Full Coverage: Navigating Barriers to Care When Treating Underinsured Patients and Those with Poor Social Support

Podcast Transcript

Carol Pehotsky:

As nurses, we want to focus on the care we provide, and of course that's important, but should we also be thoughtful about the barriers that a patient overcame to arrive at our care? Should we worry about whether they'll be able to pay for the care we provide? I'm joined today by Kris Adams to learn more. Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing from patient care to advancing your career to navigating tough on-the-job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing.

Like many of you in our audience, I've been a consumer of healthcare in addition to being a practitioner from time to time. And thankfully, the handful of surgeries I've had in my lifetime weren't urgent, and they relieved the symptoms or structural issues they were intended to. But each time I found myself reflecting about healthcare from a new perspective - from the other side of the stretcher, so to speak. Recovery from surgery is hard enough, but I had so many advantages. There was support at home for doing my PT exercises. I had childcare so I could focus on my own healing. I had money for food and medications. I had medical leave so I could take time off to rest and fully recover and not worry about going back to work and how the bills would be paid.

The list could go on and on, and all of that before mentioning the biggest issue: I had healthcare that covered almost all the expenses related to each of these procedures. For far too many, those are advantages they're denied. In the county where we're recording today in Cuyahoga County, for example, the lowest and highest life expectancy in Cuyahoga County are 23.2 years apart. In Woodhill, according to the CDC, the life expectancy is 65.4 years. We're 1.1 miles away. And Shaker Heights, the life expectancy is 88.6 years. It's just unbelievable.

So, it's my pleasure, with that in mind, to welcome Kris Adams, joining me today. She's the Associate Chief Nursing Officer for care management and ambulatory nursing at Cleveland Clinic. Although she has worked in a number of specialty areas throughout her 30-year nursing career, her experience in a free clinic inspired a special affinity for society's most vulnerable, many of whom are uninsured. Kris, welcome. I hope you'll start us off by telling us that story.

Kris Adams:

Well, thank you Carol, and thank you for having me. This is something I could talk about all day and it's near and dear to my heart. It's difficult to watch what's happening in healthcare today, particularly today. But as you mentioned, my background is in a free clinic. It was my first job out of nurse practitioner school.

Carol Pehotsky:

Really?

Kris Adams:

And it was very eye-opening, to say the least.

Carol Pehotsky:

Okay.

Kris Adams:

What I came away from that experience is the level of consciousness that I need to have as a medical professional on how the bill is going to land on our patients.

Carol Pehotsky:

Sure.

Kris Adams:

Because if you can imagine being ill, scared in the hospital, in pain and all you want to do is get your current issue resolved.

Carol Pehotsky:

Yeah.

Kris Adams:

And you do. However, you experience the double whammy which is the bill coming in the mail. And the number one reason in the United States that we have bankruptcies is medical bills.

Carol Pehotsky:

Really?

Kris Adams:

This is a very real issue to our patients, and I think for a long time as medical care providers, whether you're a nurse or a physician or a nurse practitioner or a PA, we've always prided ourselves on being payer agnostic.

Meaning, "I am not gonna look at what the patient's insurance looks like. I'm just gonna deliver the best care, and they're gonna get better." Except when we close our eyes to what they're able to afford, we could often create more stress.

Carol Pehotsky:

Sure. So, we think we're providing unbiased care.

Kris Adams:

Right.

Carol Pehotsky:

But in fact, we're perpetuating some of the systemic issues that come with entering healthcare.

Kris Adams:

Indeed.

Carol Pehotsky:

Wow.

Kris Adams:

Indeed.

Carol Pehotsky:

Okay. Well, let's dive right in there.

Kris Adams:

Okay.

Carol Pehotsky:

Should patients receive different care based on their insurance status?

Kris Adams:

Should they?

Carol Pehotsky:

Yeah.

Kris Adams:

No.

Carol Pehotsky:

Do they?

Kris Adams:

And we talked a lot about it in care management. We call it freedom of choice.

Carol Pehotsky:

Okay.

Kris Adams:

It's a Medicare COP, a condition of participation where we are incumbent upon letting the patient know whom they are going to be engaging with financially as it relates to their healthcare. So, for example, if they need to go to a skilled nursing facility, they have the freedom to choose whatever facility they want.

Carol Pehotsky:

Seems like a good idea.

Kris Adams:

It does. Except, except not every facility charges the same has the same ability to accept insurance.

Carol Pehotsky:

Sure. Yeah.

Kris Adams:

Yeah. We, we're, they're gonna get a surprise.

Carol Pehotsky:

Right.

Kris Adams:

And it's not gonna be a pleasant one.

Carol Pehotsky:

No.

Kris Adams:

And oftentimes we're all doing it out of the goodness of our hearts.

Carol Pehotsky:

Sure.

Kris Adams:

We want our patients to go to the best places.

Carol Pehotsky:

Yes.

Kris Adams:

But, unfortunately, not all insurance supports all the different things that patients want and that we want for them. So, this becomes somewhat of some moral distress, if you will within the medical community as well as within care management and social work on how we help these patients navigate what it is we can offer you, which is a very different way of looking at this.

Carol Pehotsky:

Sure. And focusing on those safe outcomes and making sure they get that.

Kris Adams:

Yes.

Carol Pehotsky:

It may not come with the amenities, but it comes with the safe care you'd want.

Kris Adams:

Exactly. Exactly. And when you mentioned in your opening about the amount of support you had for your surgery. You know, you had people at home who could take care of you, neighbors that showed up presumably with casseroles.

Carol Pehotsky:

I sure did.

Kris Adams:

All of those things support a healing environment.

Carol Pehotsky:

Yes.

Kris Adams:

Unfortunately, so many of our patients don't have that social support.

Carol Pehotsky:

Right. Yeah.

Kris Adams:

So not only do you have to look at their financial ability to pay, but you also have to look at that social support that's going to help their finances. For example, I had some patients recently I was seeing, and they are back and forth for all these appointments, and they don't have any family in the area, so I help them download Uber to their phone. Some can afford that; others cannot.

Carol Pehotsky:

Sure.

Kris Adams:

So that becomes an access issue and an access point.

Carol Pehotsky:

Yeah.

Kris Adams:

If you have somebody in your family who's like, "Yes, I'll take off work and I can take you to the doctors, or I can do the follow-ups with you." Those are all things that cost money and time.

Carol Pehotsky:

Absolutely.

Kris Adams:

And we have to think about that and assess for that as nurses, nurse practitioners, providers of healthcare. Am I setting them up for something they cannot do based on what they currently have available to them?

Carol Pehotsky:

The things that any patient has to go through to even get just an intro appointment.

Kris Adams:

Indeed. Yes. Yeah.

Carol Pehotsky:

All those hurdles they had to, had to jump and we just thought, "Oh, great. You're here. Let's take care of you." But there are things we need to take care of to help them come back the next time.

Kris Adams:

Yeah, for sure.

Carol Pehotsky:

Yeah.

Kris Adams:

It's a domino effect.

Carol Pehotsky:

For sure. So, there's a lot in the literature in the media today about these social determinants of health, right? And, and we could spend hours talking about this. But along those lines, I'm a brand-new nurse at the bedside, or maybe I've had some experience in my lifetime, but what should I be thinking about from my nursing perspective to really identify some of those hurdles you talked about?

So, I'm really making sure I'm that nursing philosophy, I'm tr- treating the whole person and not their chief complaint or their reason for admission.

Kris Adams:

Mm-hmm. Yeah. That's a good question. So, there's been a lot of focus on the social determinants of health, and as we look towards 2024, CMS is really asking us to assess that in our patients.

Carol Pehotsky:

Oh, okay.

Kris Adams:

The issue is how are we gonna act on whatever answer we get? But as nurses, we can come at this with the philosophy that things like food are medicine. Housing is medicine, transportation is access.

Carol Pehotsky:

Sure.

Kris Adams:

All of these things start to frame up in our head as to what, beyond just my teaching about the biological issue that's at hand or the medications at hand, or the follow-up that has been planned in the care plan, what other things do I need to look at globally to make sure that they can even deliver on this?

Carol Pehotsky:

Sure.

Kris Adams:

And I, going back to my free clinic days, it was always so hard for me, especially with a diabetic, to impress upon them the need to not ration their insulin but they're looking at me saying, "I can't pay the rent this month."

Carol Pehotsky:

Right.

Kris Adams:

"I can't, I don't have food."

Carol Pehotsky:

Right.

Kris Adams:

"I don't have..." I mean, these were really real issues and there, they're issues that we face today. Even, you know, back in 2010 when I started in the free clinic – and we were going through at that time the throes of Obamacare, you know, the Affordable Care Act.

Carol Pehotsky:

Yes. Yep.

Kris Adams:

It was a step in the right direction. And it was actually completed, the ACA was completed in 2014 but we need to go further. Sure. It's time to look at this from a healthy perspective and how we're gonna move patients to stay well because that is going to be going forward and how we at least address some of these issues going forward.

Carol Pehotsky:

With any change, there's the unintended consequences you have to work through and sort of the next step of it. Yeah. How do we get from what this current state is to wrap around what we, what we would want as patients, right? We want somebody to acknowledge, you know, the things that I had to do to get to that doctor's appointment again, are very minimal for me.

But if I'm coming in tearful, I want somebody to say, "Gosh, Carol, what's going on?" "You're, you're here for an allergy appointment."

Kris Adams:

Right.

Carol Pehotsky:

And I had it easy.

Kris Adams:

Right.

Carol Pehotsky:

So how do we as nurses use every encounter to say, "How you doing?"

Kris Adams:

"How you doing on this?"

Carol Pehotsky:

Yep.

Kris Adams:

I mean, I, I really come at this, you know, I just look at the struggles our patients have even on a good day. So, and how do we help them navigate this? The complexity, first of all, of healthcare, plus you layer in all the social determinants of health that you mentioned. There's a really good reason why we're not in a good place for healthcare in this country.

Carol Pehotsky:

Sure. And it didn't, it didn't start overnight.

Kris Adams:

It did not, yes.

Carol Pehotsky:

And it's not going to get fixed overnight. But it's so important that we're all in our own spheres doing what we can to make it better. Do you think it's important that a bedside nurse knows what kind of insurance their patient has or the type, whether they have it or not, or what type it is?

Kris Adams:

Yes. Yes.

Carol Pehotsky:

Okay.

Kris Adams:

And again, this flies in the face of a history of, "I'm just gonna take care of the patient the best way I know how regardless of what it costs." The reality is it all costs.

Kris Adams:

"Or we need to have a conversation around getting you out and what can we set you up with on the outpatient side." Now, care managers are often good at this.

Sometimes nurse practitioners can be facile in this, but it's something that we have to put in our tool belt as nurses as part of these conversations. For those of you maybe who work in rapid ops units maybe you don't know why they're cohorting these patients. And it is because of financial reasons, not only for the hospital, which of course is important, but even more so to what financial implications the nurse carries an incredible amount of weight with the patient.

They are looking to us for that guidance and for that advocacy and for that answer. So, I don't want to burden our nurses any more than they are, but to be mindful of that, yes. We need to understand insurance.

Carol Pehotsky:

And within your organizations, figuring out how you can learn more, what resources you can tap into. Are there triage guidelines?

Kris Adams:

Yes.

Carol Pehotsky:

Are there call-tree guidelines so that that nurse who happens to pick up the phone isn't out there flying solo, but has those resources those scripts, et cetera, so they, they really feel supported by their scope of practice, by their organization by those things. So, they feel confident that they're giving thoughtful advice.

Kris Adams:

Yeah. So, if you're not already in your ambulatory practice, you should be following the Schmidt Thompson guidelines.

Carol Pehotsky:

Okay.

Kris Adams:

These are evidence-based guidelines. We use them in our electronic medical records. It's built right in.

Carol Pehotsky:

Yeah, yeah.

Kris Adams:

And it's a, it's an algorithm, triage decision tree. It takes time to go through it. But you have to take that time. And this is sort of getting off-topic, but triage is one of the highly litigious areas in nursing.

Carol Pehotsky:

Oh, sure.

Kris Adams:

So, you have to make sure you get it right. And using those algorithms and guidelines and evidence-based practices is just the safest way to go.

Carol Pehotsky:

And when you think about all of the different specialties of nursing, it becomes incumbent on all of us to think about our specialty and learning at least enough about insurance and payment to be able to say, "We need to be able to document the reason why that outpatient surgery patient is now spending the night."

Kris Adams:

Yes, yes. Like, it's the story we tell.

Carol Pehotsky:

Yes.

Kris Adams:

And it's the story we tell that either helps or hurts the patient in that medical record because we have these fabulous nurses behind the scenes. Well, mostly they're nurses. They are in touch with the payers throughout the entire hospital stay of these patients. And they're selling it to the insurance company that this patient either needs to be here or, "No, I can't make a case for this."

Carol Pehotsky:

Right.

Kris Adams:

And that is all based on documentation. So, the story we tell has huge implications on how a patient gets billed out and statuses through their medical procedures, for sure.

Carol Pehotsky:

And being able to advocate with the providers, whether I'm in the ED or the OBS unit or what have you that says, "I hear you when you say clinically that patient needs to be admitted or they need to spend the night we need to document it. Can you explain to me so that I can be clear in my documentation."

Kris Adams:

Right. "How could I support this?"

Carol Pehotsky:

"How can I support this?" Well, gosh, that 20 minutes went by so fast. We could talk for ages about this.

Kris Adams:

Yes. Yes.

Carol Pehotsky:

But I can't thank you enough for scratching the surface on some really important topics. If I wanted to learn more about insurance payments in a way that's nurse friendly, any resources you'd recommend?

Kris Adams:

So, I would go to the Case Management Society of America.

Carol Pehotsky:

Oh, okay.

Kris Adams:

They work a lot on the payer side and understanding. The other website I use all the time is medicare.gov.

Carol Pehotsky:

Okay.

Kris Adams:

Any questions you have about Medicare, and we could go on and on because I would love to talk to you about Medicare Advantage and what that looks like to patients which is very different.

Carol Pehotsky:

That's fantastic. Well, we're gonna wrap up a little bit. You've shared so much with us about your specialty of nursing, but we're hoping we could spend a few minutes talking to us about who you are as a nurse. We have some speed-round fun questions I'd like to ask you.

Kris Adams:

Oh, okay. Wait, let me buckle in.

Carol Pehotsky:

So yes, buckle in.

Kris Adams:

Okay. I'm ready.

Carol Pehotsky:

Let's see. We'll start with, what's something you do to recharge?

Kris Adams:

Oh, I love crafting. I have a craft room in my basement. I spend as much time down there as I can much to the chagrin of my husband. But if I can hot-glue gun or cut something or, yeah, create something, that helps tremendously.

Carol Pehotsky:

Excellent. It's an outlet for that energy. Let's say you're headed back to the, well, I know actually recently you headed back to the floor to help out, various points of the pandemic with bedside patient care. What's your favorite shoe choice for a long shift on the floor?

Kris Adams:

Oh, shoe choice. Brooks.

Carol Pehotsky:

Yeah.

Kris Adams:

Brooks tennis shoes. Yes. They're super lightweight and they have a memory foam cushion.

Carol Pehotsky:

Oh, all right.

Kris Adams:

Yeah. The other thing you have to be careful of when, and I forgot about this going impatient, you cannot wear a lot of layers of clothes. It's hot in those rooms. It's hot.

Carol Pehotsky:

And it's hard work. Yes.

Kris Adams:

Yeah. Yeah. So lightweight shoes, T-shirt max.

Carol Pehotsky:

Excellent. Well, Kris, thank you so much for joining us today.

Kris Adams:

Thank you, Carol.

Carol Pehotsky:

As always, thanks so much for joining us for today's discussion. Don't miss out. Subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out at clevelandclinic.org/nursing. Until next time, take care of yourselves and take care of each other. The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.