EMPLOYER WAS THE ONE WHO PURCHASED THE PLAN!!! MOST LIKELY YOUR PREVIOUS EMPLOYER WAS NOT SELF INSURED, HAD THEY BEEN YOUR EMPLOYER COULD HAVE MADE THE HMO MAKE AN EXCEPTION FOR YOU. HOWEVER, SINCE THEY WERE NOT SELF INSURED(IE: THE HMO IS THE ONE WHO PAYS THE CLAIMS)THEY(THE HMO) LEGALLY DO NOT NEED TO MAKE ANY EXCEPTIONS...

    AGAIN I SAY THAT IT IS NOT THE HMO- IT IS WHOEVER BUYS THE HMO'S HEALTHCARE PLANS! IF HMO'S AND INSURANCE COMPANIES PAID FOR EVERY MEDICAL CLAIM THEY ENCOUNTERED, THERE WOULD NO LONGER BE ANY HEALTH INSURANCE!!!

    mirn, look at this site: http://www.insure.com/health /

    THIS IS AN EXCELLENT SITE FOR PEOPLE WHO DON'T UNDERSTAND HEALTH INSURANCE/HMO'S OR HOW THEY WORK.

    ALSO, TRY THIS ONE EVEN THOUGH IT'S A LITTLE EXTREME: http://www.hmopage.org /

    I THINK THAT AS NURSES WE SHOULD ALL ARM OURSELVES WITH AS MUCH KNOWLEDGE OF HMO'S/INSURANCE AS WE CAN!!!


  11. by   mirn
    I appreciate the references you provided, (if not your delivery of them) and will definitely check them out.
  12. by   judith
    Hey, nursedude,
    follow the money...the ceo's of hmo's (has a jazzy ring to it , no) get paid MILLIONS, plus yearly bonuses. A good HMO is one that pays a lesser percentage of its assets to patients or to care providers. So I think it's somewhat disingenuous to blame employers entirely...of course they want to save $: who wouldn't, with insurance companies and hmo's increasing their costs by more than 30% each year while simultaneously reducing benefits and paying themselves and stockholders more.

    the other reality is that it is effectively the hmo's (not employers) which are making what in essence are medical decisions without any accountability whatsoever for adverse outcomes.

    Anyone who buys into an hmo is perpetuating the problem: that includes any of us who decide to use an hmo for its "convenience" as well as employers who buy in. we American's love a "deal", even when it's a scam. i would recommend to most of you that you think long and hard about buying catastrophic coverage with high deductables, and create your own savings account to pay that deductable and/or your minor out of pocket expenses. At some point soon, such self administered medical savings accounts may well be deductable on taxes, but in the mean time, the money will be in your bank, earning you interst.

    For a lighthearted (but truthful) look at the subject take a look at this site http://www.theawfultruth.com/hmofuneral/hmofuneral.html
  13. by   nursedude
    Okay Judith,

    Yeah, I realize that the HMO's make tons o' money but how do we account for the HUGE HMO's (for instance XXX BlueCross/sheild-I am leary about using thier real name) that is a Non-profit company??? I believe XXX BC/BS is in the top 10 of the nations largest(by revenue) managed care companies. I worked there for a while as a Nurse case manager. The purpose of my job: Cost Savings ie: Patient Denials...

    Now XXX is not driven by the stock market, yet it has Billions of dollars in the bank. XXX has an HMO, PPO, POS, Medicare HMO etc etc and in addition I believe that there are over 10 additional companies under the XXX name.

    There are more doctors and nurses working there than all the nurses and doctors combined in all of the hospitals in the city of Pittsburgh. All these docs and nurses make pretty good salaries. Now this company is "not for profit" yet it has over 3.5 billion in assets, its employees draw large wages and it is not driven by the stock market so how, I ask, do we account for this situation?

    The reason "IF HMO'S AND INSURANCE COMPANIES PAID FOR EVERY MEDICAL CLAIM THEY ENCOUNTERED, THERE WOULD NO LONGER BE ANY HEALTH INSURANCE!!!"

    Also, lets clarify something here... The HMO's/insurance companies customers are not the people it insures(ie: me and you and Mr John Q. Public). The customers that they serve are thier clients- ie: Employer groups looking for insurance.

    Also worth mentioning here Judith, is "What about the thousands of self insured companies?" These employers have bank accounts set up to pay claims for thier employees. They go to a Third Party Administrator (TPA) such as a managed care company (that does Utilization Review/enforces the HMO plan drawn up by the employer). This saves the employer even more $$$$$$ because they are not bound by state laws like commercial insurance/HMO's are!!! (Example: most state laws require an X number of inpatient days for a certain diagnosis/proceedure- The self insured Employer/HMO doesn't have to abide by this law.) So in this situation it IS the EMPLOYER who is the bad guy.

    And I would also like to discuss another point with you Judith:

    " the other reality is that it is effectively the hmo's (not employers) which are making what in essence are medical decisions without any accountability whatsoever for adverse outcomes"

    To some extent I agree with your statement. However, the medical decisions that HMO's make are based on things like "Milliman and Roberts length of stay guidelines". This is a book written by the first two MD's who put down in writing the average length of stay for patients with any given diagnosis. So decisions made by the HMO based on this are supported by medical rational. The 1 800 CALL HMO thing is also based on algorythms written again by DOCTORS. Again I remind you that there are a lot of DOCTORS who sit high up in HMO's that make medical decisions. I don't know of any HMO/insurance company that makes medical decisions that are not based on some kind of medical rationale(ie: DOCTORS decision). I do not disagree with you on your statement about the HMO not being accountable.

    And one last thing Judith. Don't you find it extremely ironic (given your statement-"Anyone who buys into an hmo is perpetuating the problem"),that HOSPITALS give thier employees (RNs included) HMO's for insurance????? What a coincidence...
    I don't know any RNs with insurance from thier employer-especially hospitals, that don't have some form of an HMO...ROF, LOL!

  14. by   CHUBBY
    Nursedude, why did you leave your job with the HMO?
    I think the picture is we no longer have the right to choose (for the most part)who we see. Another issue is physicians...pediatricians don't stitch. Why? Liability and OSHA regulations. Why do CVA's get admitted to monitored beds now...a decade ago they wouldn't. Why? Liability. Why does every person who comes to an ER have to be seen by a "physician" (or extender) to be medically screened according to EMTALA regulations? Liability. So perhaps the problem lies with the uneducated public AND HMOS AND this countries love for litigation...

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