Chapter 29

Hospitals

One of the most difficult things to contend with in a hospital is the assumption on the part of the staff that because you have lost your gallbladder, you have also lost your mind.

—Jean Kerr

 

Whether you choose a hospital and then pick a doctor who has privileges at that hospital, or choose a doctor or managed care organization and use the hospital with which they are affiliated, the hospital you use can be important to your health.

Hospitals in this country are among the best in the world. This chapter will make you an informed consumer with an awareness of the simple steps you can take to assure you get what you need and want, and to avoid potential pitfalls.

Think of the hospital as another of your team members—in this case a partner in the health process.

Section 1. Choosing the Right Hospital

You probably already know the hospitals in your area. However, it may still be worthwhile to obtain a list of medical centers from your local GuardianOrg because it will point you in the direction of hospitals that are best suited to care for people with your condition or to supply the treatment you need. You are less likely to suffer complications from treatments done at hospitals that perform a large number of them.

Evaluate the different hospitals. Ask for recommendations from everyone you know, especially people who work in the health care field. Ask people in your support group or others with your condition about their experiences with the different hospitals in your area. Were they treated as numbers or as individuals? Were they treated as partners in their care? Were all tests and procedures discussed ahead of time, or did doctors just show up for them? How about the cleanliness of the place? Which emergency room worked best for them? Check the books listed in the resources section.

By phoning you can also obtain and compare

• room costs. They will vary from hospital to hospital.

• whether the hospital will accept your form of payment.

• the hospital’s rate of nosocomial infections, medical terminology for infections acquired in the hospital. To obtain this information, ask the hospital, your doctor, and/or contact your local department of health. Every accredited hospital has an infection control committee, which generally includes physicians and nurses, and often a hospital administrator. Their reports are usually available upon request.

• report cards from various organizations to help make decisions about a hospital. If you use one, be aware that unique conditions can skew the results. For example, a hospital may have a high mortality rate because it gets the most difficult cases.

It may be worth taking a trip to the hospital yourself or ask a friend or relative to do it for you. What is your overall impression of the atmosphere, as well as cleanliness and the way people are treated?

Public hospitals. Don’t take a hospital off your list just because it is a public hospital. Some public hospitals are very good. If the hospital is a teaching hospital, it is probably equipped with better doctors and equipment and is on top of the latest developments.

Section 2. Outpatient

Patients who come to a hospital, have their treatment, and leave on the same day are known as outpatients. Inpatients stay overnight.

As a general matter, as many procedures and tests as feasible should be done on an outpatient basis. You will save money and Life Units and minimize the risk of picking up an infection. Nevertheless, being an outpatient is not always in your best interest. As with most aspects of life, a balance is required. Neil N. needed a series of gastrointestinal tests. If he had done them as an outpatient, it would have required four trips to the hospital on as many different days, with four accompanying enemas. Instead, by checking into the hospital for two days he accomplished all four tests with only one enema.

If you have managed care coverage, the managed care company is likely to require outpatient procedures whenever possible—including in some instances when it may be better to be an inpatient.

If you believe you should be an inpatient for a treatment for which the managed care company insists on outpatient status, appeal the decision. (See chapter 14, section 6.)

Tip. If you have hospital indemnity coverage covering the cost of your hospital stay (see chapter 14, section 10), you receive money for each day you are in the hospital. Take this into account when deciding whether to have a procedure as an outpatient. Getting paid may make it a little easier to be hospitalized.

Section 3. Entering the Hospital

3.1 In General

Before the need arises, prepare a wallet-size list of your medical history, including a current list of medications and allergies or other chronic conditions, previous operations, current diagnosis, and drugs you are taking. If you have insurance, include your insurer and policy number. If you have a living will or other advance directive, mention it, as well as the contact information for your health care proxy. This way, you won’t have to remember a lot of information when you are not feeling well and preassembly will speed up your admission.

If there is too much information to keep on a wallet-size sheet, keep the information in the emergency room tote bag described in the next section.

3.2 Entering the Hospital Through the Emergency Room (ER)

You have a legal right to be treated at a hospital ER if you have an urgent medical condition—regardless of your ability to pay. You must be treated until your condition is stable or the advantages to you outweigh the risk of a move and the hospital to which you are to be transferred has agreed to accept you.

Emergency rooms work on the triage system: people with the most immediate medical need are taken care of first. Life-threatening situations are always given priority. A broken arm may be the most pressing medical problem in a walk-in center, but not at a hospital that gets people from an area with a high rate of violence. You can usually get faster treatment if you arrive in an ambulance or the police bring you to the hospital. If you arrive in the hospital’s ambulance, you are treated as if you are the hospital’s patient, and hospital patients generally receive priority.

Tip. Prior to needing to use an ambulance, check your insurance coverage to find out if ambulance fees are covered and under what circumstances. If they are covered, by all means use the ambulance to get to the emergency room.

Tip. Check your insurance to determine whether it requires pre-authorization of emergency room care. If there’s no time, and the need is urgent, head to the emergency room and call from there. If they don’t give you the approval, you be the final judge as to whether you should go to the emergency room. You can battle with the insurance company later.

When you have to go to an emergency room.

• If there is time, inform your attending physician and ask him to meet you at the ER so there will be someone there with direct concern for your health who already knows your history. If he can’t make it, perhaps he will at least call and smooth the way for you. It helps if the ER thinks someone in the hospital is looking out for you.

• If at all possible, take an advocate with you or have a friend or family member meet you there. If you don’t have someone, be prepared to advocate for yourself. Perhaps the hospital has a patient representative (also known as a patient advocate or ombudsman) who can help you. The patient representative is supposed to be the link between you and the hospital, helping you with any complaints or questions you may have about the hospital or staff.

• Be firm in making your needs known. Request comfort items such as food or liquid. Until assigned a room, you should be able to get attention from the staff. After that, you may be in for a long wait for attention.

• Always request a blanket. It sometimes takes so long to get one that it is better to have one just in case.

Tip. Have an emergency room tote bag packed at all times. Keep in it pajamas, toiletries, nonperhishable food, bottled water, a book, copies of your health insurance information and health history, a batch of quarters and a list of people to call with their phone numbers. Attach a note to the bag reminding you to take a cellular phone and an inexpensive compact disk or cassette player with headphones if you have them. Leave the bag in a closet near your front door, or ask a loved one to bring it to you if you can’t stop at home on the way to the hospital.

3.3 Elective Admission to the Hospital

If there is time before going into a hospital, you’re likely to get better treatment by meeting beforehand with the hospital administrator. Tell him you’re concerned about your stay and would appreciate his personal interest in your case. Look for something you can bring up that suggests it is in the hospital’s interest to take good care of you. For example, you agreed to report on your experiences to your GuardianOrg. Mentioning the administrator’s name in passing to your nurses can’t hurt either.

Avoid admission on a weekend or holiday. It adds days to your stay. In most cases, you will receive only minimal medical care on those days.

Your rights as a patient. In addition to any rights the hospital may voluntarily provide, you have the right to make decisions about your medical care (see chapter 25, section 1). If the hospital accepts Medicare or Medicaid patients, you must be provided with written information about these rights as well as your right to execute advance directives. The covered facilities are also prohibited from placing conditions on the provision of care or discriminating against individuals in other ways.

Section 4. Staying in the Hospital—Making the Best of It

In general. There is always the risk of error, even in the best of hospitals. The best way to lower the risk is to be alert, assertive, and informed. If you aren’t used to doing this for yourself, think of yourself as acting on behalf of your child or your best friend. There is a difference between being assertive and demanding: you’ll know it when you see it, but if there’s a question, err on the side of taking care of yourself. Do not rely on the hospital, or anyone in the hospital, to anticipate or take care of your needs. Be prepared to do that on your own. If you are in no condition to do it, ask a friend or relative to do it for you.

Partnership. Just as you treat the hospital and its staff as a partner, insist that they treat you as a partner as well. Ask for the same amount of information you would require from your doctor.

Intimidation. Don’t be intimidated. If you feel too sick, vulnerable, or dependent to stand up for yourself, tell the staff to wait until someone who cares about you is there—and ask that person to stick up for you.

Avoid infection. Pay attention to the cleanliness of your surrounding area, of staff members, of equipment and its handling. Speak out, or have a friend or loved one speak out, if you see something wrong. If you have any fears of infection, insist that all staff members wash their hands or put on sterile gloves before coming into contact with you. If you have a catheter or other device for treatments through the skin, be sure all precautions are constantly taken.

Check the name band that is usually attached to a patient’s wrist. Is it your name? Does it list any allergies you have? Be sure the nurse or other attendants check your band when giving you drugs or taking you for any tests or procedures.

Changing rooms. If you are assigned to a room with another patient, ask about that person’s medical status to be sure you can deal with that person’s illness. You won’t be able to change rooms for any discrimination prohibited by law (such as because of a person’s national origin or color). If you are immunosuppressed and the other patient is infectious, then by all means have your room changed.

Be informed. Learn what is supposed to happen with your medical care, why, and when so you can follow up. Also learn what should not happen, so you can guard against it. For example, you don’t want to take unbuffered aspirin if you have or are prone to ulcers.

Understand what is happening. Just as you do with your physician in his office, ask the doctor to restate explanations in another way until you are sure you understand what is being discussed. Consider repeating to the doctor what you think is being said, in your own words. Ask the meaning of words, or signs near your bed, that you don’t understand.

Tests. When you’re in the hospital, it’s easy to order tests, especially if they’re covered by your insurance. Avoid unnecessary or duplicative tests, whether at admission or once you’re in the hospital. They can easily become excessive. Ask for prior approval of each and every test and be sure it is noted in your record. If there are multiple blood tests, ask that they take one sample for all the tests.

Question

• the purpose of the test.

• what would happen if you postpone the test to see if your condition worsens.

• whether it will be covered by your insurance.

Tip. Refuse to have blood drawn for any unexpected or unexplained tests.

Drugs. Check, or have someone check for you, all drugs that the nurses administer to be sure that they are the ones you are supposed to be getting and that the dosages are correct. Although hospitals do have systems of checks to keep mistakes from ever reaching patients, mistakes can happen.

Tip. You may receive resistance from the staff to your checking up on them. This is an understandable knee-jerk reaction. Explain as you would to someone you care about and don’t want to offend that this is not personal. You have heard about errors in hospitals and are being a careful consumer. If you didn’t trust them, you wouldn’t be in that hospital in the first place.

Tip. Take a list of your medications to the hospital, including the dosages, so that the doctors in the hospital can order those drugs for you. Ask whether there will be any charges. Add that information to your list including the name, dosage, purpose, and instructions. If possible, find out the shape and color of any new pills. Use your list to check any pills the nurse brings you.

Tip. Before undergoing a procedure

• ask the questions starting in chapter 25, section 2. Take a photocopy of the list to the hospital if it will help.

• find out how much it will cost.

Food. Hospital dietitians will generally try to meet your reasonable requests. If it’s allowed by the hospital, and you’re not on a special diet or having your intake measured, consider calling a restaurant that delivers, or ask friends and family to bring you food.

Doctors. If you become uncomfortable with your doctor for any reason, you can change even if you are in the hospital. Before changing, see the discussion in chapter 36, section 1.2.

Residents and interns. Residents and interns are in the hospital to gain practical medical experience. They also help the attending physicians by providing care for patients while the attending physician is not present. If you believe that any of them are not up to proper standards, request that they be removed from your case.

Nurses. Work with the nurses as part of your team. They are the people in the hospital who tend to your needs. It helps to befriend them. It can’t hurt to be polite, even as you make sure they follow up on your requests and get answers to your questions.

Many facilities now use less qualified staff for many functions formerly performed by registered nurses. Since you have a right to refuse treatment by anyone, you can require that registered nurses, and not nurse’s assistants, handle all procedures. If you’re not comfortable with any other activities assistants handle, speak with the supervisor.

Tip. Don’t be concerned that the hospital may not have enough staff to do the things you request. You have a right to expect good care, and too few staff members is not an excuse.

Complaints. If you’re not happy with your care, complain in the proper order: the offending person first, then the supervisor, then the hospital administration.

Advocate. Ask a friend or family member to act as an advocate to be sure you get the service you deserve and are paying for.

Friends and family. Do not hesitate to tell friends and family what you need, whether it is a neighborhood update, bringing you your favorite foods, or taking care of matters large and small. They can’t know what you need unless you tell them. The odds are they will be willing to help. Susan R.’s difficult day was transformed when her friend Susan S. brought her dog to the street outside the hospital room window for a play session that Susan R. could watch.

Hospital care. If you need in-hospital hospice care, read chapter 30. However, just because you are in hospice care does not mean that the advice for maximizing the use of the hospital, and minimizing expense, should be ignored. If you become too sick to tend to these matters, be sure a friend or family member will do it for you.

Section 5. Tips to Make Your Stay Easier

• Take framed and/or unframed photos of loved ones or places that evoke peaceful feelings.

• Either take or rent an inexpensive VCR so you can watch your favorite movies or educational tapes and ask friends to bring them. Many hospitals will even supply a VCR upon request.

• Have your mail and newspaper brought to you daily. It helps to stay in touch with your home routine.

• Take musical tapes, relaxation tapes, or a radio. Earphones should be used if you are in a semiprivate room.

• Take aids for sleep and comfort, such as small pillows or favorite blankets.

• Take walking aids, such as canes or walkers.

• Take whatever you use at home to make yourself look presentable, such as turbans or head coverings.

• If a special mattress is used at home (such as an eggshell mattress), ask that the same kind be used in the hospital. If you ask ahead of time, it is more likely it will be available on admission.

• Consider purchasing an inexpensive answering machine to take to the hospital. With a machine, you can monitor your calls so you are not disturbed when you want to rest. You can also decide with whom you want to speak, and when. If a batch of people are calling you to find out how you are, you may even want to go so far as to give a daily update on the outgoing message. The machine should be inexpensive because your door has no lock and theft is regrettably all too common in hospitals.

Tip. Set up a phone tree. If a lot of people would be calling you for updates, ask a friend or relative to work out a system of calling the concerned people and letting them know, and a phone tree so each person calls another.

• No one will have a major burden, everyone will know your status, and you can get some needed rest.

• A phone tree also creates a support group for your friends and more distant relatives. Your being in the hospital will not be easy on them either.

• Keeping people in touch through a phone tree will also help them to mobilize smoothly, if and when you need them.

Section 6. Money-Saving Tips

To save money while you’re in the hospital

• avoid unnecessary tests

• Keep a daily log of the services and medications you receive. If you’re too sick to do it, ask a friend or family member to keep track for you. Include the dates of admission and release, the dates you are in a specialized unit such as intensive care, tests, medications received, doctors’ visits (including name, specialty, and what they did), and personal items received. The log should also include every item you are provided, including every aspirin, toothbrush, and supplies used as part of a medical procedure. Because many hospitals are under financial pressures and trying to control their bottom line, they are charging for every service provided, including many that used to be free.

• refuse to be seen by any doctor you don’t know. Find out who the doctor is and what he is doing in your room. After you identify who the doctor is, and what he intends to do, you can make the decision whether to allow him to proceed.

• bring your own food or have it delivered, if the hospital allows it. It’ll save you money and will probably be a good deal more to your liking. Be sure it fits within the food recommended by the hospital dietitian. Tell the hospital that you have done this, then check to be sure you aren’t charged for meals.

Section 7. On Discharge from the Hospital

When you are being discharged from a hospitalization, ask for a copy of the discharge summary. It provides a synopsis of what happened during your stay. It also lists your diagnoses, your home plan, and your future doctor appointments as well as medications on discharge. Get a list from your doctor of dos and don’ts to follow until your next visit with him.

Early checkout. While you can legally leave a hospital at any time against medical advice (AMA), leaving the hospital prior to receiving your physician’s approval may jeopardize your insurance coverage. Hanako H. packed to leave the hospital on a day her doctor had unexpectedly left town without formally authorizing her discharge. She was almost out the door when she was informed that if she left AMA, she, not the insurance company, would be responsible for the entire bill, which was over $10,000. (She created such an uproar that the staff managed within a few hours to track down the doctor and obtain approval for the release.)

Check your hospital bill. If you have managed care coverage and do not pay any part of your hospital bill, skip this section.

All too often people don’t check their hospital bill. Even if you’re covered by health insurance or Medicare, you may be required to pay a deductible and possibly even a percentage. Even without a required payment on your part, the amount of the bill can deplete your lifetime limit. This is particularly true if you end up with multiple trips to the hospital.

Hospital bills tend to be long and complex and written in unfamiliar codes. However, they are also notoriously inaccurate. For example, in a recent five-month investigation of ninety-seven hospital bills in Connecticut, state officials found errors in 31 percent of the bills.

It’s worth an investment of a few Life Units to

• demand an itemized bill and review it carefully for errors.

• look for duplicate billing, which can often happen with minor items and unrequested items. Look at the names items are given—they can be given different names and then billed repeatedly.

• look for unrequested or unauthorized charges, especially if you asked for advance approval for all tests. A “thermal therapy kit” may actually be an ice bag.

• look for charges for services that were not rendered, or items that were not delivered.

• look to see if the charge is the same for all similar tests. Dyson L. was charged different amounts for each of four chest X rays.

• watch for phantom charges. Hospitals have a standard list of fees automatically charged for certain procedures. Often a medical treatment can involve only one or two components of a procedure. The hospital administrator may assume that you had every component.

• particularly check for charges during surgery, where a lot goes on and gets charged to the bill.

• do not pay for the doctors’ failure to coordinate their work if the doctors ran duplicate tests. Redundant or shoddy testing should not be your burden.

• look at charges with general headings like “nutrition” or “anesthesiology.” Any general heading warrants further inquiry.

• If the meaning of the codes isn’t printed on the bill, ask for a copy of the explanations.

• If you have a large bill that is confusing to you, seek assistance.

• The National Emergency Medicine Alliance will provide you with a free booklet on hospital and medical bills. Call 800-553-0735.

• The National Association of Claims Assistance Professionals will refer you to a professional who specializes in medical-claims counseling and processing. Call 708-963-3500.

• The hospital billing-department representative can also be of assistance.

Tip. Don’t pay the hospital bill as you are leaving. There is not sufficient time in which to review a detailed bill. Insist on reviewing the bill before paying it.

If you find an error in your bill. Put your concern in writing and attach specific documentation for the suggested correction. Send this information to both the hospital and, if applicable, to your insurance company and/or Medicare or Medicaid. Keep a copy with your files.

If you do not receive satisfaction, contact the hospital patient representative or patient advocate. This person will explain your rights as a patient and what alternatives you have regarding any disputes. While theoretically working for your interests, this person is paid by the hospital. If you are still not satisfied, contact your health insurance company to find out the average amounts charged for similar hospital procedures in your region. If you are not insured, obtain these amounts from any health insurance company.

If you don’t receive an acceptable response, or if the charges seem exorbitant, consider sending the bill to the consumer advocate of your local television station and/or newspaper.