Indigent patient - differences in medical treatment

I am a master's degree student currently doing a paper on indigent patient care. I am wondering if all facilities and physicans are the same. I have been irritated many times to note that the level of care and diagnostic testing differs between patients who are insured vs. those who are not. Just today I listened to the head of anesthesia state that he wasn't providing an epidural to a medicaid pt. because he wasn't paying a CRNA $85.00/hr to "watch a freebie" when they would only be reimbursed $60.00. I am a nurse manager for a post-surgical and pediatric unit at a small (100) bed facility. We serve many medicaid and private pay patients and it greatly upsets me to see patients who are treated differently based on their ability to pay. What is your opinion? And have you noticed the same at your facility? Thanks for your help.

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[bunky, BSN, RN]

Hi TBolt. No where I am, the majority of my patients are medicaid and some of it amazes me. It's as though the doctors know that the gov't is at least going to cough up some money for it so we keep them a LONG time, each week highlighting a new health problem, and if they are ETOH abusers and they get DT's we even have 1:1's assigned for extended periods of time. I was actually assualted by one old guy who lived in a broken down car in a junk yard on New Year's Eve, right at the stroke of 12. Just send yours our way and we'll cure ALL their problems whether they like it or not!

[MollyJ]

Tbolt, you ask some interesting questions and I am sure not posting to claim I have answers. The dilemma we face in America is that we (as a health care system) can provided large to unlimited amounts of care, but we can only pay for a limited amount. The grotesque inequities will not be ironed out UNTIL we decide what level of care ALL people are entitled to and there is a whole lot of tap dancing going on to avoid answering that one.

The dilemma that M/caid places medical and hospital providers in is that there is some reimbursement that comes with services, but not enough to pay the "lightbill" ie overhead and no profit oriented organization (and hospitals are inspite of their non-profit label) can afford to give away unlimited amounts of care. I have heard in our neck of the woods that some commercial insurances are not reimbursing BELOW m/caid levels.

As do nurses, all HCP's want to be paid a fair wage for what they do. Only problems, no solutions.

[Barbara Rose]

Can I add my story to your list? My father had a stroke the day after he was fired from his job at the age of 61. Of course, that left him with no insurance, etc. I was horrified at the care he was receiving until I arrived (he was in ca., me in texas). Once they found out I was a nurse, this changed and they found out from me when the nurse opened up his heparin drip and ran it in to get the blood out of the tubing. Up to that point, he had had no therapy, no assistance with meals (he would lean his head down to the plate and scrape it into his mouth!)and was about to be discharged when I arrived. After standing in line at the welfare office for 7 hrs. because I spoke english, the ss office for 2 hrs, and the employment office to sign up for state disability for 4 hrs, I called my congressman! The very next day, my father received therapy, stayed in the hospital for additional services and treatment for another week, etc., etc. That is not right and yet I too see it happen frequently. Health care in this country is out of control.

[hollykate]

TBolt,

This is upsetting to hear/read. Do you work for a private hospital? I work for the state hospital, which is also the regional referral center and the level one trauma center for most of the state. When I was in the ED, I never once heard any ED attending say anything about a pt's insurance, and only heard the psych MD's complain when they could not admit a pt due to some sort of HMO type thing.

Now that I am upstairs in the ICU we see a lot of transfers of ill people from nearby institutions: these people, they say, "failed the wallet check- no insurance card..." like Bunky said, we will try to fix all their ills, even if they don't want their ills fixed. Perhaps it's because I'm not at a private institution- our attendings and residents are paid by the state, not the patient- so supposedly they get what they need.(when the residents aren't so exhausted they can think straight.

Barbara Rose, so sorry to hear about your Dad, health care surely is messed up.

[jeani]

tbolt--yes sad to say, a reply to tpn request from a pt's spouse/myself for an end stage ca pt from a physican "you have run out of tribal funds. i'm not going to start a $300/day iv nutrition on a dying pt. you need to apply for medicaid. you have a huge bill at my clinic" reported this incident to my supervisors after getting no apology or anywhere else with that doc. seems to have been just swept under the rug. evenif he didn't see any benefit to tpn, i felt his response was tasteless and crude. too bad he's the only oncologist in this rural area. if there were a little competition, he may have to actually improve his bedside tact.

[ktwlpn, LPN]

Originally posted by jeani:

tbolt--yes sad to say, a reply to tpn request from a pt's spouse/myself for an end stage ca pt from a physican "you have run out of tribal funds. i'm not going to start a $300/day iv nutrition on a dying pt. you need to apply for medicaid. you have a huge bill at my clinic" reported this incident to my supervisors after getting no apology or anywhere else with that doc. seems to have been just swept under the rug. evenif he didn't see any benefit to tpn, i felt his response was tasteless and crude. too bad he's the only oncologist in this rural area. if there were a little competition, he may have to actually improve his bedside tact.

I agree that this response was tasteless and crude-but I agree with what the doc stated.I believe that giving this type of care in a hopeless situation is a big part of what is wrong with the health care system...how long should we keep pouring dollars down black holes? Call me a communist-and maybe someday I will be a "black hole" with no hope for recovery and have to accept the cutoff of all my funding-except for hospice care..How many times do we treat sepsis in a pt in a persistent vegetative state? Or in a 95 yr old with advance directives stating no artificial feeding? Where do we draw the line?

How do we encourage society to accept that death is a part of life-and quality is more important than quantity?

[TracyRN]

I'm from Sebring, Fl and about 85% of our pts are medicare/medicaide or self-pay. You know this time of year we have so many illegal aliens... The good news is that I can't say that I've seen those without insurance being treated differently. The worst I've heard is the MD muttering as an aside that he won't see a penny for the services provided. I've yet to come across anyone being rude to the patient but I wouldn't be surprised if its happened. I can only say that its not the norm.

[JennieBSN]

BarbaraRose--I am so disappointed and angry at the treatment your father rec'd. Where I live and work, we also have a lot of medicaid/illegal aliens, but I have NEVER witnessed the kind of discrimination and abuse (which is what it IS) that you're describing!! How the patient is paying is never an issue unless they want to have their tubes tied (I'm an OB nurse) because of the paper work necessary. I can't imagine giving any of my patients less than the best care I can give simply because they cannot pay. Some of the docs here may make snide comments, but their care is always compassionate and excellent.

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