Caitlin

Uninspired

“Quotes are nothing but inspiration for the uninspired.” – Richard Kemph

 

My blog has been uninspired for quite some time.  I was – several months ago – excited about writing about healthcare during an election year. But this is not an election – this is a spectacle. It’s like watching the Bachelorette run against Duck Dynasty. It’s reality TV…not an election.

 

Instead, I allowed myself some time for a blog identity crisis. Maybe I will write about cooking? Wait, I don’t cook.  Maybe travel?  Wait, I do most of my worldwide travel with Rick Steves on PBS.  Hmmm.  I figured I would know true writing inspiration when/once/if it hit me.

 

Then I met a Mom that reminded me of why I chose healthcare administration as my career.  Like all of us, I cannot always recall why I chose this particular path over my alternate career choices. Professional ballerina? Hotel concierge?

 

Her reminder was a gift.

 

My first professional job in healthcare was working with children and families dealing with autism. This was my baptism into the world of “special” healthcare needs and the proverbial “system”. I watched patients/families face a diagnosis with no cure, dive into the deep end of an ocean and spend years learning how to swim in it. How do we get home care? Respite care? OT, PT, speech? Will insurance pay? How do we actually go to work or out to dinner again? How do I coordinate all these doctor’s appointments? What about my other children??

 

The world of autism back then (yes, I am older than I look thanks to Botox) is not the world of autism now. Back then, people only knew Rain Main. Getting an “accurate” and comprehensive diagnosis was expensive (thousands of dollars out-of-pocket) and therapeutic services were scarce and certainly not covered by insurance. Medications were still in clinical trials.  School-based services were limited.  And, as a cherry on top, The Lancet had just published the infamous study regarding (the lack of a connection to) the MMR vaccine.  In sum, families felt absolutely lost and overwhelmed…on a good day.

 

Their struggle to figure out the healthcare system had a profound effect on my career. I learned that the system was not built to help those with chronic illnesses. I also learned about insurance coverage and what IS and IS NOT a “covered benefit”. Parents of kids with autism were masterful at getting their kids the services they needed. After learning every tip and trick they could teach me, I vowed to study healthcare and “fix” the system. 3 years into my job, I enrolled in the Master’s of Public Health program at UCLA over the PhD I had intended to pursue.

 

Those children and families re-routed my entire career. I was reminded of that when I met a Mom of an infant with chronic medical issues.

 

She actually said to me “I hope we get an autism diagnosis so he can get the services he needs.” It made me think of all the fearless parent advocates that I met early in my career. The lawyer/Mom who quit practicing corporate law to become a full time legal advocate for families and lobbyist. The Dad who paid out-of-pocket to publish an entire resource guide for parents – reviews of doctors who were helpful, the best schools/school districts for special ed, camps, babysitters. He was “Yelp” for autism services before the CEO of Yelp was even born. The social worker who trained parents on exact words to have documented in school IEP’s or medical records so services were covered by insurance. I didn’t appreciate these early teachers then but this Mom’s words sent me reeling back in time.

 

Maybe we did – in some very small way – fix the system for kids with autism if this Mom is actually “hoping” for this diagnosis for her child? But she was still asking the same kinds of questions that those parents did.  How do we get 24/7 nursing care?  How do we coordinate doctors so they are communicating?  How do we get insurance to cover ____?

 

Yes, we have made progress and still have a long way to go. I only hope these fools running toward the Oval Office are inspired enough to keep things moving forward.

Uninspired
Caitlin

Finding the Right Doctor for You

How do I find the right doctor?

Before we can address this question we need to ask another important question…what kind of doctor are you looking for? To keep things simple, we’re going to talk about two general types of doctors…

Primary care providers (PCP’s) and medical/surgical specialists.

Specialists are care providers that have very specific expertise like Cardiology, Neurology and Orthopedic Surgery, to name a few.

Primary care providers keep us healthy. You most often use your PCP for annual check-ups or when you have a minor acute illness like a sinus infection, flu, etc. Here are a few things to consider when looking for one:

What kind of primary care provider do you need/want/prefer?  General medicine? Family medicine? Internal medicine? Pediatrician?

All of these types of physicians provide similar services related to general medicine and prevention but have slightly different training. General and family medicine providers usually see patients of all ages, while internal medicine physicians generally only see adults and pediatricians only see children.

Who is “in network” as far as your health insurance plan?

Choosing a doctor that is “in network” in terms of your insurance plan, will minimize your out of pocket costs in the long run.

How far away is their office  from home, work, school?

You want to choose a primary care doctor, or pediatrician, based on a location that is convenient for you to get to if you or your child are sick.

When looking for a specialist, the game changes a bit.

Ask your primary care physician for a few physicians that they recommend or who they know are leaders in their respective field.

For example, if you are referred to a Gastroenterologist for a colonoscopy, do not base your decision solely on who has the most stars on Yelp. Asking your primary care doctor about someone whose bedside manner that they know personally and can recommend wholeheartedly can sometimes completely change your experience as the patient on the other end, so to speak.

Additionally, consumers don’t always know which provider is outstanding in their field, perhaps conducting cutting-edge research that is related to the illness in question; physician-to-physician referrals are usually best for this.

If you are referred to a specialist in-network, and you are not impressed, seek a second opinion with a physician with a good reputation in the field. Call your insurance company before you go and they will let you know – for your specific health plan – how second opinions are covered (or not). Even if you have to pay out of pocket, it may save you from undergoing an invasive procedure unnecessarily.

 No matter what kind of doctor you are looking for – primary care or specialist, I also recommend:

Asking around – ask friends, ask family. Social media sources and online ranking websites like Yelp and Healthgrades are available to give some color commentary about providers you are considering. Physician credentials, board certification, photos, training, etc. are all available as part of your research.

Go for an office visit – primary care doctors and specialists usually have patient introductory appointments available. If you don’t “click” with that particular provider, move on. Don’t be afraid to ask questions like how often they have done a particular procedure successfully. The patient-provider relationship involves trust, vulnerability and seeing eye-to-eye philosophically and if you don’t jive with one provider, there are plenty of other fish in the sea.

Finding the Right Doctor for You
Caitlin

One Global Perspective on Vaccinations….

Pakistani authorities have arrested hundreds of parents who refuse to vaccinate their children against polio, officials said Tuesday.  Well….this is one way to make sure the population is compliant!  Not my first choice of interventions…

 

Click here to find out more

One Global Perspective on Vaccinations….
Caitlin

Caution…Narrow Network Ahead

Most of the questions people ask me about healthcare are insurance related. Obviously. I mean, who the hell enjoys talking about health insurance? Me. That’s who. Nothing makes me happier than health insurance companies. I love talking to them on the phone. I love filling out their forms perfectly so that they cannot send them back and say they were filled out wrong. It’s a sickness in and of itself. I’m secure. I can admit it…

I gave a presentation to some of our amazing, fabulous, wonderful nurses the other day (did I say that I think nurses are the best thing invented since the wheel?) about the state of healthcare in the US, the state, the local market, etc. As I was preparing my slides, I kept thinking, “Oh I’m sure they’ll know this already…put a few more illogical healthcare acronyms in for fun instead…”

When I gave the presentation, I was surprised at how many questions – during and afterward – were related to one particular theme. The infamous “narrow network”.

Some of you may be asking…what on Earth is that?  Some new product from Verizon?

Let me pose it to you another way…has there ever been a particular physician/specialist you wanted to see? Or maybe one that your child or spouse “needed” to see and yet, you couldn’t because that physician was “out of network”? And if you went to see her/him, it would cost $350 out-of-pocket?

Oh yeah?

Me too.

It’s crap.

Let me explain why it happens and what you can do about it…

Like car or life insurance, health insurance companies rely on covered individuals paying into the system via monthly premium and taking as little as possible out of the system, in terms of expense, in order to make moohlah. Benjamins. Coin. Dough. You know, the green stuff. Shockingly, yes…it’s a motivator.

Health insurance companies negotiate reimbursement rates with specific medical/surgical specialists so that the cost to the health plan is minimal and patients receive adequate care. In exchange for accepting lower reimbursement rates, referrals are directed to these providers as being “in network”. Thus, the network of physicians “narrows” and patients are left with access to only the specialists that the health plan/insurer has pre-selected for them via contract.

Most of the time, this is just fine. In the “yeah-it’s-just-a-mole” kind of scenario…no one cares. It’s when the mole is more than a mole and all of the sudden some physician is going to cut into the skin near your lower eyelid then you care whether or not she/he is in the “narrow network” or not.

Most health plans have provisions in their contracts about seeking second opinions. When someone wants to cut near your eye, for example…and in my own personal opinion, don’t go to the first physician the plan directs you to.

The physician in the narrow network might be perfectly competent but there are a couple scenarios to be aware of:

  1. They might have sub-standard medical credentials and therefore are the type of healthcare provider that is willing to accept lower than market value reimbursement in exchange for higher patient volume.
  2. They may be suggesting a perhaps unnecessary medical procedure (cutting your eyelid), which is reimbursed at a higher rate, to make up for the money they lost on your patient consultation paid for at a lower reimbursement rate.

Look, I’m not saying that all doctors are plotting ways to charge you for things that you don’t need. What I am saying is that there is a time to accept the “in network” choice (sniffles) and a time to seek a second opinion. When someone who is not an eye expert wants to cut into the skin near your eye, demand a second opinion by a reputable physician. Ask your health plan/insurer. Call them on the phone. It’s fun! I swear!

Caution…Narrow Network Ahead
Caitlin

2016 Presidential Candidates on Healthcare

Since the passage of the Affordable Care Act in 2010, healthcare has been a defining issue in many campaigns and elections.  In 2014, only 36 percent of Democratic candidates mentioned support of the Affordable Care Act in their platform.

Not only will next year’s potential presidential candidates from Congress have records and public statements on healthcare, but many of the governors included in Ballotpedia’s coverage oversaw the implementation of the healthcare exchanges in their states in 2014.  It is sure to be an election defining issue.

 

To see how the candidates stack up regarding healthcare, click here. 

2016 Presidential Candidates on Healthcare
Caitlin

The Vaccine Lunacy…Disneyland, Measles and Madness

I live in the epicenter of this lunacy and thought I would share this great editorial with you.  Wealthy, educated people in Los Angeles (and elsewhere) deliberately NOT vaccinating their children.  It’s an epidemic of ignorance…

 

Take a look at the madness yourself by clicking here.  

The Vaccine Lunacy…Disneyland, Measles and Madness
Caitlin

Open Confusion…I Mean…Enrollment

Ahhh…it’s everyone’s favorite time of year. The leaves on the trees are changing. A crisp chill fills the air.  Apple cider. Halloween. Holiday plans. Boots, fleece and turtlenecks rear their heads…and yes…so does Open Enrollment for healthcare benefits and the stress and confusion it brings.

Open enrollment reminds me of registering for college classes on the first day of freshman year. You have no freaking idea what you are doing and all you really care about is living outside of your parents’ house and finding the football stadium. You know the class requirements you need for your major but you are clueless about what you’re signing up for or what questions you should be asking before you enroll. You read the class description, think, “Yeah, that sounds good enough,” and run off to find the nearest tailgate only to find yourself drowning mid-term. Ugh.

It’s not until sophomore year that you start asking the questions you wish you would have known to ask. Who’s teaching the class? How many papers do I have to write? How do they grade? Who do I know that took this class? Did they like it?

When it comes to Open Enrollment, I have done your healthcare homework for you. Below are then 10 questions I think you should ask about every health insurance plan you are considering, whether you are looking at employer sponsored plans or health exchange based plans. The pressure is on for every American to have some kind of coverage. Access to care and coverage is better than ever, which means there are more choices than ever. Choose wisely! I also included a glossary of healthcare terms for when you get stumped.

 

  1. What is the difference between a PPO, EPO, HMO, POS, HDHP and HSA?

 

Healthcare nerds love acronyms. Really, they entertain us. These various types of alphabet soup plans are simply insurance products. Like cars, for example, each have different price points, different options and tradeoffs! Some are go-karts and others Bentleys.

HMO – Health Maintenance Organizations

As the name implies, these plans are great for maintaining health…when you are already healthy. HMO’s are usually lower cost and use the “gatekeeper model” via the use of a “Primary Care Physician” who authorizes referrals for specialty care. The trade off is control.  The upside is that HMO’s are cost effective and provide good preventive care. If you or someone in your family develop a health condition, you may not be able see the specific specialists you want to see within that particular HMO network. Be warned.

PPO – Preferred Provider Organizations

PPO’s provide freedom of choice. They cost the most but also give you the most control over your care. In my own personal opinion, these are the plans you want when you actually have health issues and want the ability to see who you want, when you want.  Patients do not need referrals for specialty care, which is the main attraction.

EPO – Exclusive Provider Organization

I like to think of EPO’s as “PPO lite”. With an EPO, you have the freedom to choose among providers within an exclusive network and do not need a referral to see them. If you go outside the network, however, you will pay for it.

POS – Point of Service

POS plans are like a chocolate/vanilla swirl of PPO and HMO benefits. You still need a Primary Care Physician (PCP) to coordinate your care. See an in-network specialist that your PCP refers you to – you’re in the green. Go out of network and you will pay.

HDHP – High Deductible Health Plan (with or without a Health Savings Account – HSA)

HDHP’s have the lowest monthly premium usually because the deductible is high and the risk/liability for payment is on the consumer. These insurance products are great for people who are healthy, low healthcare utilizers…especially if they can sock away some money in a health savings account.

 

  1. What is the difference between the health exchange plan levels – Catastrophic, Bronze, Silver, Gold and Platinum?

I like the WebMD summary best.  Generally…

Platinum: Covers 90% of your medical costs; you pay 10%

Gold: Covers 80% of your medical costs; you pay 20%

Silver: Covers 70% of your medical costs; you pay 30%

Bronze: Covers 60% of your medical costs; you pay 40%

Catastrophic: This plan only covers your medical expenses after you have reached the annual deductible of $6,350 for an individual or $12,700 for a family. Catastrophic plans must also cover the first three primary care visits and preventive care for free, even if you have not yet met your deductible.

 

  1. What does the plan cover?

Thankfully with the Patient Protection and Affordable Care Act, the following “essential benefits” are covered. The devil is in the details…depending on the insurance product you choose, these may be covered only partially…read carefully!

  • Preventive services (e.g., immunizations) and chronic disease management (e.g., diabetes)
  • Emergency health services
  • Inpatient care
  • Maternity and newborn care
  • Pediatric health services, including dental and vision
  • Mental health and substance-abuse treatment
  • Outpatient services
  • Lab tests
  • Prescription drugs
  • Rehabilitation services

 

  1. Does the plan cover your favorite doctors?

Check the website and call either the health plan or physician office if you are not sure. Don’t make the mistake of assuming they participate in the health plan.

 

  1. Does the plan cover your prescription medications? What is the out of pocket cost?

Learn about your insurance product’s prescription drug “formulary”. Study it and make sure all of your medications are covered, preferably as generics, which are always less expensive. Compare pricing for a 30-day supply verses a 90-day “maintenance” supply (usually available via mail order pharmacy). Call if you are not sure.

 

  1. Is your hospital/health system of choice included?

Check the website and call either the health plan or hospital if you are not sure. Don’t make the mistake of assuming that your hospital of choice or the one closest to where you live participates in your health plan.

 

  1. What are the costs associated with the plan?

Learn about: premiums, deductibles, co-insurance, co-pays and out-of-pocket maximums.

Premium – The amount a heath plan member pays to maintain active coverage. You and/or your employer (or a combination of the two) pay it monthly, quarterly or yearly.

Deductible – The amount you pay each year before the insurance company starts paying. Most/all plans have preventive health services that are covered in full even if the deductible has not been met. Keeping you healthy is in the best interest of your health plan! As an example, if your deductible is $1,000, then you pay up to $1,000 for all services (except for preventive/deductible exempt services) and then full benefit coverage kicks in.  Know which benefits are “deductible exempt” as well as those that are not fully covered until the deductible is met.

Copay – Copays are one way health plans share costs with their members. They are a set amount you pay for a specific service like a doctor’s visit emergency room visit, etc. You pay your part and the health plan picks up the rest! Plans that have low or no co-pay usually have a higher monthly premium. They are going to get it out of you one way or another…it’s all about tradeoffs!

Coinsurance – Coinsurance is different than a copay because it’s usually a percent of cost instead of a flat/fixed amount like a copay is. For example, a MRI might cost $350 and a member may have a 20% coinsurance for that type of a procedure/Radiological study. This varies based on which location/provider you chose to obtain care at. Shop around for services with co-insurance and ask your health plan if they have providers they consider “in network” for the lowest out-of-pocket expense possible!

Out of Pocket Maximum – This is the most you will ever pay out of pocket in a benefit year. Once you hit this, the health plan assumes 100% financial responsibility. Some plans have “individual” and “family” maximums. Read carefully as you may reach an individual maximum and still owe money because you have not met a family maximum.

 

  1. Does the plan cover alternative therapies like acupuncture, chiropractic, and massage?

 

  1. Am I planning to have a major life/health event? A baby? A surgery?

This can really influence what plan you choose…as it should! The last thing you want to experience is becoming pregnant and realizing that the “perfect birth” was not possible because your plan does not cover your physician, your hospital of choice or your doula! Or having major surgery planned and learning that you are going to owe thousands of dollars if you have it at the hospital you prefer by the surgeon you prefer because they are out of network.

 

  1.  Who do I know who has had experience with this plan? Did they like it?

    This goes back to the college metaphor. Ask about the class before you sign up for it. It’s easier than ever with access to online ratings and social networking. Information is at your fingertips…ask around!

     

    Please send me any other questions.

     

    Health Insurance Glossary of Terms:

     

    https://www.healthcare.gov/glossary/

     

    http://www.ehealthinsurance.com/health-insurance-glossary/terms-a/

     

    http://www.agencyinfo.net/iv/medical/health-glossary.htm

     

Open Confusion…I Mean…Enrollment
Caitlin

Thank You, Ebola

It’s not often that one gets to send a shout-out to an international health crisis/epidemic but I have to say thank you to the deadly Ebola virus. Thank you for waking me from my goofing-off-all-summer-then-burying-myself-in-work writing hiatus and forcing me to study public health once again.

Yeah, I did it with SARS, H1N1, Bird Flu, Enterovirus 68…but nothing has me obsessing quite like Ebola.

It’s not because I fear getting it. In fact, I recently watched this video of one of the researchers who discovered the virus near the Ebola River in Central Africa in 1976 handling positive blood samples with no gloves on and now I’m really not afraid.

http://www.youtube.com/watch?v=xc4gZEV8fIo

One thing he (Dr. Peter Piot) mentions in the video is the importance of studying “time, place and person.” This phrase sent me longing for graduate school and Epidemiology class when us public health nerds would sit around, read case studies and try and trace foodborne illness on a cruise ship back to a contaminated pickle. Oh, those were the days.

These Ebola times make me thankful for several things in public health.

I am thankful I live in a country with clean water, sanitation, sewage systems, access to vaccines, access to hand sanitizer, access to information, excellent healthcare and the CDC, an organization dedicated to monitoring, investigating and studying diseases that scare the crap out of everyone else.

I’m thankful to have been born after the Black Death, Polio, Cholera, Smallpox and all we learned from these outbreaks and their management.

I am thankful for people like Dr. John Snow, father of Epidemiology, whose work changed water sanitation principles permanently. Dr. Edward Jenner and Dr. Louis Pasteur, who pioneered research in immunology, germ theory and vaccination development.

We should wake up every day and wash our hands in homage to these public health grandfathers. They are the reason we are doing Ebola drills every day at work. They are the reason personal protective equipment, sodium hypochlorite and autoclaving exist. They are the reason I do the happy dance every year that it’s time to get a flu shot…it might as well be kryptonite.

As I sit in my living room each evening, eyes glued to the news watching this epidemic unfold in societies riddled with fear, skepticism, folk medicine, lack of education, lack of sanitation, lack of resources, drugs and equipment, I am in awe of this very fast moving disease. And I am thankful that I remain in my sanitary, vaccinated bubble.

Thank You, Ebola
Caitlin

2 New Questions

Below are some hopefully helpful answers to questions I’ve received recently. Thanks to those of you who submitted them. I reworded them slightly to keep it anonymous and also make sure they are clear to other readers.

#1 – Doctor Disappointment

Question:
I signed up for a health plan through the health insurance exchange and thought it was a PPO plan. The name was misleading and I just figured out that it wasn’t a PPO and I can’t see my usual doctor with my new insurance. I have been seeing him for ten years. Now what? Start over?

Answer:
I’m so sorry to hear that this happened. Shopping for insurance is so confusing. It’s kind of like shopping for a computer printer. The model names are similar, they will all do the job but there’s a big difference between a good one and a not-so-good one. The best advice I can give you is that when shopping for health insurance, before purchasing anything, call your current doctors (assuming you like them and want to keep them) and make sure they accept the plans you are considering. If there is a doctor you are trying to get into – a specialist of some type – or if there is a hospital you want to make sure is “in network” be sure they accept that health insurance plan PRIOR TO selecting it. This is also important for prescription coverage. Check the insurer’s formulary to make sure medications are covered before you choose coverage. Once you’ve selected an insurer, you cannot change it again until the annual “open enrollment” period. So in this case, I’m afraid you have two choices: 1) start over with providers that are covered by your plan and transfer your care from your current physician or 2) pay cash for the doctors you’d like to see. You can try submitting a health insurance claim for services paid for out-of-pocket but there is no guarantee that they will be reimbursed in full.

#2 – Medication Meltdown

Question:
My daughter has been on a medication for over a year for depression and anxiety. We recently switched insurance companies and her medication is no longer covered. The doctor told us she should not get on and off the medication but has not provided another option. I love her doctor, but a solution would have been nice.

Answer:
I mentioned this in the answer above as well. One thing I always check when I am shopping for a health plan is the formulary. If you or a family member who is covered by the plan are on any prescription medications, make sure they are covered on the formulary before you select that plan. You may have to research various types of generic brands to make sure and you can always call to verify. In this circumstance, I’d say call the doctor to make sure there is another comparable medication, check your formulary to make sure it’s covered and then your doctor can write a new prescription for the new medication.

2 New Questions
Caitlin

Memorial Day…Reflections on the VA Healthcare System

“To care for him who shall have borne the battle.
And for his widow.
And his orphan.” – Abraham Lincoln

My Dad is a veteran. He served during the Korean War. I called him today – in between wasting away a day off and some BBQed meat – to say “thanks Dad, for going to war for our Country. I am very happy that you are alive and well.”

My uncles are vets too. Vietnam. Ugh.

The VA health system has been in the news lately…an expose over outrageous wait times for appointments (greater than 14-days). The Department of Veterans Affairs is investigating whether or not long wait times contributed to the deaths of numerous veterans. Appalling. The very people who served in the worst of the worst times in American history have – once again – been shafted. The whole situation has made the VA – who in reality has been a pioneer in healthcare quality and information technology – look very, very bad.

There has been talk of “privatizing” the VA system to make “improvements.” Hmmm. Do we really think wait times in “private” healthcare are better? A 2014 Merritt Hawkins survey makes me wonder…average wait times in private industry are almost 19 days…45-days or more for some “super-specialists”.

While I disagree with anything unethical that was done by the VA to prevent my father and uncles from getting the care they need when they need it, I also think we need to examine the real root of the problem…

Wait times are caused by lack of doctors available to see patients. Doctors are under tremendous pressure – 15-minute appointments to diagnose and treat complex patients in a litigious society where everyone is waiting for them to make a mistake. They conduct research, apply for grants, work multiple jobs to pay down student loans, educate communities, raise families and have a life of their own.

Being a doctor isn’t like it used to be. They don’t make the money that people think they do. Physician time/services are reimbursed poorly and malpractice coverage rates rise higher and higher.

On this Memorial Day, let us not only remember those who have given their lives for our Country but also those who save them…everyday.

Memorial Day…Reflections on the VA Healthcare System