Insurance: The Urban Legend.

[Zizka]

Once you're in a facility you'll be treated the same as everybody else.

It's laughible to imagine that staff look at somebodies insurance and treat them any differently. I mean it's hard enough to get them to even know the patients name, let alone know what insurance the person is using.

Of course you might not actually get into a LONG TERM facility unless you have the correct insurance.

And sure I guess you might be diverted to some place else for ER treatment if you don't have any insurance. But that would stand to reason, even if it's just a matter of geography.

I wouldn't expect to receive the same type of health care in a developing country as I might in say a European country or within the USA.

[CritterLover, BSN, RN]

ita.

from my er perspective, insurance comes into play after eval & treatment in the following 3 ways:

1) if the pt. is to be admitted, our 6 groups of admitting docs rotate daily to take self-pay pts. if it's tuesday, then it's group a ...

2) pts. without prescription coverage, if they intend to fill prescriptions, often ask about the cost of meds and whether there is a less expensive alternative.

3) if the pt. has been involved in an mva they will be asked about auto insurance and about any info they may have gathered at the scene re: the auto insurance of the other party.

mlos, i completely agree with both of your posts on this thread. (i'm only quoting the above one because i can't quite figure out the multiple-quote function )

it really bothers me that every time someone gets substandard care, they assume it is becasue of the type of insurance they have, or that they don't have any. quite simply, there are bad physicians out there. they practice. they will be bad no matter what type of insurance one has.

i almost started a thread along these lines after reading the thread from the poster whose mother felt she had a bad experience in the er when seen for lady partsl bleeding.

to say that we don't know anything about pt's insurance coverage isn't true -- i often know what kind of insurance my patients have, and so do the doctors. that wasn't true when i worked in icu -- then i never cared, never bothered to look. but it does matter in the er at times.

the first reason i check insuranceis that i work in a state that has hmo-type medicaid. so, if you have our version of medicaid, then you are restricted as to what type of hospital you can be admitted to depending on who is administering the medicaid. that means that if a patient needs to be admitted, but is "out of network," then we have to find a bed at the appropriate hospital, just like with any patient with commercial insurance. the biggest difference that i find, is that patients with commerical insuance are more likely to go to the appropriate hospital to begin with, rather than the closest one. i work in a hospital that is dead center in a very poor part of town. many of the patients walk, or take the bus (if one is running), or are dropped off. they tend to come to the closest facility. i've also notice that they are often clueless as to what hospital they should be going to. we try to educate them about this, but education doesn't help if transportation is an issue.

so that is one reason why we tend to know about insurance coverage. a second is rx drug coverage. we don't dispense meds -- have no outpatient pharmacy. but, our docs do try to write for drugs the patient can afford. if they are self-pay and low income, there isn't any point in giving them a script for a zpack. they won't fill it, they can't. then they will just be back the next week, only maybe sicker. tussinex is another example. i don't know what the stuff costs, but i field more pharmacy calls related to tussinex than any other drug. insuance (at least tenncare) doesn't cover it, and no one can ever afford it. some of our "usual" docs will write for lortab and robitussin instead, knowing what the problem will be.

a couple of docs even use insurance/lack of insurance to decide whether or not to admit someone -- but not for the reasons traditionally thought. if the doc isn't sure if the pt needs admitted or not -- say the patient will be ok to go home if they get follow up care, but will get sicker if not attended to -- some of them will elect to admit the patient if the doc thinks the patient will have a hard time getting an appointment because of their lack of insurance. i had a doc admit at 20-something guy with abd pain/crohns disease one night, and i was really surprised, and said something like "your admitting him? really?" the doc just looked at me and said "he has no insurance. he'll never get seen by a gi doc if we don't admit him."

many of the horror stories i've read that talk about mistreatment in the er were before the time of emtala. so, as many of the hoops i jump through because of that "silly" law, i guess it wasn't so silly after all. and i'm not naive enough to think that there still arn't some instances where a patient gets substandard care due to insurance issues. but i just can't believe it is the norm, or even a little bit common. i do realize that my view is skewed since i work in a predomintaly uninsured/medicaid area, and we are used to dealing with it. and if we give substandard care to them today, they will be back next week, only sicker.

[CritterLover, BSN, RN]

i work at an upscale nursing home where the payors include a mixture of medicaid, private insurance, and cash. private rooms cost $6,900 monthly. semiprivate rooms cost $4,600 monthly.

i can state confidently that management and the administrators bend over backwards for the cash patients while not providing the same service for the medicaid patients. in addition, all of the nurses stations have updated census sheets that indicate the patient's form of payment.

it doesn't surprise me at all that things are different in ltc. there is no way medicaid is paying $4600 a month for those rooms. if they don't cater to the private pay patients, they'll lose them. and that is probably the only way they make any money.

[TinyNurse, RN]

I worked at a hospital in Houston, where as if you were not insured and couldn't pay on the spot you were sent to a "seperate part" of the ER. This was in 2005. Amazing.

[LydiaNN]

In my hospital it's the one with the insurance that gets the lowest length of stays because the insurance RN comes in and deems the patient stable and "we will no longer pay for any further stay, does not meet inpatient criteria", so the insured gets thrown out quicker.

Agreed. When my son was born, I had to share a room. My roommate, who had Medi-Cal, was in an abusive relationship and didn't want to go home. This I know because pre-HIPAA, the hospital social worker just came up and started talking to her, as if the curtain was somehow soundproof. She had already stayed 2 days longer than a typical C-section and on the day of our discharge, she was trying to maneuver an extra night's stay. I couldn't think of anything I would have liked less because I wanted to bring my child home, but it did strike me that if I had tried to get an extra night paid for, when it was clearly not medically indicated. my insurance (and it was fee for service, not an HMO as is so common now) would've told me to take a hike.

[CritterLover, BSN, RN]

i worked at a hospital in houston, where as if you were not insured and couldn't pay on the spot you were sent to a "seperate part" of the er. this was in 2005. amazing.

i wonder how they get away with this?

i'm trying to remember when emtala really went into effect (in a practical sense)

when i first started working in the er, the order of things was registration --> insurance info --> triage --> to the back (unless you were in distress).

shortly after that (maybe 6 mo?), it was changed to no insurance info asked/accepted until after the doctor had seen the patient. so registration --> triage --> to the back --> md visit --> insurance info. (as an aside, this really impacts that other ed aggrivation -- turn-around time. many days, if the doc is quick and the complaint is minor, i have the patient discharged long before registration has gotten their info. so they sit in a room, waiting for a clerk to come copy their cards. i can't give their dc instructions/rx's/work excuse, because if i do, the patient will leave....)

however, my understanding is that emtala states that the mse cannot be delayed due to insurance issues (gathering insurance info, lack of insurance). it doesn't state that the doctor has to see the patient before the insurance info is gathered. in theory, if the waiting room time is pretty long, the clerks could be out there gathering insurnace info while the patient waits to get called to the back, making things more efficient. but, at some point, someone would complain that it took them longer to get called back because they didn't have insurance, or becasue they didn't have "good" insurance. (rather than the delay being for the real reason -- they have had a pain in their big toe for 3 months and thought they needed to be "checked out") so, many hospitals have developed that kind of policy (no insurance info gathered before the mse is done) because it is the easiest way to prove that insurance issues did not delay care.

i would imagine that this hospital is arguing that asking about insurance/lack of insurance isn't delaying care. somehow i doubt that is going to work for long, it will probably eventually catch up with them.

[hope3456, ASN, RN]

Reading this thread infuriates me that insurance companies have so much power to dictate what kind of care people receive. Our politicians are 'in bed' with the big insurance companies and we the voters need to demand change.

I normally vote republican but this past november voted democrat only b/c they seemed more concerned about the problems facing uninsured working americans and are more apt to do something about it.

Oh, and the day after the election, when the democrats took the majority, the major insurance companies (Cigna, BCBS, ect) and the pharmaceutical companies stocks fell drastically in value!

[Roy Fokker, BSN, RN]

NO difference in care or accomodations where I am.

Ditto.

Might have something to do with the extensive roots amongst area Mennonite churches - or the 'not for profit' status of the establishment, but there are no differences at work.

cheers,

[UM Review RN, ASN, RN]

Agreed. When my son was born, I had to share a room. My roommate, who had Medi-Cal, was in an abusive relationship and didn't want to go home. This I know because pre-HIPAA, the hospital social worker just came up and started talking to her, as if the curtain was somehow soundproof. She had already stayed 2 days longer than a typical C-section and on the day of our discharge, she was trying to maneuver an extra night's stay. I couldn't think of anything I would have liked less because I wanted to bring my child home, but it did strike me that if I had tried to get an extra night paid for, when it was clearly not medically indicated. my insurance (and it was fee for service, not an HMO as is so common now) would've told me to take a hike.

But wouldn't the hospital be liable if she was D/C'd and then went home to a stated abusive situation if something happened to her or the baby? Doesn't the SW have a responsibility to DC the patient to a safe environment?

I would think she might've needed a shelter or somewhere safe to stay.

I had a patient once who was put in ICU due to an abusive relationship, to protect her from visitors and the abuser, who was somehow still at large. That had to cost some money, but don't you agree that those were appropriate actions, given the extraordinary circumstances?

[gonzo1, ASN, RN]

Our uninsured and medicaid pts get better care because the docs are afraid they will get sued for not taking "good enough care" of these pts if something happens to them. I want to drop my insurance and be uninsured so I would get better care.

[TheCommuter, BSN, RN]

Our uninsured and medicaid pts get better care because the docs are afraid they will get sued for not taking "good enough care" of these pts if something happens to them. I want to drop my insurance and be uninsured so I would get better care.

I've never quite thought of it in this manner before. Physicians are actually catering to their underinsured and uninsured patients out of the nagging fear of getting sued someday? Interesting.....

I can recall the well-publicized situation of a welfare mom on Medicaid who was giving birth in a Los Angeles area hospital a few years back. The laboring mom, who planned to deliver lady partslly, requested an epidural because she was in pain. The obstetrician and L&D nurses all refused because, as the mother claims, her payor was Medicaid. She sued the obstetrician, hospital, and several L&D nurses, and eventually won the case.

[Altra, BSN, RN]

But wouldn't the hospital be liable if she was D/C'd and then went home to a stated abusive situation if something happened to her or the baby? Doesn't the SW have a responsibility to DC the patient to a safe environment?

I would think she might've needed a shelter or somewhere safe to stay.

I had a patient once who was put in ICU due to an abusive relationship, to protect her from visitors and the abuser, who was somehow still at large. That had to cost some money, but don't you agree that those were appropriate actions, given the extraordinary circumstances?

I'm sorry but I have to disagree. The hospital and the social worker are not the magic cure ... they do not have the means (nor, IMO, the responsibility) to fix the patient's life situation. The SW is an important link to shelter info & other resources, but if every effort has been made to place the pt. & her baby in a shelter, but there are no available beds ... just how long can the hospital reasonably be expected to act as a shelter?

If SWs (or nurses, for that matter) were to be held liable for what happens to the pt. outside the hospital ... what would happen in the all-too-common scenario where a pt. denies, denies, denies that she is being abused ... even when we bend over backwards to offer shelter or other resources? Also, off the top of my head I can think of 3-4 ER frequent flyers who move from one abusive relationship to the next ... present to the ER w/injuries from an assault ... are placed in a shelter ... and have been evicted from multiple shelters for theft, drug use or other infractions. It reaches the point where placement is next to impossible.

And no, I don't agree that it was appropriate to place a non-critical pt. in a critical care bed - an ICU is not a shelter.

[LydiaNN]

But wouldn't the hospital be liable if she was D/C'd and then went home to a stated abusive situation if something happened to her or the baby? Doesn't the SW have a responsibility to DC the patient to a safe environment?

I would think she might've needed a shelter or somewhere safe to stay.

I had a patient once who was put in ICU due to an abusive relationship, to protect her from visitors and the abuser, who was somehow still at large. That had to cost some money, but don't you agree that those were appropriate actions, given the extraordinary circumstances?

I don't know what the SW's legal obligations would be in such a situation, but a hospital is not meant to be a shelter from domestic abuse. Perhaps she could've gotten hospital approval to keep Mom there on a very temporary basis based on having a newborn child, but sooner or later, someone (probably Medi-Cal) was bound to say WTH is going on here and why are we paying for this? The SW perhaps had an obligation to help this Mom find a safe place to go, but IMHO, the hospital had no obligation to actually be that haven.