By Anne Llewellyn, RN.C, BHSA, CCM, CRRN, Editor in Chief
Question of the Week: Have we really come so far? After you review the trends/issues addressed by Florence Nightingale (below), let me know your thoughts and comments on where we are today with the same issues/trends. Email me at allewellyn@dorlandhealth.com. I will post the responses in next week’s blog.
Florence Nightingale . . . a Woman Before Her Time
I recently read an article in the May 8th issue of Nursing Spectrum that talked about Florence Nightingale’s Legacy. I have always found Florence very interesting and continue to be amazed that so many of the ideas, trends and issues that we face today were realized during her time. Here are 10 trends that she tried to get others to address in the early 1800’s:
- The outcomes of healthcare should be monitored and reported in a systematic way.
- Noise, color, light and music can impact the success of patient care.
- Healthcare students should have a means to critique their leaders. (Nightingale initiated 360 Degree evaluations at the Nightingale School of Nursing for students to critique their leaders.)
- Statistics could be used by medical professionals to understand and make recommendations in areas we now call utilization review and resource allocation.
- Systems should be developed to determine the cost and outcome analysis of healthcare. (Nightingale did design early systems to accomplish this.)
- It is the nurse’s role to help people maintain their health, as well as to help them get well when they are sick.
- Graduates of the Nightingale School of Nursing were encouraged to keep in touch and network with each other — even though they were spread around the world.
- Delegation is important. Nurses should not feel they have to do everything themselves 24/7.
- Systems of total patient care, not just care of the body, should be implemented.
- When planning for a new healthcare institution, research should first be conducted to understand the geographic population and potential patient needs of the region to be served. (When asked to consult on where London’s new St. Thomas Hospital should be built, Nightingale gathered and analyzed data on the geographic origin of the hospital’s patients.)
Source: Nursing Spectrum, May 8, 2006 Edition. Click here to learn more.
Does it have to be a WAR?
Recently, my husband brought to my attention an article in the May 22, 2006 issue of Business Week. The article intrigued me as I had just given a talk for the New England Chapter of C MSA Hospital Case Managers to share the patient’s experience with today’s healthcare system. The title of my talk was “Improving Patient Centered Care through Effective Case Management.” During my research for the program, I was dismayed to learn about the problems that patients and family continue to face when utilizing the healthcare system. In addition, the lack of information regarding the benefit that case managers provide to patients with catastrophic or chronic medical/surgical conditions was far and few between. So it was with trepidation that I read the article in Business Week: “Waging War over Coverage . . . Lessons from a bruising battle with a health insurer” by Lauren Young.
Apparently, the article was spurred by the author, Ms Young, whose infant son required plastic surgery to remove a giant mole that covered 80% of his back. She recounts in the article how she had spent the last six months battling with her insurance carrier. She estimated that she spent over 200 hours, mostly during business hours, trying to get reimbursement for an $18,000 plastic surgeon’s fee. Along the way, many others, including her doctor, and several human resource staffers, became ensnared in the mess. In the end, there was a simple solution. Her question to the Readers of Business Week was why did she have to jump through so many hoops to find it??
As case managers, nurses, physicians and pharmacist involved in the health care system, why do patient’s and families continue to have to jump through these hoops when navigating the health care system when we have so many systems in place that are suppose to decrease the fragmentation and red tape?
Take some time to think about your organization functions. Is it easy for you to get an answer regarding your own health care? When you call with questions regarding coverage, do you get accurate and helpful information that provide you with the information you need to file the claim or to assist your medical provider in getting a service/treatment/procedure covered? If not, do something about it so that your members don’t have to ‘wage a war over coverage’.
Ms. Young did learn something from her experience and did share this with her readers. To explain this to the readers of Business Week, she notes in her article: “What I’ve learned is that battling your insurance company is like waging a war. You need to attack from all fronts. Here are some tips that can help you. So for all of those in the field of Medical Management . . . here is the ammunition that consumers are going to use when waging war!”
Be an informed patient. You know that information packet that you get when you sign up for your insurance? Read it, especially the rules on what procedures and treatment need prior approval.
Get Organized. Compile a list of every important telephone numbers, with contacts at the doctors office, the insurance company, and your human resource department and keep it by the phone
Record the date and the name of the person that you talk to and take notes about your conversation.
Maintain a folder with insurance claims, filed by date, near the phone for easy reference. If you are dealing with multiple procedures, use an expandable file folder.
Bookmark your insurer’s web site, because most claims can be found online. Visit the site and monitor the status of your claim.
Create a paper trail. Make copies of diagnosis and prescriptions, and keep your records up to date.
Get copies of your doctor’s notes before you leave the office vs. waiting for the notes to be sent to your insurer.
If you write a letter, send copies of all correspondence to your employer’s head of Human Resources, as well as your employer and the person’s who handle claims in your doctors office. Also, set deadlines for the insurance company to respond.
Crafting an appeal. Know what the appeal process is at your insurance company before you get started. Appeals are like term papers: Do your own research. To be successful, you need to be able to document what you need with evidence. Provide information from medical journals to show that your treatment is cost effective.
Ask for a case manager to be assigned so that you have a point person at the insurance company. Make friends with this person who is responsible for dealing with your issues or disability. Many insurance companies who serve many companies typically have nurses who monitor employees, so get them on your side.
Schedule a teleconference between your doctor and your insurance company vs. going back and forth between all of the partiers.
Hire a patient advocate if you don’t have the time or energy to battle the bureaucracy. Some companies offer this service as an employee benefit. A company in the Philadelphia area, provides this service for $1.50-$5.00 per employee per month.
Don’t give up . . . about half of all health insurance appeals are resolved in favor of he consumer.
Click here to read the entire article.
Source: Business Week. May 22, 2006
Processing of Health Claims Speeds Payments, Cuts Costs
America’s Health Insurance Plans released a study reporting that most hospitals, doctors and pharmacies are now sending claims to insurers electronically. According to the group, 74 percent of claims are now electronic, up sharply from 43 percent a decade ago. This reflects the growing role of companies specializing in claims processing. Click here to read the report (PDF format).
Flu preparations to cost hospitals $5B
The University of Pittsburgh Center for Biosecurity estimates that the cost of planning for an influenza pandemic could be as high as $5 billion. The American Hospital Association is citing the number in its efforts to win more flu funding from Congress for its members. The AHA told the Senate Special Committee on Aging that a typically-sized 164 bed hospital should expect to spend at least $1 million on preparations. The $5 billion estimate does not include the cost of buying mechanical ventilators or antiviral drugs–the two things that most experts have argued are key for hospitals to have on hand if a pandemic does break out. Click here to read more.
HealthGrades highlights medical error issue
With hospital safety very much in the news, HealthGrades released its annual patient safety study yesterday. The report argues that patient safety remains a serious problem at many American hospitals, finding that medical errors rose significantly between 2000 and 2004. According to the company’s report, the most common patient safety incidents nationwide were:
- decubitus ulcers;
- post-operative sepsis; and
- failure to rescue or the the inability to save a hospitalized patient’s life when that patient has acquired a complication.
The report ranks New Jersey , New York , Nevada and Tennessee among the worst performers on the state level. Predictably, the Midwestern states did well, with Minnesota, Wisconsin, Iowa, Michigan, and Kansas ranking near the top for patient safety. Click here to read more.
Upcoming Conferences:
Case Management Society of American 16th Annual Conference & Expo
June 13-17th, 2006
Gaylord Texan Resort and Convention Center on Lake Grapevine, Dallas Texas
For more information, go to www.cmsa.org
The Remington Report’s Pay for Performance Conference: How to Achieve Collaborative Partnerships Across the Healthcare Delivery System
August 24-25, 2006
The Palmer House Hilton
Chicago, IL
For more information, go to www.remingtonreport.com
