My Insurance Conversation Part 2

In my email last week I talked about how insurance companies often interview my residents, my staff, and me about the condition of our residents.

They want to determine if the residents are sick enough to provide coverage.

The other email covered the general concept of insurance incentives. The sicker the healthcare industry can make the patient, the more money the medical establishment treating them receives.

Today I’d like to cover a different aspect of my conversation - medications.

The latest conversation I had with the resident’s insurance company was with a nurse. The nurse’s job was to evaluate the condition of my resident and fill out a form.

She had to read a statement at the beginning of our conversation stating she would not be making the final determination of eligibility and that she was just one step in the process.

Fair enough.

Then we started talking about general health questions. One part that really caught my attention is that she said when we go over the medications we can understand what the resident’s conditions actually are.

Here’s the translation of that statement. “The healthcare industry has one standard of care that should be followed. If you are not following it, then the patient probably doesn’t have that condition. You have a condition, you should take the approved medication.”

As I said in my last email - no real innovative ideas.

My resident for this interview received a diagnosis of dementia and diabetes. Both conditions are not severe. One of the reasons the family brought the resident to me was because they wanted to wean her off her medications.

Neither they, nor I, believe the dementia medications do much to slow down the disease. They definitely don’t reverse it. And they can have serious side effects.

The family of the resident (and I) also believe since her diabetes isn’t that bad, we can control it better with food than with medication. Our doctor for our home agreed.

Since she’s been in our home, we have had a lot of success controlling her blood sugar.

Therefore she is not taking medications for either condition.

The nurse was pretty surprised. The resident’s care plan (developed by another nurse who works for us) had both diagnoses. The insurance nurse asked why there were no medications for either one.

I told her the family and I believe in a more holistic approach. I told her we had her on a high-fat, low-carb diet for both conditions.

She just made some notes and moved on.

It just made me think healthcare really is ‘a pill for every ill’. And that healthcare profession will be taken over by AI.

Here’s how it works: Showing these symptoms?

Take X medication.

So simple even a computer can do it.

The real question is..when will people stand up and say that is not what they want for their health?