The Ship of MAH, Silver Tsunami, Tugboat Insurance, and Rehospitalization
The Ship of MAH, Silver Tsunami, Tugboat Insurance, and Rehospitalization
Here’s a little story about the Ship of Modern American Healthcare, the Approach of the Gray Wave/Silver Tsunami, The Tugboats Insurance & Medicare, and Avoidable Rehospitalization. I hope you enjoy!
The Ship of Modern American Healthcare
Recall from a previous post: the Ship of Modern American Healthcare (MAH). The Ship of MAH is drifting rudderless off the coast, ravaged by Hurricane COVID-19, and scrambling to recover and repair the internal and external damage sustained in the last 3-5 decades. The passengers (patients) and crew (Healthcare workers/HCW) are doing their best, though many have departed on life rafts in recent years.
Amidst the recovery, scientists and observers have warned of an incoming Gray Wave/Silver Tsunami farther off-shore. The Gray Wave/Silver Tsunami is a controversial metaphor for the rapidly increasing older adult population in the United States. It’s a result of the aging “Baby Boom” generation (a surge of humans born during or after World War 2), who are leaving the workforce (“retiring”) while simultaneously becoming Healthcare consumers as their bodies require increasing amounts of maintenance and repair. The Silver Tsunami is headed directly for the struggling Ship of MAH.
Injecting my voice for a moment: [As a “middle-aged millennial”, I don’t claim to speak for this population (older adults), nor do I know the preferred nomenclature (“older adult”?). I can’t fully understand the experience of getting older at this point in history, but I maintain an open mind and heart, seeking to understand and (hopefully) be helpful. I stand witness to the stories I’ve been part of: working with aging patients and colleagues, surrounded by a sizeable extended family of parents, aunts, and uncles. Aging/disabling doesn’t look easy right now. We’ve got room for improvement. I shine this light using fiction and metaphor, and together, maybe we can identify our action items].
And back to the main trail: Experts have predicted an impending wave of workforce shortages as the Baby Boomer generation reaches retirement, and an influx of care consumers as their health and abilities change with time. The Silver Tsunami will hit the Ship of MAH first as it moves toward shore, then its landfall and subsequent flooding is anticipated to have tremendous impact on existing systems and infrastructure for multiple generations. The aftermath of the Silver Tsunami will ripple through the lives of our descendants. This situation demands close attention, boundless compassion, and immediate action from experts and layfolk.
Our mantra will be WAITT: We’re All In This Together.
Passengers & Crew
The Ship of MAH is stranded at-sea while the Silver Tsunami gains strength off-shore. Alone with no help in sight. Filled with struggling passengers and crew alike; injured, tired, and, frankly, feeling quite hopeless. The passengers (patients), especially the elderly and disabled, seem to be stuck in an endless loop between the Ship of MAH and home — always almost better enough to stay off the ship, yet consistently advised to return to the ship (“rehospitalized”) for problems across the severity spectrum. Chest pain? Go to the infirmary! Shortness of breath? Call an ambulance! A fall with injury? Seek emergency care, stat!
Meanwhile, the crew (Healthcare Workers/HCW) are trying their best to provide compassionate timely care to the passengers. They’re (we’re) responsible for assessing, diagnosing, treating, reassessing, documenting, monitoring for and predicting new or worsening conditions. All in addition to the regular care of human bodies like walking, transferring, bathing, grooming, feeding, and toileting the passengers who need increasing amounts of help with these tasks. The crew works long shifts, holidays, weekends, and on-call helping passengers transition between levels of care swiftly and efficiently. Home to hospital, to nursing home, to home, to doctor’s office, to home… The crew is accountable for every outcome, and no credit unless every move and decision is documented. Every finding, every abnormality — every breath and heartbeat — must be accounted for. Coded.
The consequences of failure are dire — literal life or death choices. A missed fever could result in a preventable infection and eventually sepsis, septic shock, or death. A passenger without the right amount of assistance could experience a catastrophic fall, leading to broken bones or internal bleeding. A body that’s left in bed and not moved enough (after a stroke or with multiple sclerosis) could develop pressure injuries/bedsores that never heal. Wounds that continually worsen until they reach the bone. All of these, in a Healthcare setting, are considered potentially avoidable harm.
In addition to the potentially avoidable harm (in every level of care across the continuum), the crew also runs the risk of being accused of negligence (failing to act) or assault (acting in a harmful way) by anyone onboard, depending on circumstances and documentation. We could be sued through our employer or personally, resulting in loss of a job, license, income, or personal freedom (jail). We could end up in jail for acting, or failing to act, in a Healthcare setting. These are real consequences to working in Healthcare.
All for trying to do an increasingly impossible job: caring for other humans. The most basic needs. Try as we might, we can’t ever seem to do enough. The crew are burning out and passengers just keep coming aboard.
The passengers and crew are humans. Caring, loving, compassionate humans hoping to not only survive, but thrive. We all want the best for each other, our planet, and our species. Nobody expected it to be like this, and we all find it alarming trying to navigate the highly nuanced rules and regulations surrounding the innerworkings of the Ship of MAH. Because, believe it or not, it’s not as simple as giving and receiving care. There are other watercraft in the area, like the Tugboats.
Help Indefinitely “En Route”
[For a bit more information on American Health Insurance, check out this Stanford article. It references the book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elizabeth Rosenthal. I’ve only read excerpts, but want to emphasize the importance of understanding our Health Insurance history and industry as we prepare for a better future.]
Along the coast, like a shiny row of decorative models, is a crew of rescue boats: The Tugboat (Private) Insurance and The Tugboat (Federal) Medicare. [Tugboats are like tow trucks for ships/boats — coming to the rescue in the event of damage or a breakdown]. This set of tugboats is beautifully decorated, with chromed details and immaculate coats of fresh paint. They appear well-maintained, the tanks are full of fuel, and crewmembers are well-fed. The Tugboats are tightly secured to the dock. From a distance, the Tugboats and those aboard appear to have weathered the COVID-19 Hurricane quite well.
Rumor has it, these Tugboats are heavily guarded from misuse by officials with thick rulebooks and suspecting glares.
Let’s take a closer look.
The Tugboat (Private) Insurance was built to provide assistance when illness or injury prevented people from working, and is usually tied to a person’s employment in the US. Its intention was to maintain financial security while promoting health and wellness for individuals and families during their working years. Basically, Tugboat Insurance exists so people don’t have to choose between their health or paying the bills.
The Tugboat (Federal) Medicare was developed to provide assistance to older adults or those with specific health conditions. Medicare is funded by working class American citizens (everybody), whose money is mandatorily removed from every paycheck and sent to the government. “Buying in” to Medicare is not optional, and everyone’s expectation is that Medicare will still be available when they “retire” in their early 60’s (the current standard).
Medicare was created in 1965, when the average life expectancy was around 70 years of age. The creators anticipated people would use it for a little over a decade and then, well, die. Fun fact: the current American life expectancy is about 80 years old. Advancements in technology, medicine and pharmacology have resulted in a longer lifespan than ever before in human history. The problem is: Medicare wasn’t built for the long-game — it is inefficient and resources are finite. It’s pretty, it’s fast, but it has a small fuel tank and limited reserves. Consumers could be on Medicare for 30+ years (with or without new or existing health conditions). And there are more people on Medicare now than ever.
Private Insurance and Medicare were well-intentioned. Neither are perfect. Both are outdated and fraught with inefficiencies.
Hot Take: The American health insurance industry is gumming up the works of human care. Rather than being an aid to the needy, it’s more like dead weight. Insurance is slowing us down, and its leaders are possibly causing more harm than good.
Mother Gets Off On Being Withholding
Lately, the Tugboats Insurance and Medicare have been rationing assistance to Healthcare consumers. The rules for insurance coverage are complicated, ever-changing, and require layers of workers across the Healthcare spectrum to interpret, implement policies within Healthcare organizations, and help staff follow the rules, all to ensure we receive maximum reimbursement. Insurance & Medicare only provide help if all the rules have been followed, and increasing amounts of resources are being withheld from consumers as they cinch in the purse strings on both tugboats.
They’re withholding now more than ever.
The Rulebooks, also known as “Policies”, govern what type of help will be provided by the Tugboats, what documentation must be submitted by the recipients, and who may qualify to receive that assistance. Both Tugboats cost money in advance, and neither promise to deliver in our time of need.
Questions to ponder: Are Insurance Policies antiquated sets of rules and reimbursement structures? Does a better model than Private Insurance and Medicare exist? Could it? Will it?
Remember, Tugboats serve a purpose: If a ship needs to be maneuvered on the water, the tugboat pushes or pulls it towards its destination.
Health Insurance & Medicare had a role to play in Healthcare. We’ve outlived their efficacy. It worked for a while. It is not working now.
Also, at this point in history, it’s looking like Insurance & Medicare are experiencing a mutiny.
Tugboat Mutiny
Insurance industry leaders have executed their mutiny against the Healthcare Industry through questionable reimbursement practices, coercion of lawmakers and lobbies, and generating a feedback loop of documentation/coding/billing requirements, moving the target year after year, and preventing HCW, providers, organizations (doctors, hospitals, nursing homes, home health agencies) from receiving expected reimbursement for services already provided.
Provide care, document, code it, submit for billing, cross fingers…
The power of prayer???
We hope to get back what we’ve given?
That is our healthcare reimbursement model right now.
Modern American Healthcare.
This is what it’s like to look at the problem and feel helpless to influence change.
It’s is so much bigger than preventing “avoidable rehospitalization” or “hospital-acquired conditions” or “falls”. This is bigger than any of our “quality” metrics. This is personal.
[Side Quest: My North Star Nurse worked for an excellent Healthcare system. When she got sick, she received paid leave through her employer’s benefits. Short-term and then long-term disability coverage provided for her and her family’s financial stability. Eventually, her illness kept her off work for too long and she was fired from her job by her excellent Healthcare system. In a breath, she and her family lost their income and health insurance. All that, and then she died. I don’t accept that this is what’s waiting for me or anyone I love. We can do better.]
Private Health Insurance is its own complicated beast. What’s waiting off-shore doesn’t look much better. Medicare, the insurance supposedly waiting for each of us when we retire, that we invest in with every paycheck… Medicare with its strict rules for reimbursement, has recently become more stringent in all levels of care (hospitals, home health, skilled nursing facilities). Healthcare companies have had to create new positions and hire more people behind the scenes to keep up with the new requirements, rather than increasing support and staffing on the frontlines where the actual care is being provided.
Medicare withholds reimbursement for potentially avoidable harm, including rehospitalization.
Rehospitalization Reduction
Hospitals and Home Health agencies lose money when patients are rehospitalized (Go to the hospital, get discharged, go home, and go back to the hospital = readmitted). For example, if you’re admitted to the hospital for a hip fracture, get discharged, go home, get sick with pneumonia, and have to go back to the hospital — Medicare pays your hospital less. It’s the cookie/stick metaphor: if we keep you out of the hospital, we get a cookie. But if you get rehospitalized? Medicare keeps the cookie and beats us with a stick, then puts the cookie jar on a higher shelf.
I’m not saying that Healthcare agencies are completely helpless. We can all make it easier and safer for folks to live comfortably wherever they call “home”. They/we were already scrambling to reduce rehospitalization. It’s what’s best for our patients. Nobody wants to go back to the hospital (generally). We’re all trying our best. But here’s another stick in the mud: American Healthcare is litigious.
Litigious.
We aren’t just looking at whether insurance will cover the care we provided. Remember: if things don’t go right, we Healthcare Workers as individuals, run the risk of being sued (personally, or through our employer) for negligence or harm. So, when a patient has a new complaint/problem/symptom (fever, shortness of breath, chest pain, weakness, difficulty urinating, a fall), we try to manage it in the level of care they’re in. That’s ideal! Adjust medicine, check in more often, use telehealth…
But then… did we escalate the problem far enough… did we act fast enough… did we give the right advice to prevent harm?
And we are stuck in a feedback loop of rehospitalization.
As the Silver Tsunami grows, and the Ship of MAH recovers (which we are — I see actual, tangible improvements in Healthcare. I don’t see a veneer. I see real humans at every level of Healthcare, from the frontline to the executives, doing their damndest to make Healthcare as safe as possible. Sincerely.) Yet we can see both of those Tugboats locked on the dock, not even offering, but withholding assistance, while simultaneously creating new rules that make it harder (impossible) to implement year after year.
And we’re all in this together. We’re all current/future Healthcare Consumers! We ALL will eventually require Healthcare services. We will ALL be patients. We ALL will be passengers on the Ship of MAH. WAITT: We’re All In This Together.
“Why is it like this?” “Shouldn’t it be better?” “What can we do?”
Our action items require swift action from individuals, Healthcare organizations, policymakers, everybody:
It’s time we turn the tide on human health in the United States.
We need:
easy access to real, healthful, whole foods
the ability/time to prepare/eat healthfully
to keeping moving across the lifespan
to develop and maintain human connection
swift healthcare policy reform
This is mission critical.
It requires a critical gaze from the community to Healthcare Executives to Policymakers. From the local, state, and federal level. We need an understanding at all levels of care and government that the current healthcare reimbursement model is not sustainable. And then we can move forward, together. WAITT: We’re All In This Together.
With all the sincerity in my heart, with every ray of hope, I send this to you. Knowing with all my heart that you’ll know what to do with it. It’s bigger than any individual one of us, but together, I believe we will turn the tide on American Healthcare. And I believe in you.
Happy spring. Take good care.
Love,
Jessie