HMO's

Mijourney · Jul 13, 2001

Yes Navy Nurse I agree. All of us that consider ourselves responsible people should be held responsible and accountable in some way for the consequences of our actions. In addition to adding premiums, copays, deductibles and additional costs to an HMO program, what else would you suggest? Perhaps we need a three strikes you're out policy where people who are found to be noncompliant are kicked off of the insurance their on. Maybe there needs to be a steep reduction in the maximum amount of insurance money we can spend within our lifetime. Instead of breaking down our insurance by the benefit, the insurance company could tell us we have X amount of money to work with,and it's our or our family's responsibility to keep up with how much we're spending. Maybe insurance companies can set up our insurance plan using similar methods as credit card companies where we are periodically granted increased maximum amounts to our plan for no or minimum use of the benefits. There are many other ways to penalize or reward us for abusive/nonabusive behavior toward ourselves.

I believe that in a country like the US that everyone should have health and medical insurance. And the program needs to incorporate true quality, access, and good care. I just heard today that managed care has essentially been a failure so far in meeting its goals of providing good quality care and access while controlling costs. The problem in my opinion is that all players are not in agreement with who or what should be controlled and who should be controlling. The patient and family ends up in the middle.

As indicated under another topic, I feel that doctors, nurses, therapists, and other health care workers have not done right by the patient and their family over the years in making them or encouraging them to become totally dependent on the system. This worked when fee for service was predominant, but with managed care, we are seeing the effects of our omission or ignorance. I feel that with the next several generations of people to hit the health and medical care system in the next 10-15 years, we will see a total collapse of the system unless we totally reform this current system and curb immediate gratification seeking behavior.

**canoehead, BSN, RN** · Jul 13, 2001

I am all for increasing rates for those who have self induced illnesses, but deciding what is self induced would be a nightmare. Also how would we know if someone was engaging in risky behavior- self report? spies? Most unhealthy behavior can be hidden for the few minutes spent at the MD's

Another thought, I think of insurance as helping a person through a catastrophic event, like a house burning down, or car accident. Health insurance is not like that as everyone needs preventative visits to avoid the catastrophes. We could force people to pay for regular checkups, but save insurance for admissions (result; more admissions).

Jeez, I don't see a solution. I guarantee though that making government run health care is not the solution, nor is treating each patient as a "market share" to maximize profit.

I also have a problem with spending millions on one person, when the same millions could save 10 000 others through immunizations, good nutrition, regular visits with a consistent primary care provider. Maybe I agree most with giving each person a set amount to spend in their lifetime. Would we allow people to transfer their "allowance " to others? That would probably result in the kid with cancer and a big family getting more well, and no donations to the homeless alcoholic. Is that OK?

Sharon · Jul 13, 2001

I agree with some of what you say. I have had the pleasure? (I think fear is better) of influencing our benefits purchase for our employees. The issues that make management cringe and complain about are not the ones you are citing.

Questionable and expensive ongoing care. We have a 38-year that has been on dialysis for 8 years with no transplant work up. Two years ago he almost died from multiple iatrogenic caused injuries and illnesses related to the dialysis. Even though he is now stable for 18 months there still is no work up. We have more then one in this situation.

Amount of time staff must take off from work to correct billing errors. A staffer who has a compensation package of 200/hr must take off 8 hours to correct paperwork that was completed and filed correctly the first time. When you add up all the hours of staff taking time away from work to deal with these issues it is nauseating especially to a CFO.

Pharmaceutical formularies used by hourly workers with no exceptions for allergies to drugs on the formulary or failure of the drug formulary to work on their disease. Therefore instead of paying the higher cost out of pocket, (which they can't afford) they don't receive the medication and either use the ED for management or end up hospitalized or with a more serious and expensive condition.

If the cost of the errors I clean up each week occurred in the retail business, people would be fired and probably the business would go bankrupt. I have this impression that financial fiduciary responsibility of the insurance companies are focused too tightly on the outside providers with none on the inside financial disasters.

hoolahan, ASN, RN · Jul 13, 2001

OK, I agree people should be responsible for preventing illness, but that can be quite expensive to do. This would be feasible IF the HMO's were willing to assist in getting people well. For example, what if someone really wants to quit smoking, but can't seem to do it. Why doesn't the insurance compnay pay for patches? Or pay for other assistance via preventative programs??? If someone is overweight, why don't they have a company sponsored weight management program? Pay for a gym membership or discount, or cover the expense of a medically managed weight loss program?

If it was easy and cheap to loose weight and quit smoking, don't you think people would already be doing it???

As far as the HMO's needing to make a profit, I am sorry, I don't think so. The employees get bonuses for saving the companies money, this may one day be at your expense. HMO's don't pay bills in a timely fashion, and then the patient's get on bad credit lists for unpaid bills. I did work for a Medicaid HMO, and though the company was very generous, they had to allow what was laid out in the states Medicaid program, they made a $19 million dollar profit one year. From what I hear from other nurses, some companies make WAY more than that!

I just spoke with a nurse yeterday about my difficulites getting auth for home health visits. The pt had stasis ulcers on her LE's. The doc ordered an una boot, to be changed once a week, he then upped that to 3x a week due to copious drainage, so in the meantime, the nurses used up the allotted visits earlier than planned. So, here it is saturday, and the nurse says I don't have auth, there are no more visits. I call the insurance company, the person on the other end gives me such a hard time because apparently, the nurses had not re-measured the wounds, so I had no measurements to give her. After a 10 minute inquisition on the phone, I finally said, look I don't have time for this, if you're not going to give me auth, let me give you the patient's number, and you can send her to the hospital to be admitted for this care! Suddenly, we got auth! Why? It's more expensive to send the pt to the hospital. The bottom line was, there was COPIOUS drainage from the wound, which required increasing the freq of care, it would not matter what the measurements are, though I admit, it was embarrassing to find none of our nurses measured the wound in a week and a half. Getting back to the nurse I spoke to about this, her M-I-L worked for HR for a major insurance co, and she said they gave personality tests on hire to find people who had defensive and mistrusting personality traits, so that God forbid, they wouldn't allow more than what was needed.

I also agree that when HMO's came into existence, there was a lot of misuse and frivilous medical care, and fraud happening, but just like any system, eventually, people learn to "work it", so that if someone really wants to get one over on the insurance company, they still will. The probelm is still, that if particular individuals doctors or patients are the problem, they need to be addressed, or dropped form the plan. The idea should not be to punish everyone. I have had some very depressed patients tell me that were not allowed to have Open Heart Surgery until they failed PTCA 3 times, per the insurance company. Who the hell is someone sitting behind a computer screen to tell another human being and their cardiologist that they cannot have this needed surgery?? Because they are overweight? Did they offer to send him somewhere or do anything to help the pt with that problem? It burns me up!!!

And in my experience with this company, I can tell you, if the state came and reviewed our paperwork, they would be very impressed with all the wonderful things that were done for the pt's. Problem is, it's all on paper only!! They paid big $$ to give asthma programs to members, but the High-school grads, non-professionals, who were in charge of this effort forgot to mail out the invitations to the members, so 3 people were there, only one of them was a member of our insurance company (It was at a health fair.) Yet, we did community education, wooohooo!! What a JOKE!

There were a lot of hard working nurses there, but unfortunately, they were in the minority. Many left out of disgust.

Sorry, didn't mean to go off, but this subject really bothers me. Fine, hold people accountable, but help them to prevent illness then. THEN, if they are non-compliant, you can say, we tried to help them in every way, NOW we are dropping them.

Mijourney · Jul 14, 2001

Hi Hoolahan. I agree with you that a prevention program should provide the tools that help prevent. For instance in smoking cessation programs, I feel that every possible technique to help that person stop smoking without the benefit of medications should be used initially. Anytime we can reduce our dependence on synthetic medications is a plus for our bodies. This applies to weight reduction as well. I feel very strongly that nurses who specialize in home visitation are in a unique position to be a part of prevention programs. Being in a home and "seeing" may speak volumes to how an individual or family may be coping with lifestyle changes.

As indicated in your post I think that one of the major problems with insurance is that we take for granted that our insurance covers everything. I've had to learn the hard way that this is not true. So now I look at my insurance policy every now and then. I made the choice to purchase it so I guess I'm primarily responsible for knowing what's in it.