Among our Healthassist team members, we have healthcare advisors focused on the clinical side of the business and insurance advisors focused on that aspect of healthcare delivery. 

Of course, these two areas are very much intertwined. Still, I often find in our weekly, all-team meetings that there are many important and even surprising understandings shared from one group to the other.

With that in mind, here are four insights that emerged while planning an onboarding session for a new team member who will be joining us later this month…

#1. The Value of an Agenda

This concept is so basic and yet so underutilized in physician meetings. Stating an objective, listing topics for discussion, outlining specific questions, and wrapping up a meeting with a summary of the care plan, helps accomplish the following:

• Initiating the meeting with a sense of control. This is especially important, since on average, physicians interrupt patients approximately 20–30 seconds after the patient starts to speak.

• Setting expectations for outcomes.

• Challenging the power differential between physicians and patients by rebalancing the paternalistic model from one that expects patients to be passive and compliant, into a negotiated relationship. 

• Moving toward a shared decision-making modelwhere “What Matters to You” is at the forefront of the discussion.

• Helping the patient remember to ask critical questions. As Jerome Groopman, M.D. outlines, these are especially important when discussing a new symptom or condition (e.g., What else could it be? Is there anything that doesn’t fit? Could more than one thing be going on?).

#2. The Role of Outpatient Palliative Care Consults 

• The palliative care specialty focuses on clarifying goals of care and managing symptoms to promote comfort and reduce suffering.

• These consultations can be initiated as an outpatient.They are especially helpful for individuals with multiple chronic conditions and/or situations in which treatment decisions and outcomes may be ambiguous.

• Palliative care can be used at any stage of a serious illness and can be delivered alongside active treatment.

• You can request a referral from your primary care physician. In some cases, a referral is not even required and you can call yourself.

#3. The Intersection of Healthcare and Insurance

• More than ever before, healthcare delivery and insurance overlap. Team members must consider the details of each client’s health insurance coverage.

• There is a need for a clear understanding of prior-authorization requirements, in-network parameters, and the necessary steps to follow during an appeals process when in disagreement with insurance denials.

• Team members are responsible for educating their clients about these topics, even in cases where someone is gravely ill and may not think knowing this information is a priority. Not following the rules could lead to an inability to access needed care and/or result in huge, unexpected health care costs.

#4. The Complexity of Medicare Part D Prescription Drug Programs

Many of our clients take more than 10 medications on a regular basis. Not only are drug interactions a potential problem, but the cost of these drugs can lead to resistance to taking all that is prescribed. Things to keep in mind:

• Algorithms on the Medicare website allow you to review a medication list and project the expected cost for various medications month to month.

• The algorithm alerts you to when a drug requires prior authorization, has quantity limits, or requires the use of step-therapy before a specific medication will be approved for payment.

• Plans should be reassessed every year, as they can change significantly, causing the drug cost to rise or no longer be covered at all.

• There can be major differences in cost among competing pharmacies.

• Some drugs involve a “specialty pharmacy,” in which case obtaining that drug requires an additional administrative process.

Summary

Recently, I was chatting with a physician. I asked, “How do you define a perfect patient?” At first, she was surprised by the question. But then she said, “A perfect patient is one who is interested in educating themselves and who allows me to share in that process.”

I couldn’t have been happier. That’s because a question I am repeatedly asked by clients is, “How do physicians respond to you? Don’t they get annoyed?” No, they don’t. As this conversation revealed, in our vast experience, most physicians welcome a patient who is informed and motivated to participate in their own care. They want a collaborative — not paternalistic — approach.

And while I wish it were different, accessing healthcare in the United States is an extremely complex process, involving both clinical care and the insurance industry that supports it. As consumers of healthcare, it requires both our understanding of how it works and our hands-on involvement in the process.

You may not be able to control the system, but you can control yourself and the way you interact with it.