I am an RN who works in a Pediatric ICU, so I see first hand the internal workings of our healthcare system. I work as what is known as a traveling nurse. I work in a location for 13 weeks and then move on to a new location, so I also have experience in more than one area of the country as well as different types of hospitals. I have worked at Duke University and also at the county hospital in Phoenix, AZ. Currently, I work at a hospital just outside Washington, DC. Throughout all these experiences, I have gained pretty strong opinions about what is wrong with the system and what it will take to fix it.
First, what I believe to be wrong with the system. In a nutshell: insurance companies, including government programs. Actually, the medicare/medicaid system is probably the biggest offender here. Every hospital I’ve ever worked at has had to have a number of people on staff whose full-time job it was to “deal with” insurance issues. I am not referring to the accounting and billing people, these are clinical people (nurses, social workers, etc), who spend their entire day talking to insurance companies about why a patient is still in the hospital, why they’re still in ICU, etc. We have insurance adjusters picking apart the patients medical condition and attempting to micro-manage their medical care. On a daily basis, the nurses and physicians involved in the patients care are asked to explain and justify why we’re doing what we’re doing. I understand the need for accountability, however, when physicians are spending a couple of hours everyday justifying their actions to an insurance adjuster, how are they compensated for this time? Further, how can a nurse provide appropriate care when they know that every action is going to be torn apart for billing purposes? People often wonder why a visit to the doctor costs hundreds of dollars yet they only see the doctor for 5-10 minutes. Because that 5-10 minute visit results in 1-2 hours of additional work for the doctor, the nurses and the office staff. Some of this time is due to legal paperwork having to do with licensing requirements in the sense of “we may need to defend a complaint over this visit to keep my license”. Even greater is making sure paperwork is in order enough to withstand being torn apart by an attorney in a malpractice suit, justified or not. I have experienced this same problem in my own family. When I made the decision to step down from a staff position as a nurse and begin to travel, it resulted in a change in employer, hence a change in insurance. My 3 year old son is on a couple of different medications for severe allergies. We were unable to keep him on his established medicines because the insurance would not pay for one until another, cheaper, alternative had been tried. Of course, we had already done this previously, but this documentation wasn’t good enough. He had to spend 3 months in agony ‘trying’ this other medication because the insurance would not pay for the one that we had already established worked for him. In speaking with the insurance company myself, I asked the adjuster I was speaking to (who had the power to approve the correct medication) what type of college degree she held. I was shocked to learn that she had no degree at all. I have since asked this question anytime I have had to deal with an insurance company professionally and found that commonly, the people at insurance companies deciding whether to approve or deny coverage either have no degree at all or have a degree in business or accounting. In my opinion, these people are making medical decisions with no medical training whatsoever. My question regarding insurance companies is this: Why should someone with no medical training or background at all decide what medical care someone should receive? We have people with no more than a high school education second guessing medical specialists in their care of their patients. Does this make any sense at all? I have witnessed this and can tell many more stories in great detail if you would be interested in listening.
I work in an ICU where split-second life or death decisions are made. i.e. the patient is dying and we must save them…do something in the next 15 seconds or they are dead. If you have ever watched an episode of ER when they are scrambling to save someone and doing many things very quickly, remember that all those actions must be documented to defend against an insurance company’s examination days later, calmly sitting at a desk somewhere with all the time in the world to sit and think. Worse yet, to defend against a lawsuit up to 10 years later being microscopically examined by attorneys with all the time in the world. I am sure you have seen episodes of different attorney shows where the attorneys are dissecting a physician’s action on the witness stand. Keep in mind the statute of limitations for malpractice suits is 10 years, longer if the patient is a child. They have until they turn 28 to file a suit. We as healthcare professionals always must keep in mind as we do our “charting” that we must write enough information so we can confidently defend our actions 10 or 20 years and hundreds to thousands of patients later. I make a point of remembering my patient’s names while I am caring for them, but I am just not good enough to remember them all by name forever. Even a few months later, I am sorry to say I remember them better by their medical course than by name. Therefore, in addition to changes in how insurance operates, the court system as relates to malpractice must be changed. You do realize that malpractice insurance costs more for physicians than a lot of people make in a year? For physicians that I work with, their malpractice insurance costs up to $100,000/year. This money must come out of their billing rates. Hence another reason why your 5-10 minute visit costs hundreds of dollars. People tend to think of doctors as rich. Nothing could be further from the truth. Yes, they make a good living, but they literally make life and death decisions on a daily basis. Remember, I work in a Pediatric ICU, so if your child were critically ill or injured, how much is it worth to you for the doctors and nurses who save your child’s life? Thinking about it from that perspective, how much should they make? And keep in mind, the doctors to make quite a bit more than us nurses. Add to this equation that most of the doctor’s decisions are made based upon information they receive from the nurses and we get into a whole other argument regarding nursing salaries.
I could ramble on more and more about the problems, but it does not fix anything. Solutions are needed and I have a few thoughts in that area as well. You may think I would be in favor of nationalized healthcare. Actually, I think nationalized healthcare would be even worse than what we already have. As I stated earlier, the government programs are the worst offenders when it comes to what I call insurance meddling in medical care. They say no the most often and have no avenue to make a more detailed argument to attempt to prove the necessity of a needed treatment. Talk to anyone, especially someone in the medical field, who has emigrated from Canada and they will tell you how poor the healthcare is in Canada. Sure, everyone is covered and all healthcare is essentially free, but what level of healthcare do they have. I have worked with many nurses from Canada who have stated without reservation that the medical care provided in Canada is vastly inferior to that of the care here. The principle of free enterprise and competition improving the quality of a product applies in healthcare as much as it does anywhere else.
I sincerely feel and believe with all my being that the insurance industry as it exists is the very foundation of the problems in the healthcare system. How to fix that? Somehow create a system whereby decisions on coverage are made based on sound medical grounds, not financial considerations. Perhaps a law requiring physicians in the appropriate specialty making decisions regarding coverage and authorizations without regard to costs. Insurance companies always complain about the high cost of healthcare, yet they are the primary reason for it. Perhaps a standard form whereby the physician can state “this is the patients condition, this is what we need to do”, and then get a yes or no without multiple requests for more information. This would result in the physician performing much more efficiently, thus enabling the billing rate to be more reasonable. There are other ways to address this as well.
In combination with this must be some kind of reform of the malpractice laws. There are much too many frivolous lawsuits being filed and making it all the way to trial. There has to be a way to hold attorneys accountable for clogging the system with cases that should not even see the light of day. I have encountered respected attorneys who have medical personnel on their staff who research cases for merit before deciding to even take a case. The burden in medical malpractice is “acceptable medical practice”. This perhaps needs a more specific definition. Also, not to put a value on a life, but is “uncle john”, who dies at 85 due to complications after surgery really worth $100 million? This seems outrageous to me. The constitution states “a jury of peers” in criminal cases. Should a doctor or nurse in a malpractice case not be afforded the same protection? Perhaps a jury composed of doctors or nurses who actually have the training and experience to judge the actions taken in the case?
I do not claim to have all the answers to this problem, but I do feel I am extremely qualified to pinpoint the causes of the problem. I would be happy to answer any questions and/or discuss further with anyone who is interested in discussing this issue with an open mind. Bottom line is this: show me a government run program in ANY AREA that works, and I may rethink my position somewhat.
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