I drained an abscess for a patient today. It was rather deep, and so I packed it, and ordered in visting nurse services over the weekend to change the dressing, irrigate and repack the wound, and was planning to see the patient again in a week to assess the healing process.
Well, turns out my patient’s insurance (a supposedly good PPO) declined to pay for visiting nurse services. When the patient asked the insurer “So what do I do to get the wound care I need?” their answer was “Go to the Emergency Room.”
Great post. Unfortunately, so true. I posted a link to your post and my own story like this at http://www.progress-notes-blog.blogspot.com.
Was there no family member willing (and teachable) to do the dressings over the weekend? I’m assuming the patient couldn’t reach it to do her own dressing changes.
RL- Turns out the patient had a nurse friend who is doing the wound care.
to rlbates:
that may seem reasonable to a doctor, but to non-physician or nurse patients and family members, pulling a packing, irrigating a wound and repacking it can be disturbing and frightening. I know, because I’ve done it, reluctantly, but only after watching a nurse, and then having a nurse watch and reassure me. If the patient is elderly (or just uncoordinated), it can be a mess and presents the danger of infection.
A patient and his/her family deserve health *care* coverage from their insurer, not a DIY kit. We shouldn’t be put in the position of having to refuse to provide medical care to our loved ones if we don’t feel comfortable with the tasks involved. Do it yourself or go to the emergency room is an untenable choice.
Sorry for the strong words, but even after 3 years, I still get the willies thinking about my father’s open harvest site.
I’m glad the patient had a friend to do it.
I am glad that the insurer feels that the ER is for primary care/home care. That is really unfortunate.
OK, so I am comfortable in the Devil’s advocate role here…
If denied, I would not hesitate to pay for this service myself. If the care is needed, you pay for it.
While this may be a big financial strain for many, how much could it possibly cost? We need to put things into perspective.
While I find the insurance company’s response totally irresponsible considering that they are now essentially fining patients that use the ER for non-emergency care (at least mine is…$50 for ER visit if an emergency, and $250 if not an emergency).
At some point we need to take care of ourselves. If that means spending money out of pocket, so be it.
This is an example of the health insurance industry. It would cost over $1,000 in the emergency room, while a nurse would probably cost much less than half that amount.
shruggling, your point of view stinks. no, people with insurance should not have to clean and pack their own wounds, or be fortunate enough to have a nurse friend.
good for you, having the option to pay for it yourself. a LOT of people don’t have that option.
my young-adult son is now uninsured, so i hope nothing bad happens to him. when he was insured, with kaiser, an ER visit cost a $100 co-pay. he was assaulted on the street, had a tooth knocked out, his mouth was torn badly, and he wouldn’t go to the ER until i took/dragged him the next day because he couldn’t afford the co-pay. he had no money for it. that was just his co-pay, and kaiser is on the cheap side.
i would argue that wound care is not optional, not elective, not cosmetic. there is nothing funny about sepsis or wound infections. shame on that PPO for denying this reasonable treatment!
it is unfortunately common for insurance companies to deny necessary treatment, hoping that the insured will not challenge the denial, but just pay out to avoid the hassle. tbatm, i hope your patient challenges them. and that her nurse friend submits a reasonable bill.
p.s. — my grandfather died of sepsis, or complications thereof, from bedsores. my father picked up MRSA in a surgical wound that would not heal properly. wound care is tough, and this insurance denial sucks.
Wound care is difficult at best. And visiting nurses are a God-send. I’m horrified to think that an insurer finds it more feasible to wait for hours in a GERMY ER for wound care, than a quick visit by the visiting nurse.
My father had an awful bed sore on his heel. The visiting nurse came 3x a week. She showed me how to handle everything on the off days. It was a phenominal service and quite an education for me.
Will socialized medicine (think Obama) make this better or worse?
i believe that basic health care is a basic human right. and that wound care is part of basic health care.
john donne said, “No man is an island, entire of itself; every man is a piece of the continent, a part of the main; if a clod be washed away by the sea, Europe is the less…any man’s death diminishes me, because I am involved in mankind…”
can’t we figure out a way to get this done?
kathy a.,
Clearly you missed my point. I don’t think that it was at all reasonable for the insurance company to deny the treatment, but I also don’t think the treatment is optional. Sorry to hear about your son’s attack (truly – I hope his recovery is going well), but if he needs to go into debt to ensure his proper recovery – so be it. His health is more important than not having the care.
I will continue to be provacative – does your son have expenses he can cut such as having a cell phone, cable, internet access, entertainment budget? These things can be and should be sacraficed first to ensure proper health care.
Ultimately my point is this – no one owes anyone anything. If you NEED it, then figure a way to deal with it. Does this situation totally stink? Yes, but that’s the way it is.
All-
Am loving this discussion.
Just so all are clear, the point fo my post was how ridiculous it us for an insurer to advise a pt to go to the er for non-emergent care, and (sorry if I did not make it clearer in the post) that they would PAY FOR THIS over VNS services, which are cheaper.
And to point out yet another reason why our emergency rooms are overcworded.
Another solution would have been for me to do the wound care for this patient over the weekend at my office, which I would have done if my patient’s friend had not offered to step in. Rest assured I would have NOT let her go to the ER.
my son’s mouth healed up fine. he is still missing a front tooth — his insurance covered only routine dental work, and he is very very reluctant to accept the thousands it would cost to get an implant.
the point i was trying to make is that even if people are lucky enough to have some insurance, they may still be unable to get the care they need because of copays and exclusions. my son was working full-time, living very frugally [in a shared apartment, located in a part of town where all the windows have bars, no car, no landline, etc.] — and the $100 was money he simply did not have, if he wanted to pay rent.
your position seems founded on an idea of personal responsibility. has my son made some choices that were less than ideal? sure. but he has shown a great deal of responsibility and worked very hard to support himself these past couple of years. when he decided to work and move out on his own instead of going to college, we closed the bank of mom and dad — and he has learned to live with that, and indeed embraced it. but, there’s no financial cushion for emergencies. he’s not the only person who works hard and cannot make ends meet when a crisis comes up.
sorry for wandering off on a tangent, tbtam. i’ve got issues with underinsurance.
and you’re right, it makes no sense for the ins. co. to deny a less expensive benefit and tell your patient to go to the ER.
When mon mari was in and out of the hospital this summer we had a visiting nurse every day for 2 1/2 weeks total… not serious, just a shot. Cost? 9.40 euroa a day… fully paid for.
The US system is so sad…
Not only would a visiting nurse service be cheaper…but I would rather an expert wound care nurse treat my wounds anyday.
Here’s a thought —
What if we all paid for our own health care? Without insurance companies in the middle, would services be less expensive? I’ve had catastrophic coverage for years (currently with some preventative benefits) and every time I pay my premium, I feel like I’m betting my insurance company that I will get sick, and they’re betting me I won’t. In a way, we both win if we’re right, but because I have been right, in 20-20 hindsight, I could also have banked that $40,000. (The cost of benefits I receive doesn’t come close the the amount I pay in premiums.)
I hate that family doctors (especially) don’t get paid enough, or that there isn’t enough incentive to become a family doctor, and I don’t mind paying for routine care. I would gladly pay my provider directly, especially if I weren’t paying prices inflated by the overhead necessary to bill my and every other patient’s insurance co. and wait 6 mo. for reimbursement.
Without an insurance policy that covered annual checkups, would people really not go to a doctor until they got very sick?
What am I missing? I feel like our society is at the mercy of insurance companies and that we need to change our way of thinking.
I agree with TBTAM that this was a ridiculous denial of coverage. But some of you need to go out and walk around the streets a bit and come back to reality. Let me ask you this, if your secretary came down with cancer, do you honestly think he or she could cover the co-pays, much less the entire cost of treatment? Could you? There are many people who you come into contact everyday that are making sacrafices to come up with the co-pays, or just can’t do it at all. Today I parked my car in a parking lot and walked 3 blocks to my doctors office because after I paid my $30 co-pay I have no money to pay $5 for parking in the lot at his office. If I needed a visiting home nurse I couldn’t afford her, and I have a job.
Hello,
As a ER nurse practitioner I would totally agree with TBTAM that this was a ridiculous recommendation. ER's are overcrowded, full of germs, expensive, and mostly understaffed. I actually do a lot of incision & drainage of wounds in the ER, but if the person has a primary care provider I call them and arrange for a follow up there, rather than back in the ER. VNS care allows a person to have an uncomfortable procedure done in their own, comfortable, generally germ-free environment, on their own time, and a fraction of the cost. The person who said that we need to "rethink" how we deliver care and insurance is correct; the insurers call all the shots at the moment. To the person who refers to Obama as the candidate who is going to "socialize" medicine, please point me in the direction of some proof of this statement.
Laurie Anderson, MSN, RNP
As a Home health service RN we run into issues like this all of the time. We have a first class wound care center in town that we work very closely with. We have a wound care patient whose insurance denied daily visit recently, thankfully the wound care doc took it upon herself to call the pts insurance company. She told the company if they wouldn’t cont to pay for daily visit she would be left with no other choice than to admit the pt to the hospital for care and then transfer the pt to a skilled facility for the care. Needless to say the company changed there tune and okayed the daily visit. FYI our agency charges $150.00 per hour for skilled nursing visits if you have no insurance coverage.