Author Archives: Dianne Savastano

Recommended Reading: Health Insurance

These two articles demonstrate how confusion around health insurance is beginning to play out:

Coronavirus survival comes with a $1.1 million, 181-page price tag

I Didn’t Have to Pay a Penny of My $320,000 COVID-19 Hospital Bill. Is That a Good Thing?


This article, “When 511 Epidemiologists Expect to Fly, Hug and Do 18 Other Everyday Activities Again,” helped me in my own decision making about partaking in these activities, now and in the future.

Coping With COVID-19

In previous newsletters, I’ve related personal experiences with my older adult parents as a means of sharing my views on how best to manage a variety of healthcare obstacles and situations. The COVID-19 Pandemic is no exception.

One of the many factors resulting in my decision to cancel a vacation was my need to be within reach (i.e., in the United States) to care for my 84- and 85-year-old parents in the event one or both became ill. I also wanted to be present to meet the needs of clients and their families — supporting, educating and (hopefully!) influencing their behaviors.

Here are some of the things I have been sharing…

Physician visits

We suggested avoiding trips to healthcare organizations whenever possible. We made decisions together to postpone elective appointments and diagnostic testing that could wait.

For those who had urgent problems, we made phone calls to the physician practice in question, to inquire about precautions they were taking. We were so pleased to hear that many of these had already instituted thoughtful and careful steps for protecting patients.

Pharmacies

We recommended avoiding pharmacies but had to be specific about where clients were in the cycle of receiving refills on their medications. Calls to pharmacies and insurance companies were needed to ensure extended supplies of medications where possible.

In some circumstances, clients had someone in their lives who could pick up their medication for them. In other cases, pharmacies were delivering. Those that had to go out, first checked with the pharmacy about picking up via drive through and/or going early, when there were fewer customers.

Greetings

Limiting hand shaking, hugging and kissing, especially with children. We discussed the use of a wave, bowing our heads, or elbow bumps as a means of showing affection.

Appropriate handwashing, how and when

This topic, although being espoused by everyone, had to be elaborated on as most people have never received formal training about how to do this appropriately. Many found the singing of the “Happy Birthday” song twice as an easy guide they could employ.

Everyone laughed when I relayed my sexist attitude about men on this topic. I joked that it was from an observational study of watching the most important men in my life — my husband, father, and grandson — that I have concluded that men don’t wash their hands adequately. A little humor always helps!

Not touching one’s face

This topic was a hard one as everyone reacted with how difficult it is to do. Raising our consciousness was a place to start. My parents have begun reminding each other when they observe this behavior, with the hope they can train themselves to resist the urge.

Staying home

This was a tough conversation with my parents, particularly regarding church attendance. They thought it would be okay because they attend with friends and know everyone who sits near them. I struggled with their desire to attend and to respect their choices.

At the same time, I know that how well you are acquainted with someone has little to do with their potential for infection. In the end, being able to point out that Catholic Bishops all over the country were providing dispensation from attending mass came in handy!

Social Isolation

Many articles and television segments have been devoted to the potential for loneliness as a result of social distancing. I always encourage my mom to be more social, and now I am telling her to do the opposite!

Yes, there are other ways to stay connected. But we must all be conscious of the limitations many of the newer technologies may pose for the less tech-savvy older adults among us. I am fortunate that my parents have each other, and we created a plan to speak twice each day by phone.

Final Thoughts

We must plan to manage the care of our loved ones should they require hospitalization, particularly if they are not local to you. I refer you to previous newsletters — here and here — that describe how to prepare, by having a HIPAA compliant medical release form on hand, along with a Personal Healthcare File.

Unfortunately, we cannot rely on medical record systems to interact with each other, so we must plan to be the conduit of information about our loved ones, representing their baseline level of health and functional abilities. I highly suggest that you take the time to organize your information, just in case.

So much has changed in just the past 24 hours since I sat down to write this newsletter. Please care for yourself, so that you are able to care for others. And, as you reach out to care for the older adults in your life, remember to listen to what they are thinking first and plan from there, constantly adjusting to the crisis at hand.

Health Insurance — What Exactly Am I Buying?

Many of our clients complain about their inadequate health insurance coverage. Often, the cause is a lack of understanding regarding the true costs of coverage, as well as the inherent administrative barriers that exist.

Our goal, always, is to educate our clients. This way, they can make informed selections about Medicare coverage and/or purchases on the Open Market and avoid unwelcome surprises. Of course, when it comes to understanding the role of insurance, there are many factors to consider.

In our experience, these three things have the greatest impact…

Where you access care

When researching options, it is critical to identify the insurance networks in which your primary care physicians, specialists and preferred hospitals participate. Often, this is less straightforward than it may at first seem.

Consider the example of Joe, a recently retired 62-year-old man. Not yet 65, he was ineligible for Medicare. He wanted to purchase an insurance product that allowed him to seek care from a group of physicians associated with a hospital system that he had just retired from. He narrowed his choices to two Preferred Provider Organization (PPO) options. Although he was positive his doctors were in-network for both products, closer examination revealed a different story.

Many insurance products have “Select” networks; these are a subset of a larger provider network. As it turned out, for one of the company’s products, Joe’s doctors did not participate. He identified this only after some painstaking research — first, by looking at the provider network the insurance product listed online; next, by calling the business office of each physician; last, by calling the insurance company directly.

Because the difference between an in- and out-of-network benefit can be significant, verification of this kind can save you a lot of money. In Joe’s case, it meant the difference between 100% coverage with an in-network provider and just 50% out-of-network.

When you access care

At this time of year, we find ourselves reminding clients about deductibles — the set amount you must pay out-of-pocket at the beginning of a plan year, prior to your plan paying benefits. Deductibles are reset annually and can significantly impact your out-of-pocket cost until their requirements are met.

In the case of our client Joyce, and since she is enrolled in a Medicare Part D plan with a $435 yearly deductible that we calculated she would meet in March, we suggested she wait until then to obtain the Shingles vaccines. This way, her out-of-pocket copay for the vaccines will be significantly less than if she obtained them sooner.

How you access care

Joe’s insurance product required prior authorization for any in-patient surgical procedures. Joe knew this because he read the Evidence of Coverage document that accompanied his policy.

After speaking with his insurance company, Joe also learned that it was his surgeon’s responsibility to make the authorization request, so he assumed he was all set. (I think you can guess where this is going.)

Surprise. The day before the scheduled procedure, his doctor’s office called to cancel because there was no prior authorization. As it turned out, the surgeon’s office had not followed through as required.

In the end, and thanks to some last-minute assertive scrambling, the surgery occurred as planned. But it’s our premise that Joe should have confirmed well in advance, to make sure everyone had done their part.

Some Practical Suggestions

As you begin your new insurance plan year, be sure to do the following:

Read the fine print. The Evidence of Coverage outlines all the details. But we know, it’s a lot to read (often more than 100 pages). Another option is to call your insurance company, describe the scenario, and ask what needs to be done to ensure the most comprehensive care. Make sure to document the conversation in your notes and ask the customer service representative how they plan to do the same in their system.

Don’t make assumptions. Your physician is not in the insurance business. Don’t assume they know the specifics of your coverage or what the administrative requirements may be. Sometimes, a three-way call between you, your insurance company and a member of your provider’s business office is necessary. Ask the customer service representatives to outline the specific language in the Evidence of Coverage that addresses your issue. Again, document everything.

Verify and re-verify provider participation in a network. Network participation can change. Make sure your providers continue to be covered by your insurance products!

Summary

Few people enjoy learning about health insurance coverage and its impact on cost and treatment. But it is a reality with which we all must live.

Please, make it a practice to read information about your insurance in advance of receiving care and take advantage of the knowledgeable customer service representatives available to speak with you.

These actions can save you a lot of frustration, anxiety and cost, and allow you to focus on what really matters: taking the best care possible of yourself and your loved ones.

Avoiding a Health Care Crisis

When our client Jean received a phone call from the case manager about her mom’s impending discharge from an acute care hospital, she found herself completely unprepared. From Jean’s perspective, her mom (who had suffered a stroke) still seemed so ill. Jean could not imagine a transition.

What Jean did not understand at the time was that her mother had made enough physical progress that she no longer met the criteria to be in an acute care hospital. At that point, there was another level of care that fell under the guidelines to be paid for by Medicare.

Fortunately, the case manager responsible for discharge planning had been down this path before with many families. She acknowledged how frightening these transitions can be and explained to Jean that a Skilled Nursing Facility(SNF) was now the most appropriate place for her mom.

Research is Critical

Jean had to act fast. She took time off from work and put her other family responsibilities on hold as she prepared for this stage of her mom’s illness. She now understood why an SNF was appropriate, but she was still faced with the decision of which SNF was best.

Jean took the list of facilities provided by the case manager and, with our guidance, developed an action plan. Included below are some of the things we recommended.

#1. Reach out to healthcare professionals.

Jean acknowledged to the case manager that this was all new to her and said the following:

“You do this all the time. You’ve given me a list but how do I know which facility is best for my mom? Tell me about your experiences with these facilities for people who have had strokes.”

Next, she asked similar questions of physicians on her mom’s care team.

Of course, the level of first-hand knowledge of specific facilities will vary from person to person. But given how many people come under their care, day to day, these professionals can often provide tremendous insightinto specific programs and experiences realized by others at various locations.

#2. Decide on the most important criteria for you and your family.

Of course, we all want a facility with excellent quality scores. With her list in hand, Jean made use of two very helpful web sites: Medicare.gov’s Nursing Home Compare site and CMS.gov’s Five-Star Quality Rating System. These helped Jean evaluate the options available.

But other criteria may matter as well. Location, for example. Jean’s dad was very involved in his wife’s care and had hardly left her side following the stroke. Proximity and ease of visitation was very important to him as well.

Additional considerations may include:

  • Quality of medical oversight. What team will provide the care and how accessible are they?
  • Experience with the condition your loved one has, such as post-stroke care.
  • Whether rehab professionals are permanent or contract employees.
  • Availability of a private room, if desired.

#3. Visit potential facilities.

Call the admissions professionals at these facilities and arrange for a tour. This will give you a direct experience with important members of the team and allow you to assess the overall feel and physical surroundings. For Jean, it was important to imagine her mom in one of the rooms and her dad driving there on his own.

Ask about admission criteria, bed availability, medical oversight, ratings, the rehab team, etc.

Also, make sure to meet with more than just the admissions professionals. When possible, ask to meet with the Director of Nursing, the Medical Director, and the Rehabilitation Director.

Time permitting, ask the facility to provide a short list of other client families you can speak with. This will give you another important window into the experiences of those who may have found themselves in a similar situation.

Finally, present your list back to the hospital case manager in order of priority. If you feel strongly about one facility over another, and bed availability timing is not aligning, try to negotiate for additional inpatient days that might allow you admission to your preferred facility.

Don’t Wait for the Last Minute

It’s important to keep in mind that once admitted to an SNF, the same cycle will repeat — the facility will begin planning immediately for discharge. Make sure that you are preparing right from the start, too, for the coming transition:

As soon as your loved one is admitted to a new facility, make yourself available in the first 24-48 hours, to be present for the initial assessments done by the physician, nurse, PT, OT and Speech Therapist. It is during those assessments that the objective and measurable goals are outlined for the first couple of weeks; that will determine when your loved one will be discharged. It is important for you to know what the goals are and how they will be measured.

Request a family meeting within 72 hours of the admission, during which the entire team should come together to discuss the plan of care, the objective and quantifiable goals, and the anticipated discharge date. Reassessments occur regularly and the date can change. But knowing from the start where you stand will help you plan effectively and discuss issues that require problem solving.

If it appears that a discharge to home, even with services, may not be possible, begin the process of investigating long-term-care facilities, using the approach described above.

Summary

I am pleased to say that things are going well for Jean’s mom and that she met her goal of transitioning home. That’s wonderful.

Still, the same result could have been achieved with less stress for everyone involved, had Jean known earlier how important it is to take steps immediately and plan for resources that may be needed.