Toe Saga Enters Health Insurance Maze

toes
toes (Photo credit: ribarnica)

The first bill of sorts came today for my young not-so-invincible son for his recent torn off big toe (previous post). The letter is in reference to a $17 radiology charge from the emergency department of the university-affiliated hospital where he was seen. I assume this charge was for flipping the switch to warm up the X-ray machine, but it doesn’t specify what it was for.

The letter came from his student health insurance company. They are requesting documentation that my son’s missing toe was not a preexisting condition. Their specific wording: “Has (dearest son of mine) received any medical care or medicine for diagnosis code 729.5–pain in limb (for the three months preceding the X-ray)?”  Like what, he’s been running around for the past three months with his
toe in the refrigerator just waiting for his health insurance to kick in
so he can have his toe reattached?

Do U.S. health insurance companies purposefully hire stupid people so they can spend even more on administrative overhead and pass those charges on to us, the mostly overwhelmed and confused health care consumers? At least 15% of our country’s total healthcare expenditures is spent on this sort of inept health insurance administration. That’s over $360 billion annually just for paper pushing. Medicare’s administrative costs are less than 2% of total Medicare expenditures. Meaning: that paper pushing can be done a lot more efficiently.

As Jeffrey Pfeffer wrote in his Bloomberg Business Week News article (4-10-13), “Because insurers are paid a fixed percentage of the claims they administer, they have no incentive to hold down costs. Worse than that, they have no incentives to do their jobs with even a modicum of competence.”

A good overview of the obstacles to reducing administrative costs within our healthcare system is included in this brief NEJM article. The authors point out that Obamacare/ACA has some provisions to address these problems. Here’s hoping.

Young Invincible Health Insurance Saga

IMG_1227Last night I had to take my ‘young invincible’ son to a local emergency department to have his toe sewn back onto his body. He had heeded my advice to get back to the gym to exercise, and somehow combined ballet with karate and lost a big toe in the process. His ED physician said he’d never seen anything like it in his 33 years of practice. Oh so reassuring. Also unsettling was this physician mug shot on the vending machine in the ED waiting room. He glared at me all night as I tried in vain to figure out what he was doing there, what his message was. Don’t you dare drink these sugary drinks? You’d better have good health insurance if you want to be seen here? I have some bad news: we somehow lost your son’s toe?

Fortuitously (or so I hope), my son listened to me and signed up for student health insurance–the day before his ballet/karate accident. As a mom and a nurse it was taking years off my life to have him ‘going bare’/uninsured. I now know some of what it feels like to live in fear of an accident, injury, or illness that could ruin my son (and by extension, me) financially. Even though he officially has health insurance to cover his expensive ED visit (X-rays, sutures, IV Vancomycin, physician quips) and ortho follow-up, I do not trust it. There are pages upon pages of exclusions to his health insurance plan, including bungee-jumping and intercollegiate sports–neither of which would seem to apply to losing a toe in ballet/karate. But I know how crafty and devious health insurance companies can be in trying to deny medical claims. I would hope that the university where I am employed and teach (and where my son is now a student) would have a decent health insurance plan option for its students. I guess I’m about to find out.

Health Insurance: Good Luck

Insurance
Insurance (Photo credit: Christopher S. Penn)

If anyone ever questioned whether or not US healthcare is political, they should now be convinced that it is. What with the drama of Obamacare, that Texan Tea Partier/Green Eggs and Ham reading/White Castle hamburger loving/Obamacare hating Senator Cruz, and then the looming shutdown of the federal government.  Not to mention Vanderbilt Medical Center’s recent creative administrators’ cost-cutting move to require nursing staff to take over housekeeping duties, for which they invoked the ghost of Nightingale (yes, HER again!) as the rationale behind their decision. Oh Nightingale! Rise up and smite them with a mop!

And then there is the desperate, mostly behind-the-scenes scramble for state health exchanges to be up and working by this coming Tuesday, October 1, when they are all slated to open for business. As described in today’s NYT article, many state exchanges will most likely be delayed. I especially like the article’s photograph of a roomful of intensely-working computer programmers trying to fix things for Oregon’s health exchange. I wonder how many of those workers have health insurance, and if not, how many of them now understand how to shop for and purchase health insurance once the system they’re working on is functional. Many of them do not look healthy.

My son, age 26, recently aged out of my health insurance plan. He was able to stay on my plan thanks to that provision of Obamacare. For the past few months he has been one of the many ‘young invincibles‘ (or ‘young invisibles’ perhaps?) who has no health insurance. Of course, I bug him constantly about this and want him to be insured. He’s now in graduate school at the University of Washington and is now eligible to purchase their student health insurance plan. The annual fee for one student (including 2014 ACA fees/whatever that means) is $2,748. School started this week, the earliest he would qualify for the insurance. I just checked their website and it has a statement marked urgent: “due to a system error some students who registered for Autumn quarter have had their coverage cancelled.”

This is complex stuff. I have a doctorate in health policy, teach, live and breathe health policy, and I can’t figure it out. Our healthcare system, especially the health insurance scene, has always been complicated, but I’m convinced that this specific part of Obamacare is creating more problems than it solves. It adds layers of administrative complexity and a huge burden (time and frustration–heart attacks anyone?) on consumers to ‘shop and pick a plan.’ These add up to a substantial increase of costs and inefficiencies in our already overly costly, inefficient, ineffectual healthcare system.

The best (mostly fully functional that I’ve seen) interactive tool for consumers ‘explaining’ ACA/Obamacare in more or less vernacular (English and Spanish), is Consumer Report’s Healthlaw Helper. Good luck.

‘Obamacare’ Working for Young Adults

English: Barack Obama signing the Patient Prot...
English: Barack Obama signing the Patient Protection and Affordable Care Act at the White House (Photo credit: Wikipedia)

One of the provisions of the Affordable Care Act (ACA) that took effect in September 2010 allowed children/young adults to stay on their parent’s health insurance policies until their 26th birthday. The reason for this provision was that young adults ages 19-25 had the highest rates of being uninsured of any age group in the U.S.

For the past two springs in my health policy course I’ve asked students to raise their hands if they were now receiving health insurance under the ACA provision. This past spring about half of the students in this age range raised their hands. My own son who is in graduate school has been able to continue on my health insurance because of the ACA. Highly unscientific evidence for this part of the ACA working, but evidence nonetheless.

Now there is more objective evidence that the ACA is working for young adults. A NYT article today by Sabrina Tavernise “More Young Adults Have Health Insurance After Health Care Law, Study Says,” reports on data from a recent CDC/National Health Interview Survey. Lack of health insurance among young adults 19-25 fell from 33.9 percent in 2010 to 27.9 percent in 2011, translating into about 1.6 million fewer uninsured young adults. There was a corresponding increase in young adults having private insurance over the same time period, from 49.3 percent in the third quarter 2010 to 58.8 percent in the fourth quarter 2011. These positive changes for young adults were seen across different racial groups. Additional evidence that the ACA is working for young adults is that lack of insurance grew for adults ages 26-34.

As most everyone knows by now, young adults have been the hardest hit by the Great Recession. It is good to hear that something is going in their favor.

Dear Nursing Grads: Please go directly into Community/Public Health Nursing

First District Nurses in Melbourne
First District Nurses in Melbourne (Photo credit: Wikipedia)

That is, of course, if you are at all interested in this type of nursing work. Please do not believe anyone (and especially not your nursing professors who have probably not worked as a nurse anywhere since the 1970s) if they tell you to first work as a nurse in a hospital to “get experience.” That simply is not true. People can and do hire new grads for community/public health nursing. Hiring decisions for these sorts of jobs have more to do with the individual applicant—with his or her personality traits (flexibility, patience, humor among others), understanding of (or interest in learning about) community resources, passion for patient/community education and empowerment, and a personal value placed on prevention vs. costly curative/acute care. In your resume and interview remember to include any relevant work (including volunteer or service-learning before or during nursing school) experience in health and social service provision in the community. Do your homework before an interview—including making sure you understand important terms used in the job description. For instance, “harm reduction” does not mean sitting close to a door to escape from a potentially volatile patient…

Non-hospital places to consider when job-hunting: public health departments, community health clinics, nurse-managed community clinics, Health Care for the Homeless clinics, migrant health clinics, Indian Health Service clinics, home care/hospice agencies, nursing homes/long-term care facilities, school-based clinics (and school nursing in general), and occupational health clinics (including perhaps jail/corrections health care?). Similar to hospital residency programs for new nursing grads, some health departments and community clinics are piloting paid internships for new grads/new hires. Health departments in Wisconsin and North Carolina have examples of these.

And despite setbacks/job losses brought on by the recent Recession, health departments and community health programs are hiring nurses. And if the Affordable Care Act survives the caprices of the US Supreme Court, health care reform promises to bring a substantial increase in public health/community nursing jobs—or as the Future of Nursing IOM report states, it promises “to return the profession (of nursing) to its roots in the public health movement of the early 20th Century.” (pg 24).

If you are wondering whether going directly into public/community health nursing after graduation precludes you from ever getting a hospital job in the future—that is not the case either. Especially now with hospital systems’ focus on health care transitions, patient education, and patient care management/coordination, having had previous experience in public/community health nursing is an advantage. Hospital units always do additional training for any/all new hires anyway, so you can get back up to speed on the relevant patient care equipment, meds, etc.

Meanwhile, how to find jobs in public health/community health nursing? Like with any job search, working your personal contacts is important. Ask your community/public health nursing professor or clinical instructor (a fair number of students asked me–hence this blog post response). In the Pacific Northwest, here are places I recommend looking for jobs:

University of Washington School of Public Health online Job Postings (search with ‘nursing’ and there currently are six listings, including some cool-sounding Public Health Nursing jobs in Eugene, Oregon).

Public Health—Seattle and King County online Job Postings (some amazing ones currently for the Nurse Family Partnership among others—and yes, they do and have hired new grads).

Washington Association of Community and Migrant Health Centers online Job Postings.

And–thank you Paula for these suggested sites:

Washington State Public Health Association “New Job Opportunities” online postings

American Public Health Association online careers search (this one requires you to create an account but you don’t have to be/become an APHA member to do so. You can then upload/post your resume if you want–is easy to use and a relatively sophisticated job search system.)

Happy job hunting!

~p.s. For those of you who would love to go right into public/community health nursing but find yourselves in a hospital or other setting instead–don’t despair of ever being able to transition back into the community. Just try to find opportunities to volunteer in a community setting, doing health/social services sort of work. That will help you build your resume and skills for making the transition back out of acute care.

No More Free (drug) Lunches or Pens

As part of the Affordable Care Act (ACA) health care reform, drug companies will soon be required to report payments and free lunches/dinners/cruises/vacations/gifts to physicians or payments to teaching hospitals. It includes any free ‘educational’ service for physicians or teaching hospitals. This is section 6002 of the ACA and is known as the Physician Payment Sunshine Act (sunshine, as in shedding light on or transparency). As part of the mandatory reporting, individual physicians and hospitals will be named, along with what items of monetary value they received and by which companies. This information will be publically available and easily searchable. Companies will be assessed hefty fines of up to $1 million for failing to report the information. This Sunshine Act was supposed to have already been implemented, but has been delayed while government officials at the Centers for Medicaid and Medicare sift through public comment and iron out final details.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!