MANAGED CARE 101 AND THE COST OF NURSING

  1. HELLO NURSES...

    I AM WRITING THIS BECAUSE THERE ARE SO MANY NURSES THAT DON'T UNDERSTAND WHAT IS GOING ON...

    I AM A REGISTERED NURSE LICENSED IN THE COMMONWEALTH OF PENNSYLVANIA. HAVE BEEN A RN FOR 11 YEARS. I HAVE EXPERIENCE IN ER NURSING(6 YEARS) AND ALSO HAVE BEEN EMPLOYED BY A BLUECROSS/SHIELD AND A NATIONWIDE MANAGED CARE COMPANY (THESE 2 TOTAL 5 YEARS).

    HMO'S ARE NOT THE ONLY "BAD GUYS"...

    HERE'S THE WAY IT WORKS: EMPLOYERS PAY HMO'S, HMO'S PAY HOSPITALS, HOSPITALS PAY NURSES...

    HMO'S DON'T MAKE THE RULES...EMPLOYERS DETERMINE WHAT GETS PAID FOR-THEY PAY THE PREMIUMS AND DETERMINE WHAT PLAN TO BUY FROM THE HMO.

    THE HMO SIMPLY ENFORCES/ADMINISTERS THE PLAN...

    WHY DON'T MORE NURSES UNDERSTAND THIS???

    DON'T YOU ALL REALIZE THAT AFTER THE HMO/EMPLOYER GROUP PAYS THE HOSPITAL THE HOSPITAL IN TURN PAYS THE NURSES?

    THIS IS WHY NURSES ARE PAID WHAT THEY ARE PAID- HOSPITALS SEE NURSING AS ANOTHER "COST" OR "EXPENSE"....CUTTING BACK ON THIS "EXPENSE" WILL INCREASE REVENUE...

    ASK YOURSELF THIS QUESTION: WHO PAYS THE BULK OF MY INSURANCE PREMIUM?
    THEN ASK: WHO REALLY DETERMINES WHAT MY HMO/INSURANCE PAYS FOR?

    IF YOU WORK FOR A HOSPITAL, I BET THAT YOUR EMPLOYER- NOT THE HMO, DETERMINES WHAT GETS PAID FOR!!!!

    [This message has been edited by nursedude (edited September 29, 1999).]
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  2. 10 Comments

  3. by   mirn
    You may have nursing skills, but you have sure proven to me that your communication skills are seriously lacking. So far, you are the most ignorant nurse I have read a posting from.
  4. by   nursedude
    you are breaking my heart...
  5. by   Heather27
    I gotta agree with MIRN on this one...
  6. by   Brian
    nursedude,

    I dont really understand why you start your first comment out with "HELLO IGNORANT NURSES"???? This is an offensive comment directed at all nurses. You have the right to your opinion (right or wrong), but please be respectful of others and more professional. When you signed up for this BB account you agreed to the following statement:

    "You agree, through your use of this service, that you will not use this BB to post any material which is knowingly false and/or defamatory, inaccurate, abusive, vulgar, hateful, harassing, obscene, profane, sexually oriented, threatening, invasive of a person's privacy, or otherwise violative of any law. "

    Please keep the postings professional.

    Thanks


    ------------------
    Brian Short
    WORLDWIDE NURSE: The Internet's Nursing Directory
    wwnurse.com/

  7. by   MollyJ
    Yo, nursedude. I am reading you to say that insurances are not the "bad guys", hospitals are because hospitals underpay the nurses. I gather that you are maybe doing some case management for an insurance person, or some such perhaps? I am trying to clarify your main points, and have come to the discussion a little late. Sorry, this ole nurse (and former government insurance related case manager) will not be awarding haloes to hospitals or insurance companies or docs or patients or anyone. (Nurses don't make the list because we have rarely been players, more often pawns.) I think our health care system is in the shape that it is in because of a systemic lack of self-awareness. We as consumers have a "want it all" attitude. Sooner or later, we will have to define what we really want and then we will have to pay the piper. Insurance agencies are making nice profits and I have heard many stats about how insurance execs are seeing some of the nicest wages in health care industry. I think the insurance industry has done alot to encourage accountability in the hc industry but they need to realize that sometimes they are practicing medicine on people they've never even really met and that is tricky (like when a doc pleads with a psych admissions person for a hospitalization for a suicidal patient & is refused and told, "We don't loose too many people with this criteria and so we are stickin' to 'em.") Some docs are greedy and do procedures to make bucks; many just try to good care and CYA care and try to make a little money, which is, by the way, supposed to be the idea in capitalism. Hospitals are tap dancing, trying to make money and serve people, but the medicaid and medicare under-reimbursement that is happening will likely be precipitating the ultimate, soul searching crisis. With medicaid and medicare [way]under [cost]-reimbursement and commercial insurances marginally reimbursing without any "extra" that used to cover indigent care, the real hard decisions, it would seem are looming.
    I think health care is a bowing, creaking system and I am not sure blaming ANY ONE person/group is helpful.
    Look to hear more clarification if I've missed the boat on this one...
  8. by   suellen e.
    I think we all are in the boat together trying to comprehend this one. We have different levels of understanding on managed care - I guess this is an indication of how complex and mystifying it is. What I've experienced in the family practice where I work answering medical questions for patients on the telephone (I'm a triage nurse) is that we recently cut back 150 staff hours per week. Personally, I work 4 hours less per week since the cut and have lost my medical and dental insurances. Yet, we continue to take on between 50-75 new patients weekly! Needless to say we are moving faster and working much harder to take care of more people with less staff! What is happening? If my employer were calling the shots, I doubt that this situation would have arisen. I think we are all facing the consequences of being accustomed to the very best health care in the world. USA's medical care is fantastic. People from all over the world want to come here for it, but....we know how immensely expensive it is. Having said that, it doesn't make sense to me that (I have read) there are insurance company CEOs who are earning $937 million a year! How can this be? It's perplexing.
  9. by   CHUBBY
    I can understand your frustration, but NOT your anger at the situation regarding health care in this country AND as the populace gets older (thank you BBA) and the number of the unisured full-time workers grow, it will only get worse. Based on your postings,you obviously take a very defensive stance regarding the HMO issue. Why? Do you feel the need to defend a corporate conglomerate that could buy,sell and bury us all in the blink of an eye. Save your strength. I am afraid, right or not, you are outnumbered by the general opinion of americans regarding HMO's. (Please refer to comment about CIGNA in another posting about the golfcourse/resort.)
    I agree that, as a rule, we are woefully ignorant of the particularities of insurances.My friend, who is a hospital case manager, said the insurance companies shift patients to other caseworkers, so that the caseworkers won't get too friendly or attached to the client...maybe becoming a little generous in approving costly treatments, you tell me?
  10. by   suellen e.
    A nurse who worked for a HMO in the prior authorization pharmacy told me he resigned because he couldn't handle the job ethically, any longer. If he liked a nurse or doctor who called him up to get medicine approval for a patient he would approve it, and otherwise if he didn't like the nurse or doctor. From what he said it was possible to justify a pharmacy decision either way. What do you make of this? Mismanagement? The HMO administration has gotten so large that it has gotten out of hand? The consumer is obviously suffering. How do we solve the problem?
  11. by   CHUBBY
    Oh, I almost forgot, if you look on the back of a Keystone/Mercy Insurance card, at the bottom in bold letters it says
    "Payor of last resort"...
  12. by   KatMcRN
    Reading these messages just enforces the fact that NONE of these entities - hospitals,HMO's,insurance companies,and most doctors - could survive without US!!!
    I only wish someday they would realize this.

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