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
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.
mn nurse
35 Posts
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.