Insurance never used to play such a large role in health care. However, now it’s a principle topic and one of the most regulated parts of health care. That begs the question: is healthcare patient or insurance driven?
Insurance Companies – Patient or Insurance Driven?
Insurance companies have guidelines which dictate how long a patient can be in the hospital. For example, if you went in for an appendectomy, the insurance company may allow four days for your recovery.
If the doctor feels you need to stay in the hospital longer, he then fights with the insurance company to approve an extended stay. Case managers, at the hospital, also work with the doctors and the insurance companies.
I cannot tell you how often you may have a case manager call the office and want to speak to the doctor. Part of their job was making sure the physician met the insurance guidelines. If a patient remained longer in the hospital and the insurance did not give their consent, then they would not pay the hospital. They would then call the doctor and complain for not complying with the guidelines.
In addition, many patients are discharged according to insurance guidelines and end up returning to the hospital in one to three days.
These same patients come to the emergency room and end up being readmitted. In the end, the cost to the insurance companies double as the second admission is longer than the first admission.
Emergency Rooms
Another trend I have noticed is that the emergency room turns many people away as not needing hospital admission. I have seen where these same people come back to the emergency room two to three times before they are admitted to the hospital.
The inconvenience and the long wait in emergency room are a hardship when one does not feel well. When someone is very sick, they do not need to spend six hours or more sitting in the emergency room and then doing that two to three more times.
Have you noticed that many patients go from the hospital bed to a rehabilitation center? Does this not cost insurance more money? If they allowed them to stay in the hospital a few days longer, then they may not always need the rehabilitation admission.
Most rehabilitation centers have come into existence over the last seven years or so. Have you noticed that what they once called nursing homes have added ” rehabilitation center” to their signs and their listing in the telephone books?
I have personal experience viewing rehabilitation centers and there is no difference, from what I can see. Some will designate a wing of their facility for people who are there for rehabilitation.. Others will designate part of a floor for their rehab patients.
Insurance again drives the therapy that a patient will receive. Each insurance has their own guidelines but they allow so many weeks for your rehab, depending on what your diagnosis is. They do not base it on your progress or if you still need the therapy.
Insurance Placement – Patient or Insurance Driven? Definitely Insurance.
Insurance will also dictate, sometimes, what rehabilitation center you go to.
The family works with the nurse who handles placement. The family is able to ask for their own preferences of where they wish their loved one to go. If they do not accept the patient at the first two rehabilitation centers contacted, then the patient will go to whatever facility has a bed open for them.
This can mean placement out of the area where the patient and their families live. It could also mean being placed in a facility that does not meet the standards of the family.
Once placed in a center, getting placement elsewhere is hard. Furthermore, if the family wants to take the patient out of that facility and the doctor doesn’t agree… Then insurance might not pay anything toward the time the patient stayed there. This bill would go to the patient.
Once in the rehabilitation center, the therapy that the patient needs, be it physical therapy, occupational therapy or speech therapy will be dictated by the insurance you have. Some insurance companies will pay for one hour every day of therapy. Other insurances will pay for a half hour. Some insurances pay for so many times a week of therapy. This has the potential to delay returning to the home setting.
Conclusions
So, in my opinion, insurance has too much say in how long we stay in a hospital, how long we get the therapies needed and even, sometimes, where we go.
As the new healthcare has taken over in this country, insurance has become the principle figure. This sometimes results in a lose of the best interest of the sick individual.
Sadly, our answer to ‘is healthcare patient or insurance driven?’ is clearly the latter. I hope with new healthcare laws and a diffusing of insurances, we can return to a more patient-centric structure for healthcare sometime in the future.
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