Our Christmas Day tradition includes dinner and a sleep-over with some of my favorite people in the world. It’s filled with three generations of family members, ranging in age from four to 80. Careers represented include a hospital president and vice president; a hospital-based pharmacist; a social worker; a teacher; several retirees and me. Needless to say, healthcare tends to be a hot topic!
One issue covered was my dad’s recent difficulties walking; it appears that the arthritis in his hip is becoming worse, altering his gait, causing pain and leading me to worry about the dreaded implications from a fall of an older individual. As an only child with snowbird parents, I was also thinking about the implications for me!!! It is time to develop a plan for hip replacement so my parents can continue to enjoy the independence and wonderful quality of life they now have. (Note: Permission was granted this month by my parents to tell you about all this!)
Humor was abundant as we chatted about our respective health issues, particularly regarding who would be caring for whom as we all continued to age (the younger generation wanted nothing to do with this, but they’ll come around!). So common were our collective ailments, in fact, that it was suggested I break this newsletter up into more specific sections, such as “The Coumadin Corner,” “The Total Knee Replacement Club,” and “The Happy Hip Update.”
But when the conversation shifted to health insurance, the tone became decidedly more somber – it was obvious that the changes already occurring regarding the ways in which we access and pay for healthcare are causing much confusion and frustration. When we dove still deeper into the topic of Medicare, the festive mood evaporated entirely.
Change is everywhere
As our Christmas dinner conversation demonstrated, and as I notice every day in both my personal and professional lives, big healthcare changes are here, with many more still to come. Navigating these smoothly and in a way that points towards creating the “Perfect Healthcare Consumer Experience” (my primary professional goal) requires both knowledge and assertiveness.
Here then, are some trends worth understanding in order to adapt as effectively as possible.
- You’ll spend more to get less.
As you embark on a new plan year with your employer-sponsored or Medicare insurance plans, be sure to read the fine print regarding the premium, the plan, how it generally works and, most important, how specifically it will work for you.
Chances are, your benefits will be less generous than in the past. For example, medications that once fell into one tier may have changed and now your co-pay has increased. Or maybe your deductible and out-of-pocket maximum are higher and you need to prepare for greater out-of-pocket costs. Read the fine print in order to avoid surprises.
- Networks and referral requirements will be more restrictive.
It’s more important than ever to follow the protocols outlined in your Evidence of Coverage – the 100-page (or so) document that is your official contract with your insurer. Failure to do so can lead to unplanned healthcare expenses.
As always, if you are unclear as to what is expected of you, go to your insurer’s online resource (you may need to register first) or call the customer service number on your ID card. When speaking to a customer service person, rather than settling for general information, describe your scenario and ask specifically how such a claim would be paid. And if he/she uses insurance terms you don’t fully understand, be sure to ask them to restate using different language. (Can you tell this is a pet peeve of mine?)
- Retiree medical plans are being reorganized.
For those fortunate to have retiree medical benefits, be aware that these plans are going through major overhauls as large employers seek more cost-effective solutions for delivering health care to their pre-65 retirees. Today, thanks to increases in cost and the availability of new individual coverage options under the Patient Protection and Affordable Care Act(PPACA), they may have found some new alternatives.
Over the past two years, I’ve worked with numerous clients who are totally overwhelmed by the changes being made to their retiree medical benefits and the way in which these benefits are delivered. The large packets of information received in the mail by older individuals can wreak some havoc in their lives so do your best to understand how these changes affect you or your parents.
- Primary care practices are evolving.
As physician organizations change to incorporate Patient Centered Medical Home Models of Care, you can expect…… nurse practitioners and physician assistants to become a major point of contact for you as a patient.… nurse care managers, patient educators, social workers and pharmacists to interface with the more complex patients, with the goal of helping patients be more compliant with outlined plans of care.… greater availability and use of Patient Portals for communicating with patients.… patients being asked to become more responsible for lifestyle changes that focus more on achieving and maintaining health rather than treating illness.This is all music to my ears but, again, it requires each of us to pay greater attention to our relationships with our providers and to managing our own health and healthcare.
I know, all these changes can sound a bit scary. But don’t worry, as was evident during our Christmas dinner conversation, attempts to understand and manage our respective healthcare in this new environment is something we are all going through.
One thing is for sure – healthcare will continue to evolve, requiring us all to be flexible and open to change. Next year, I’ll be sure to let you know how everyone is feeling about the topic. And I’ll keep you posted on my parents too … with their permission of course!