The intricacies of health care: Part 1.

The time I accidentally dressed like a Park Ranger when I worked at the Assisted Living Facility (ALF), but my favorite resident, Michael*, still liked me enough to want to hold my hand.

I don’t claim to be a medical professional; I’m not a doctor or a nurse, and I don’t have any medical training. I’ve gotten really good at spelling out medical terminology phonetically and googling symptoms during meetings with those who are medically trained and love to toss impressive, seven-syllable words around over my head. I’m starting to recognize some terms now that I hear them on a more regular basis, and I’m also gaining a better understanding of how the health care system works.

Oftentimes the facilities take the blame from upset patients or their families when in reality their frustration should be pointed at the system, but that’s a lot more difficult to find a scape goat for. One example is when a patient is recovering at a Skilled Nursing Facility (SNF) and their insurance decides they’re not progressing or improving with the services there, and they will no longer be covered. The insurance company can access the SNF’s patient records any time, and can see notes from their physical, occupational, and speech therapy sessions, as well as any doctor or nursing notes.

This means that the facility must issue a Notice of Medicare Non-Coverage (NOMNC) (because nine times out of ten Medicare is covering at least some part of their stay at a SNF) notifying the patient that after 48 hours they will be paying out of pocket if they wish to remain at the SNF. Sometimes this spurs the patient into recovery and can motivate them to return home, but more times than not this leaves the patient in a bit of a lurch, even if they’ve been warned by a social worker that a NOMNC might be coming.

The average cost per day paying privately (not through insurance) to stay in a SNF in 2016 was $282, or $102,900 per year*. That’s not a cost that most can afford to pay, and if insurance cuts them off but they still need the level of assistance that only a SNF can provide, then the patient or their family has to pay out of pocket. The patient can appeal the NOMNC, which can buy them some more time, but if the insurance company overrides their appeal, they have to vacate the SNF. The tough part for the facility is that they’re the ones who have to navigate this whole process with the family, and that includes being the bearer of bad news if the NOMNC appeal fails and the patient must leave the SNF.

This is just one example of what I consider to be a breakdown in our health care system. I knew health care in America was flawed before I started this job, and that no system is perfect, but I guess I just never understood fully the effect that insurance has on a patient’s access to care. I’ve touched on the fact before that our home health care can’t work with certain patients due to the insurance they have, regardless of whether or not we’re the team they want to be seen by.

So, what’s the solution?

https://www.mcknights.com/news/report-average-annual-cost-of-skilled-nursing-care-breaks-100000-for-first-time/article/638336/