The broken spirit of health care in America

In 1979 I took my first job as an inpatient psychiatric nurse. I left inpatient psychiatry in 2009 to become a psychiatric assessor. I decided to start a blog because of a conversation at lunch.

I am posting this writing a week late, but I will write again today and hopefully catch up.

The incredibly efficient, competent, sharp utilization review nurse sitting across from me at lunch was speaking a mile a minute, as usual. We share an office, but have different jobs, and I learn a lot about the money matters of healthcare from her. In spite of the snow on the ground, we were eating pineapple and oranges on our coconut shrimp salad, the specialty of the hospital chef to take us to the tropics in the midst of winter. And she said, “But the hospitals did used to defraud Medicare when it came to discharges to nursing homes.” As she was rushing on, she used the word defraud a few more times. I simply had to stop her. Now I am aware that the Medicare rule requires three days of acute hospital care before follow-up in a nursing home will be paid for by Medicare, but the term defraud was driving me crazy. In her explanation, since the three days were needed, doctors and hospitals who knew a patient could not go home for some reason, but wasn’t necessarily sick enough to warrant staying in the hospital, would get extra days “on Medicare’s tab” so that they could go to a nursing home on Medicare’s money. It was good for everybody, and she said Medicare used to have so much money they “didn’t care” that they were being defrauded.
No, and again I scream, NO! To defraud is to use falsehood to deprive someone of something of value. I am well aware that these days Medicare thinks it was deprived of the value of two days pay for a hospital stay as well as the obligation for nursing home care, but it has no right to look at the situation that way even though it tells utilization review to report that way.
The value that was to be provided by Medicare was care to the elderly. The hospital is the institution that was charged to do that job .The doctor is the judging professional. Of course Medicare has to have some guidelines, but they do not become expert in individual evaluations just because there is a question as to whether someone fits into the guidelines. It is the doctor’s decision whether or not to keep a patient. If the doctor declares the service is needed, it is defrauding the patient if someone overrules the doctor. It is easy for someone to look at a spread sheet of statistics and think they know what is going on, but they don’t. You must see people to know about people. This is the missing spirit of all the healthcare bedlam. They have forgotten how people are because they are so caught up in how insurance is.
Sometime in the 1980’s, we went from a charity model of money management for health care institutions to a business model. Charity is when money comes in, and the institution is then allowed to use it for the greater mission. Business is when someone outside the institution is directing the use of money down to the dime.
So my response to my co-worker was that Medicare had been set up knowing that at times doctors would make judgments that did not always save Medicare money, but since hospitals are set up to take care of social needs that government cannot really address, the extra money was considered an appropriate grant due to the overall work of the hospital. In the past, the honest judgment of the doctor was not considered defrauding. When the “business model” of health care (things like charging for every gauze pad used and individualized medicine packets for efficient charging) started overtaking the hospitals, those bigger global uses of money to care for the poor and allow special expenditures for unusually ill patients got pinched out, because the government decided it was going to parse its part to the dime. O.K., that is a figure of speech, they probably only really parse it to the dollar, but never-the-less, it was a change in the spirit of the law from the beginning of Medicare to now that makes smart, good working nurses think that what used to happen was fraud. It wasn’t fraud; it was care. People were supposed to be first, not money.
“I don't read no papers, and I don't listen to radios either. I know the world's been shaved by a drunken barber, and I don't have to read it.” Walter Brennan as The Colonel in “Meet John Doe” Directed by Frank Capra-1941.