UnitedHealth paid nursing homes to reduce hospital transfers
theguardian.com
theguardian.com
At this point, it looks like criminal murder charges (seeking the death penalty) + federalizing the company would be minimal next steps towards fixing the problem.
Of course, that won't happen under the current administration.
That's not just near a the line. That's not just over the line. That's "absolute fucking evil" territory.
Somehow it always ends up as projection, and none of those same people will care about literal death panels.
Sometimes people are unable to vouch for themselves, or demand very invasive procedures. It's easy to claim that others deserve to have their demands met about procedures in the face of rational argument.
My parents have a DNR because they are both doctors and have spent too much time forcibly keeping people alive-ish because they were ordered to keep people on the edge of death alive, consuming incredible amounts of money, manpower, probable pain, and medication to keep someone barely alive for a week or two.
So many people are kept alive in arguably incredibly painful and shitty situations because of the inability to deal with the fact that sometimes people die
But marking somebody as having a DNR when they do not want one is evil.
Everyone can easily make a choice willingly to not file a DNR if they do not know what that requires. So now your grandmother is getting is a intubation tube shoved down their throat, chest compressions, and whatever and is not a state to figure out "wow this fucking sucks" anymore, also someone just collapsed your rib-cage giving you chest compressions.
Keep you alive at all costs is easy to agree to if you have no fucking clue what "all costs" mans
That's exactly the behavior you're defending.
Your implicit argument is that if the patient doesn't sign a DNR, and their family/HCP doesn't sign a DNR, that it is ethical for the medical system to do it anyway on their behalf. If you want to make that argument explicitly, go right ahead. But it's going to get rejected out of hand in a thread about the healthcare industry making such decisions out of expedience, and rightfully so.
You don't just pick up a POLST form at the grocery store. You have to get one from your doctor and go through it together. https://doh.wa.gov/public-health-provider-resources/emergenc... is the one in my state and it is very clear about exactly the things you mention. Full treatment is described as:
"Primary goal is prolonging life by ALL medically effective means. Use of intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Includes care described below. Transfer to hospital if indicated. Includes intensive care."
The care described below includes "IV medication access", "invasive airway management". It even includes "assisted nutrition", i.e. feeding tubes or ports.
It also requires a demonstration of comprehension of these choices by the patient, not just the HCP.
> someone just collapsed your rib-cage giving you chest compressions.
Frankly, while not pleasant, most people who walk out of a hospital post-arrest have recovered from this in days, and it is generally not particularly painful (because contrary to popular belief, you almost certainly haven't broken ribs, just separated some of the sternal cartilage around the xiphoid process - the little notch midline at your lowest non-floating ribs). There are far more important concerns.
I entirely agree with your parents about the level of effort, not to mention the unpleasantness, pain and suffering associated with fighting off a natural death.
But in the context of this article, we are specifically talking about the patients themselves, having coherently expressed a wish to be resuscitated were being pressured into signing DNR paperwork.
That's not the same thing as your situation, and I say that as someone who has had to coach hundreds of family members through end of life events, both expected and unexpected. I have done things like ordering continuing CPR on a patient who had no survival outcome expected, just because he was still minimally responsive and his spouse was almost there to say goodbye (he was bleeding internally and could not be stabilized for surgery). She got to squeeze his hand, and feel him squeeze hers back before we discontinued resuscitation and allowed him to pass. And I have done things like brought the "head of the family" into the resuscitation bay because he and the family were adamant in the face of all reality that "God was going to pull their father through" the cardiac arrest he was in. Though painful, it took him but a few minutes to grasp the reality, that all stops had been pulled out, but that we were at the end of the road. Following that, he was able to understand, ask us to discontinue, and be able to go back to the family and explain.
I was a paramedic (and before, an EMT) who has responded literally thousands of times to SNFs (skilled nursing facilities).
Dozens, if not hundreds of these calls were for the most trivial of concerns. A nurse told us at one facility that their policy was "anything larger than a bandaid, call 911", so we'd do "first aid" while two nurses stood by and watched us. I'm sure they (the facility) had motivations on liability, etc., but nonetheless, it was utterly galling that you'd leave such a facility and see big proud billboards or ads offering "24/7 nursing care!" - and knowing that they were certainly charging the patient or their family for a rate commensurate with that, potentially five digits a month, while offloading all their work to 911 and relying on skeleton crews of an LPN per floor supervising way too many CNAs.
They'd also routinely "forget" to fill out paperwork on ambulance necessity (Medicare, and many insurers, have paperwork to justify why the patient was not suitable for private vehicle or wheelchair van transport and instead needed a "fully equipped BLS/ALS ambulance"). It wasn't onerous, a single pager with a bunch of checkboxes, "Does the patient pose a fall risk?" "Need for oxygen?" "Unable to support themselves in a sitting position", etc. But we'd have to fight tooth and nail to get anything more than "patient name, DOB, and an illegible provider signature". Insurance would routinely reject payment, etc.
UHG involved in more of these shenanigans? Not surprised. They were slapped several years ago for denying HEMS (Heli EMS, aka "Life Flight") from severe MVA / trauma scenes due to lack of pre-authorization... ("This is John, I'm a paramedic working on one of your patients who was hit by a truck. We would like to fly him to the hospital due to his extensive multisystem trauma but we need your authorization. His name? Hang on, let me find his wallet. No, that's Smythe, S-M-Y-T-H-E, sorry, I know, it's a bit loud with the jaws of life in the background... Uhh, sure, I guess I can hold for a nurse consultation...")
Basically the road to hospitalization is paved with Vaseline and gingerbread cookies. In my experience, every effort is made at every level to unfailingly recommend a hospital visit at every opportune moment, regardless of the underlying medical necessities.
Surprisingly some of the most neutral situations I've encountered are 9-1-1 calls to my home. Being conscious and responsive, the EMTs will determine I'm stable, and then the $64,000 question: "Do You Want To Go To The Hospital?" and all you need to say is "no".
Once I visited a mini-clinic in a pharmacy. Not Urgent Care, no emergent condition, just a clinic visit with a nurse to check my BP. After reading my BP the nurse informed me she was duty-bound to contact 9-1-1. No fewer than seven extremely buff and very male EMTs poured into the tiny exam room and very insistently tried to induce me to go to the hospital with them. I became obstinate and told them that they were the only cause of my stress at that point. They finally dialed the attending physician and made me listen to him read off all my risk factors before they relented.
I've been at Urgent Care telemedicine visits and if I admit to the wrong symptom they will immediately shut down the call and refer me directly to E.R.
I was once signing admission papers to a BH hospital. I was conscious and responsive and arguably quite sane. The papers had a series of agreements which included one blanket consent to transfer me to any other facility they pleased. The ensuing argument and the occurrences within the BH facility led me to believe that this is a cash-cow kickback arrangement for them to funnel mentally ill patients into the "real" physical hospital with flimsy pretenses. Every medical-based exam I received seemed oriented to finding a reason to send me out there, but they would've discovered that I never granted them the consent to do so.
Often, I would say that LTC and palliative care facilities may not have staff equipped to determine necessity for going to the hospital. If they have an issue with a resident and they don't know what it is, or they're feeling over their head, they're going to just punt to 9-1-1 and let the hospital figure it out on their end, and you can be sure the hospital can find stuff in a patient population like that.
Every time I read about someone lamenting how medical "care" was denied by insurance, I simply consider how many medically unnecessary propositions have been placed before me, and I needed to be the voice of reason, to shut those down, before I was exploited and viewed as a cash cow to slip claims past the insurance company.
What happens out on the streets here is that someone has an oopsie, maybe they go unresponsive, or have massive pains or something, and some well-meaning dope contacts 9-1-1.
Then the EMTs show up and the circus begins, and inevitably the ambulance transports the patient and gets them to the E.R., post-haste dispatch.
When I broke my leg while roller skating, I was firmly expecting an ambulance ride. Thankfully I was in a large group of very sane and pragmatic individuals who said "just call a taxi!" It's not like I would die of a broken leg if the taxi took an extra 30 minutes! [Unfortunately, taxis do not like bodily fluids that soil their interiors.]
I once dipped into the hot tub where I live. Due to the pandemic, all our pool furniture had been disappeared, and so when I exited the hot tub, I just lay on the ground to bliss out and enjoy the relaxation. A neighbor immediately began shouting at me and brandished her phone to call 9-1-1. I told her to please cease and desist. Well-meaning citizens have a hair trigger on emergency services and it's exceedingly unnecessary. But your insurance doesn't need to pre-auth an EMT/ED circus.
Conversely, I had an urgent visit with my PCP once, and feebly attempted to describe symptoms. He shrugged. No testing, no diagnosis, no speculation. I can't do nothin' for ya, man. Two days later I was ambulanced to the E.R. with a kidney stone. And yet, no hospital was necessary. Nothing my PCP could've done for a kidney stone. 6 hours, let it pass. It was painful but it passed. All that medical care? Unnecessary. PCP? No reason to sue -- he did nothing wrong. He could've referred me to a CT scan -- for what reason? Let it pass. No lawsuits.
Karen Ann Quinlan's case had a poignancy that touched my heart. I had heard of Terri Schiavo, but Karen Q was before my time. Karen's parents weren't malicious -- they didn't want her to die -- they simply wanted to take away her pain. Physicians insisted that "pulling the plug" would be tantamount to murder! Her parents fought the state and the medical establishment, and ultimately, won for her nine years of life and peace.
Imagine yourself in their shoes. A patient says "I have chest pain". After you leave the clinic, they have a mountain of documentation they need to complete. How can they justify that you weren't having a heart attack, aortic dissection, etc - it is safer in their mind to just refer to ER. Not saying that is the right thing, it is just the world we live in.
> In my experience, every effort is made at every level to unfailingly recommend a hospital visit at every opportune moment, regardless of the underlying medical necessities.
> Being conscious and responsive, the EMTs will determine I'm stable, and then the $64,000 question: "Do You Want To Go To The Hospital?" and all you need to say is "no".
There are legal aspects to this. As a paramedic, I am not a physician. I don't have access to much in the way of diagnostic imaging (very few, but more, ambulances are getting ultrasound) nor do I have labs, nor did I go to medical school.
The question I asked (and taught the EMT and paramedic students I have taught) is "What do you want to see happen here today?". "Do you want to go to the hospital?" far more often is replied to with "I don't know, that's why I called, what do you think I should do?". Really, often the answer is more around "I want to know I'm not in any immediate danger". I can explain to the patient what we did and considered, and give them that perspective.
> Once I visited a mini-clinic in a pharmacy. Not Urgent Care, no emergent condition, just a clinic visit with a nurse to check my BP. After reading my BP the nurse informed me she was duty-bound to contact 9-1-1.
Hypotension without access to knowledge of your history of same can absolutely be a medical emergency. I love EMTs, but they also only have bare medical training (160-200 hours), and they are very much trained to "err on the side of caution" - the rationale is that it's better to send 10 people to hospital for heartburn than it is to advise the patient having upper abdominal pain to stay at home and see if they feel better the next day when they are actually having an undiagnosed MI.
> I've been at Urgent Care telemedicine visits and if I admit to the wrong symptom they will immediately shut down the call and refer me directly to E.R.
Telemedicine can't (really) see you, has only the grossest visual cues to assess sickness (in EMS, "sick" means needs a hospital, urgently, and "not sick" doesn't mean not sick, just less acute). If you say you're feeling weak or dizzy and they can't assess vitals, of course they're going to refer you somewhere that can do those things, and not just truck along with "oh well, let's do the best we can".
> I was once signing admission papers to a BH hospital. I was conscious and responsive and arguably quite sane. The papers had a series of agreements which included one blanket consent to transfer me to any other facility they pleased.
Hospitals are largely only set up for psychiatric stabilization (leaving aside for now your statement), and honestly, generally, pretty poorly. Varying facilities have different ability to cope with patients who may be psychotic, physically violent, or otherwise, symptoms that may not be immediately apparent. Note that regular hospital admission paperwork will also have blanket consent to transfer you to a facility better equipped to care for you if they cannot.
> Often, I would say that LTC and palliative care facilities may not have staff equipped to determine necessity for going to the hospital. If they have an issue with a resident and they don't know what it is, or they're feeling over their head, they're going to just punt to 9-1-1 and let the hospital figure it out on their end
Sadly, I absolutely and utterly agree with you on this statement. I have gone to far too many 911 calls where the chief complaint is "patient/caregiver personality conflict", not an acute medical issue. However I'd argue that the hospital isn't trying to "find something". They want you out of the ER and back home (even at its most cynical - you sitting in an ER bed while they run some tests but everyone knows there's no real issue, is a bed that can't be used for someone acutely ill, who will, for better or worse, generate more income).
> Every time I read about someone lamenting how medical "care" was denied by insurance, I simply consider how many medically unnecessary propositions have been placed before me, and I needed to be the voice of reason, to shut those down, before I was exploited and viewed as a cash cow to slip claims past the insurance company.
The issue with this is sometimes to make you be the voice of reason, and have autonomy. Like near the top of my reply, "Do I need to go to hospital?" "Well, I've assessed your heart rhythm. Your vitals look within normal limits. I've done X, Y, Z. That means [blah]. What I haven't done and I can't know is A B and C, and that can only be done at a hospital." and then I can say "In my opinion you need to be at a hospital, for these reasons", or "I don't see an immediate need. You can follow up with your PCP, urgent care, or you can absolutely call us back if things deteriorate."
Which all comes down to quality of care provided. The system is ... fucked. EMTs making barely minimum wage often running 24 or even 48 hour shifts... SNFs tend to (often, not always) attract the lower tier of nursing provider quality. And then we throw in health insurers (and it's not even insurance in almost any definition of the word[1]) and healthcare.
[1] By which I mean, map health insurance to auto insurance: Your car gets totaled. Your insurer says, "Hey, we're going to pay out $25K for your vehicle. You have a $1,000 deductible, so that's us down to $24,000, and then your copay for a total loss is $2,000, so that brings us to $22,000. For total losses, your coinsurance 'as your contribution for your vehicle coverage' is 20%, which is $5,000, so here's your check, $17,000. But that's only if you're buying a Hyundai, otherwise the vehicle is out of network and you'll get a check for $8,500 instead."