Getting High Quality Medical Care in a Changing Healthcare Landscape
When searching for good medical care, it used to be that the hunt focused on whether the physician was the best in his or her profession, had a good bedside manner, was conveniently located and referred patients to the hospital with the most up-to-date equipment.
But nowadays, rules imposed by insurers for scheduling and receiving care can sometimes place roadblocks between you and the physicians and hospitals you prefer.
For people with diabetes, this new healthcare environment can be especially disconcerting. In an effort to save money on the spiraling cost of medical treatment, employers can decide to switch healthcare insurance options they offer employees — and all of a sudden you may discover that visits to your family doctor or diabetes doctor are no longer covered, and you need to seek out a new physician or physicians to provide your medical care. For people with diabetes, this can mean learning new philosophies and methods of care which may differ from lifelong established systems that the patient has successfully used to manage the disease.
So, what do you do in this new healthcare world?
Here's some general guidelines to follow:
- Understand what's going on in healthcare these days, so you can better understand and work with the changing roles of healthcare providers, and the different pressures they are facing.
- Be knowledgeable about your own diabetes so you can ask questions and pinpoint areas where you and your primary care physician need to focus extra attention — and perhaps get additional help from a specialist — to keep your diabetes on track.
- Be your own advocate. Know what preventive care and screening the American Diabetes Association recommends, and ask your physician when it is time to have these various aspects of your care provided. Try to find an insurer that supports (i.e. pays for) getting these preventive measures done. Don't hesitate to call or write your health insurer and provide them with a clear and compelling argument as to why you need them to pay for some aspect of your healthcare that they don't cover — a referral, or an educational program for example. Include in your arguments any research that supports your need for the referral, and be sure to note that the insurance company will benefit if a needed referral will decrease your risks of developing more costly medical problems down the road.
- Choose your primary care physician wisely. Look for someone who is both knowledgeable about diabetes and who seems interested in working cooperatively with you.
- Make sure your primary care physician will, and more importantly can refer you periodically to a quality diabetes or other specialist, or to education programs for help with hard to manage problems.
- If possible, be prepared to pay for some things out of pocket, particularly diabetes education, and an occasional second opinion from a physician who may not be covered by your insurance.
- When possible, choose the health plan that enables you the greatest freedom to see different physicians and pays for the care you need.
- Don't hesitate to express concern if you have questions about the quality of your care.
The changing roles of physicians
Today's world of medicine is very specialized, yet efforts to contain costs are placing increasing burdens on primary care physicians — the traditional family physician — to provide as much medical care to patients as possible, because their care is the least costly. Yet, in caring for your diabetes, it is likely that your medical needs will require both a primary care physician and a team of healthcare professionals who can back your primary care physician up when needed. "If at all possible, you should find a medical setting where your diabetes is cared for by a team of professionals, each an expert in a particular aspect of your total care," notes Dr. Richard S. Beaser of Joslin Diabetes Center. This team should include the primary care physician, a diabetes expert who is usually an endocrinologist, a dietitian, nurse educator, exercise physiologist and someone who will provide psychological counseling and support when needed. Other team members may be added as needed to treat or prevent complications.
Your desire to have your diabetes treated by a team of specialists — and your insurer's desire, in many cases, to have as much care as possible provided by a primary care physician — may seem to be at odds. "Some believe that those two needs are in conflict," notes Kenneth E. Quickel Jr., M.D., president emeritus of Joslin in Boston. "But in fact, the best, most cost-effective care in the long run will occur for people with diabetes when the primary care physician and the specialty care team work in collaboration with each other."
Physician as traffic cop
Your primary care physician is trained to care for you as a total person and treat a wide range of medical problems, from colds and the flu, to checking your cholesterol levels and checking your diabetes care. This person serves as a traffic cop, in many ways, coordinating your overall medical treatment.
But in addition to acting like a traffic cop, this physician also serves in many health insurance settings as a gatekeeper, managing day-to-day health needs and regulating the flow of patients to more costly forms of care. In essence your primary care physician works on your behalf and the insurer's behalf to be sure that you are receiving care for your medical needs in the most cost-effective way possible. Frequently, payments to primary care physicians from insurers are tied to how effectively they can reduce the use of expensive tests and services — and the physician may be penalized for a perceived overuse of specialists and expensive tests.
"Back in 1916 Elliott P. Joslin wrote that 'the number of cases of diabetes is so great that it at once becomes evident that their care must rest in the hands of the general practitioner. It is ridiculous to expect that the treatment of diabetics should all be under the supervision of a specialist,'" notes Dr. Quickel. "So, while this role of 'gatekeeper' is just a fact of life today, in fact it has always been important for the primary care physician to work with the diabetes specialist. Picking an excellent primary care physician is as important for people with diabetes these days as it is to pick an excellent diabetologist or endocrinologist, and being certain that they can work together is essential.
Diabetes specialists as primary care physicians
In some health insurance programs diabetes specialists are registering as primary care physicians, as well as diabetes specialists, to enable patients to pick a diabetes expert to serve as their primary care physician. This is due, in part, to the fact that most diabetologists are first trained in general internal medicine or pediatrics before they receive additional training in diabetes and endocrinology. But they are also doing this because the line where primary care ends and diabetes care begins can be very blurred. In the Boston market, some of Joslin's diabetologists are enrolled as primary care physicians in some health plans for this very reason. "Joslin physicians have frequently served as primary care physicians for patients over the past 50 years or more, because diabetes is a lifelong disease that affects so many aspects of a person's health, " notes Dr. Quickel.
Other insurers don't allow diabetes specialists — even though they are certified to practice general internal medicine — to enroll as primary care physicians. In some cases, they may even insist that specialists associated with a medical school be classified as 'tertiary care physicians,' which severely limits your ability to be referred to them. The insurers do this because the insurance company perceives these specialists and the institutions they hospitalize patients in as exceptionally high priced. So the same Joslin physician may be enrolled as a primary care physician in one health plan, and a tertiary care specialist in another.
"In the perfect world, our preferred role is to serve as the diabetes expert, and to leave the primary care to the primary care physicians," notes Dr. Richard Jackson, a senior physician at Joslin. "But because patients sometimes want and need more from us than insurers will allow them to get if we enroll in these health plans as specialists only, we do in some cases enroll as primary care physicians."
The ideal scenario is that you identify a primary care physician who is knowledgeable about diabetes, has an interest in the disease — and knows his or her limitations and will refer you for additional care when needed, irrespective of any disincentives insurers may place on making the referral. "Most physicians aren't going to let the insurers get in the way of making a referral for a patient who really needs it simply because of some small financial incentive," notes Dr. Quickel. "But a primary care physician has to know a lot about a mind-boggling number of different diseases and conditions. He or she may not be as immediately up-to-date on new thoughts in diabetes care as a diabetes specialist, whose role is to know a lot about one disease or group of diseases and their complications. What this means is that the primary care physician can manage most of your medical issues — including many of those surrounding your diabetes. But at a certain point, the primary care physician may need to seek a specialist's advice if things aren't going as well as they need to."
"What we're really advocating is a holistic approach, focused on preventing problems," notes Dr. Jackson. "By focusing on preventing problems rather than acting upon them when they occur, we can actually lower the cost of healthcare by limiting the amount of money patients need to spend on specialists to treat costly complications like artery disease, a heart attack, stroke or other problems."
Be knowledgeable about your disease
How can you as the patient know if the diabetes portion of your medical care is going as it should? "By being a knowledgeable patient," says Hill, who is director of educational services at Joslin.
Below are some key questions you should know the answer to in assessing both how your diabetes is going and how your primary care physician and diabetes healthcare team's combined management of your disease is fairing. "If you don't know the answers to these questions, ask the person who provides the bulk of your diabetes care (whether that is a primary care physician, a Joslin specialist, a nurse practitioner, or a diabetes specialist elsewhere) the answers to these questions at your next visit," Hill says.
These are also good questions to discuss with a new primary care physician or diabetes specialist that you may be switching to as a result of a change in health plans, notes Jackson.
Be your own advocate
If you don't know the answers to all of these questions, discuss them with the clinician most involved in your diabetes care over the next couple of visits. Then ask yourself how you felt while you were asking your physician some or all of these questions. If you felt increasingly comfortable as the conversation continued, this may suggest that the physician was a good listener, and didn't send out "bad vibes" suggesting that he/she didn't like being questioned about his medical practices. If, on the other hand, you felt that you needed to stop asking questions fairly quickly, was that because the physician — either overtly or covertly — was sending you signals that he/she didn't like being questioned about his knowledge of your disease? Or was it just your own discomfort with questioning a traditional authority figure?
"You're paying for your health insurance — get what you need and are paying for," says Dr. Jackson.
What to do if you are uncomfortable
Many people will find it difficult to discuss these questions with their physician. "Many of us have been raised to believe that we can't question the parish priest or the doctor, that they will take care of us and it's just as well not to ask too much," says Hill. "But as research like the Diabetes Control and Complications Trial (DCCT) increasingly shows us, the results of careful blood sugar control will reduce complications risk. It becomes increasingly important to make sure that all the members of your healthcare team know what they are doing — and that includes you. You, the patient, are the most important member of the team managing your disease. You have every right, as a result, to know that the other members of the team are working with you, and have the skills to make your life with diabetes as manageable and risk-free as possible."
What do you do if you are genuinely uncomfortable with your healthcare provider, and your choices are limited to the physicians enrolled as provider for your insurance company?
"Ask around," recommends Hill. "Go to meetings of the local diabetes association, and try to find other people with diabetes who have found good primary care physicians and/or good diabetes specialists-primary care physicians who may be covered under your insurance. Check out the primary care physicians of friends who don't have diabetes, but who say their physician is approachable and seems knowledgeable about whatever medical conditions they have. Perhaps such a physician will also be knowledgeable about diabetes — or perhaps if he/she isn't, at least he/she will be willing to refer you to someone who is for your diabetes care, and continue to provide your overall non-diabetes medical care."
Can your employer help?
You may also want to consider letting your employer's human resources or benefits department know if you are uncomfortable with the quality of the care you are receiving under your health plan, particularly if the health coverage has been recently changed and you feel your healthcare is suffering because of it. While insurance companies, on average, will have an individual as a subscriber for three years or so before the subscriber either switches insurers or switches jobs, statistics show that your employer will, in all likelihood, have you as an employee for much longer. Poor healthcare can result in poorer performance on the job, lost work days and lost productivity, not to mention higher insurance costs in the long run if you develop complications. Your employer is likely to be very interested in knowing if you are concerned about the quality of your medical care as a result of a change in health coverage. And the insurance carrier may be more likely to listen to the voice of an employer who is paying for insurance for hundreds or thousands of workers, rather than listening to you, who is the voice of only one.
Perhaps even more importantly, your employer may be interested in knowing of ways that they can continue to offer a lower cost health plan that meets the needs of most of their employees, while offering some additional work-site programs to help meet the needs of their workers with diabetes, or others with problems such as obesity, high blood pressure, high blood fat levels, etc. Perhaps you can talk with your employee benefits department about providing on-site nutrition counseling free of charge to people with these kinds of problems; or perhaps offering a fitness benefit or weight loss program in addition to the basic health plan, which might enable you to develop an exercise or weight loss program at lower cost to help manage your diabetes; or perhaps a stress management program free at work to help lower blood pressure.
Be prepared to pay out-of-pocket
People need to recognize that increasingly, having health insurance does not automatically entitle you to have all your medical care for free. People with diabetes have long had to pay for diabetes education out-of-pocket — and in some cases have balked at doing so. "Part of being an educated consumer is having a good diabetes education," notes Hill. "While insurers are increasingly covering some diabetes education, you may still have to pay something for that."
In addition, a change in health insurance coverage and a resulting change in healthcare providers may leave you longing for your former diabetes healthcare team. You may find that advocating for yourself to get the referral you want to see your former team just isn't working. Or the effort of managing your diabetes and all the other things going on in your life may leave you without the emotional energy you may need to do all the spade work required to get that referral. Or, admit it, some people just feel too uncomfortable to complain on their own behalf. Or the environment at your workplace may make you feel uncomfortable about calling attention to your medical issues with your employer's benefits department.
If any of these situations is the case for you, then perhaps, if possible, you should simply plan to spend out of pocket once a year for a good diabetes-specific medical evaluation (doctor visit, lab tests, diabetes education, eye exam) with your former diabetes specialists, even if they aren't covered under your health plan. See it as augmenting the care you are receiving and getting covered by your insurer. "After all, to make sure your car is running smoothly you would spend $500-$1000 a year on tune-ups, oil changes and other things which are over and above your warranty," says Dr. Jackson. "Why not do the same thing for your body?"
This can serve two useful purposes — first, it can help reassure you that your diabetes care is on track, and provide you information about how you can improve your overall diabetes care. Second, if problems with your existing medical care are uncovered, you can use this information to go back to your own physician and health plan and seek improvements. Or perhaps you can parlay the information into an out-of-plan referral to the physician team you wanted to see in the first place, or some additional action (i.e. specialty referrals) within the plan to physicians who may be categorized as super specialists, only to be referred to in the most dire of circumstances.
How do you choose your insurance wisely?
Despite changes in the market place most people covered by insurance at work still find that they have some choice in health coverage. What should you look for when the annual opportunity to make your health plan selection comes along? What should you look for in health insurance coverage if you are going to change jobs and someone in your family has diabetes? How do you minimize upheaval in your healthcare team coverage? Here's some questions to make sure you know the answer to when considering health plans:
Are the physicians I currently see covered under the insurance plan?
If they are, how easy or difficult is it to gain access to these specialists I am seeing? How easy, in general, is it to get a referral?
Just seeing the name of your physicians on a list of providers may suggest that you'll be able to see them whenever you wanted, just as in the past. This may not be the case, however. Some plans, for example, list certain physicians as part of their health network. But they are as tertiary care providers, which means that you can only be seen by one of these physicians if your primary care physician recommends it and the medical director of the health plan OKs it. "Getting this approval is a long process and your request will often be rejected. Instead, the plan will offer to cover you seeing a specialists in the local area — an endocrinologist in the community not associated with the physician you want to see, even though the physician you want to see may be in your local community."
So, before signing up with a new health plan, don't just check with the health plan's provider book to see if your specialists are covered under the plan. Also check with your specialists themselves to see how difficult it is to get a referral under the health plan you are considering.
Other questions to know the answers to include:
- What co-pays and deductibles are required in the health plan I am considering? How do these differ with physicians I may see who are "out-of-network?"
- Does the insurance plan cover such things as diabetes education? Weight loss programs? Fitness programs? One-on-one counseling with dietitians, certified diabetes educators, etc.? Can the costs of these services be included in your deductible? Does the insurance plan cover costs associated with these programs at any institution, or only at certain places?
- What coverage is provided for medical supplies such as blood sugar monitoring equipment and supplies? What does the drug benefit include? Are insulin and syringes covered?
- What is the mental health benefit? Will it cover such things as a diabetes-related support group or one-on-one counseling? How difficult or easy is it to get a referral to such a program through your health plan?
- If the person with diabetes to be covered under the health plan has a diabetes complication, what rules governing preexisting conditions may limit how much money your insurance will cover to pay for those complications? Or for diabetes care itself?
- Is the person to be covered under the plan who has diabetes planning on becoming pregnant? If so, will the health plan cover the more frequent testing and doctor visits required? Who are the specialists in diabetes and pregnancy covered under the plan? Where will the baby be delivered and what are the neonatology services available?
Keep in mind that each insurance plan has numerous different sub-plans that it sells to employer groups. The only way you will know for sure if your care at Joslin is covered, for example, is to check with your insurance carrier.
"Getting healthcare just isn't what it used to be," notes Hill. "People just have to be prepared to be more aggressive consumers to get the care they used to simply get by paying their health insurance premiums and their doctor bills. It takes a lot of work. But now, more than ever, an informed, intelligent consumer who is willing to be a little aggressive will get the best healthcare."
Page last updated: January 31, 2015