Author Archives: Dianne Savastano

Young Adults and the Healthcare System

Not long ago, I was chatting with a special teenager in my life. As we talked, he asked, “What do you do for work?” I knew he had medical issues that required some specialist care, and so I said that I help people to talk with their doctor.

I was shocked when he recounted how much he liked his new doctor, “because she really listened.” (Unlike a previous specialist he had been seeing for the same condition.) He also said that the doctor asked a lot of questions and gave him some homework, including keeping a simple journal to track his symptoms for future discussion.

Overall, he said she had helped him understand what was going on with his body and that when he left the office, he felt like they had a plan to tackle some of what he was experiencing. This was music to my ears! After all, isn’t that what we all want when we visit our physicians?

But it made me wonder how many parents actually teach their children how to create productive, two-way relationships with their physicians. Most of the parents I know have told me about reaching a stage in life when their children go in to see the pediatrician alone — to afford some privacy. But I never hear any of them talk about preparing their kids for what to say when they get in there!

Here is what I recommend. Tell your young adult kids that…

… a relationship with a physician is a two-way street

… their job is to think beforehand about what they want to discuss, and to describe what is going on with their body, since they know it best

… the physician’s job is to listen to what they have to say; if the physician is not listening, it’s okay to ask that they do

… the end of a visit is a time to create an action plan together, and to decide when the next visit will be

(And yes, in case you’re wondering, these same guidelines apply to older adults and their physicians as well!)

Planning for College

In one my many previous professional lives, I was the Director of Managed Care for an insurance company that provided health insurance to college students. In that role, I worked closely with student health centers to offer insurance products that wrapped around the primary care offered through the center.

Our student members had to access health center services first, and then use their insurance if an emergency happened or a referral was needed to a specialist outside of the center. Students that did not have our insurance would use their parents’ plans, a situation that often became complicated if there were regional, in-network restrictions.

One topic that frequently came as a surprise to both students and parents was that if the student was over age 18, and became ill or sought care, the student had to grant permission before information could be shared with their parents. As you can imagine, this could create problems in an emergency situation in which the student was unable to communicate.

With all this in mind, here are some things young adults need to think about and understand in the context of college and healthcare:

What services are available at the student health center and what do you need to do to access that care?

Does the health insurance offered by the college or university require you to first see a provider at the student health center, or are you on your parents’ plan? If it’s the latter, does their coverage extend to your new location?

Is there a Patient Portal associated with the student health center? If so, go ahead and enroll in it so that health information is more readily accessible, and communication can be streamlined.

If you need specialist care, what are the requirements? For example, do you need a referral and/or do you need to stay within a defined network of providers to have any coverage?

Have you signed a HIPAA Release Form? Parents should keep copies of these for emailing/faxing, in order to stay informed as necessary.

Insurance After Age 26

As you may know, once a young adult turns 26, they can no longer stay on their parents’ health insurance plan— they need to get one of their own. This is an opportunity for the young adult to become directly engaged in how our complex healthcare / health insurance systems work, and to pay attention to something they may have previously taken for granted.

But when I insist that the young adult participate in our work together, I often hear things like:

I’m healthy, I don’t need insurance!

Do I really need to spend money on this when I have other things I need?

I’ll just go to an emergency room if I need something!

As we talk further, I end up explaining the following:

The status of their health and any conditions that require management, along with preventive care required to keep them healthy, directly relates to their coverage

How insurance coverage mitigates risk against large, unanticipated healthcare-related costs that can leave them in debt

How an out-of-pocket maximum included on a healthcare insurance product can protect them and their parents

That the Affordable Care Act may help them to enroll in a plan that has adequate coverage for their individual circumstance and may not cost much at all

How health insurance may be a valuable “employee benefit” of a current or future job and how employer-sponsored coverage works

How health insurance must be considered if one plans to start a family

Summary

Whatever your age, it’s important to understand how our equally complex healthcare and health insurance systems operate together. Developing relationships with our providers and our insurers is critical to navigating these well.

The earlier in life one learns such skills, the more informed and satisfied you will be!

Silver Linings During COVID-19

The COVID-19 pandemic has given me a gift this winter: spending more time with my parents. We decided they would stay in Rhode Island, rather than spending the October-May timeframe in Florida, as they usually do.

In our little pod, we have been able to continue our holiday traditions and to develop some new ones along the way, such as adding Scungilli salad with warmed Italian Bread to our Christmas Eve menu. (Someday, I’ll share the story about my Irish husband’s experience on Federal Hill on Christmas Eve 2020, picking up the Scungilli Salad and the Italian cookies we just had to have!)

Having my parents nearby this winter has also given me the opportunity to follow up on some long-backburnered items surrounding their healthcare and to get myself more organized on that subject. (I tease them all the time that they are my favorite non-paying clients!)

Read on for some of the steps I have taken, along with suggestions for how you, too, can improve in these areas.

COVID-19 Vaccination

Of course, I jumped on the first opportunity to get them vaccinated. Unfortunately, we were unsuccessful at our first go-round: having a permanent residence in one state while trying to obtain a vaccine in another proved to be problematic.

Despite my skill and experience in managing healthcare-related obstacles, I had no choice but to walk away from a pharmacy receptionist who said she was just following the rules, and who was unable to see beyond them. Fortunately, we were ultimately successful in getting both my parents vaccinated five days later.

The lesson here is that while it is important to persist (always with politeness), there are times when it makes more sense to walk away and regroup.

Even as a professional in this field, I don’t always succeed initially at getting done what I know is in the best interest of the healthcare consumer. Tremendous patience is often required.

Ordering a New Hearing Aid

One unanticipated downside of constant mask-wearing is that older adults with behind-the-ear hearing aids are losing these (unknowingly) at epidemic proportions as they take the masks off. Mom was no exception.

One would think replacement would be easy. But for us, the process involved no fewer than 15 phone calls to the following:

  • The physician’s office (9 calls)
  • The insurance company
  • The insurance company’s new hearing center
  • The second provider where the hearing aid will be purchased

We’ve now had three separate appointments, some during snow events, and finally, the new hearing aids are on order.

In this case, the lesson is the importance of utilizing post-provider surveys. When I saw one of these in my in-box, I seized the opportunity to provide polite and constructive feedback on the experience, stating honestly that I would not recommend them to others.

Fortunately, I received a call from the Practice Manager and we had a wonderful conversation. She appreciated my feedback, responded professionally, helped problem-solve and, to her credit, altered my perception of the practice. Most important, she helped facilitate the process from there.

Managing Patient Portals

My parents have primary care and specialist physicians in Rhode Island, Massachusetts, and Florida. Each of these offers its own Patient Portal.

One day, after spending an hour trying to find a particular medical record so that my dad would not have to repeat a diagnostic test, I decided it was time to get these organized. I was shocked: there were a total of 12, each with its own username and password!

With some effort, I now have them organized in one file along with new copies of both their Original Medicare ID Card and their Medicare Advantage ID Card, both of which were requested when they had their COVID-19 vaccine.

Taking Multiple Medications

It’s not unusual for older adults to have numerous prescriptions, over the counter medications, and prescribed supplements. A phenomenon we often encounter is an eventual reluctance on the part of an older adult to consistently take these medications.

Sometimes it’s because swallowing has become difficult. But more often than not, it’s simply because they have tired of “taking so many pills.” So they just stop. Unnoticed, this can contribute to a crisis and even a hospitalization.

Here are some ideas:

  • Create an accurate list of all medications, listed in order of importance
  • Ensure that all are necessary and that drug interactions are not occurring. Ask the primary care physician to conduct a medication reassessment
  • Among those that are most important, create a schedule for when they should be taken throughout the day
  • Investigate if some can be taken in a different form, such as a liquid or a transdermal patch, or if they can be crushed and taken with an enjoyable food, such as applesauce, jam, pudding, etc.
  • If you are living with the individual and you take medications, take them at the same time, so you can model the behavior
  • Be sure you develop a way to monitor compliance and adjust accordingly

Organizing Paper Files

Despite all my parents’ patient portals, I still rely on paper files to manage multiple competing priorities and to help facilitate communication among healthcare providers. In the past, I used a three-ring binder in chronological order. My new filing system includes a different file folder by specialty. Here are some of my mom’s:

  • Primary Care
  • Medications
  • Pulmonologist/Sleep MD
  • Neurologist
  • Otolaryngologist/Hearing Aid
  • Physical Therapist
  • Insurance
  • Patient Portals

The lesson here is that while there are any number of ways to keep medical information organized, the “best” approach is the one that works for you.

Summary

As we continue through these winter months of the pandemic and find ourselves missing the activities we usually rely on to get us through to spring, please look for the silver linings in your life.

More time with those you love, completing projects you’ve put off for a long time, and organizing your healthcare or that of a loved one, can all be incredibly gratifying.

Medicare Open Enrollment — What It Means For You

By Camille Barron

Your mailbox is flooded with literature urging you to sign up for a different Medicare plan. Your insurance company has sent its annual notice, telling you about the changes in your policy for 2021. And your head is spinning, because you don’t know what you should do.

You’re not alone. Medicare can be confusing enough, but every fall the barrage of mixed messages is enough to make anyone feel overwhelmed. Here we will help you sort things out, so you’ll know what’s important and what’s not.

First, a quick refresher on the different components of Medicare and what they each cover:

Component

What it Covers

Part A

Inpatient care, such as in an acute or rehab hospital or in a skilled nursing facility. Hospice services at home

Part B

Outpatient care, including office visits, outpatient surgery, lab work and testing

Part D

Prescription drug coverage

Part C

Known as “Medicare Advantage,” Part C packages Parts A, B and typically D into a single policy

Medicare Supplement

Also known as Medigap, this supplements Parts A and B, which cover just 80% (approximately) of medical costs

During Medicare Open Enrollment, which runs from October 15th to December 7th of every year, people who have a standalone Medicare Prescription Drug plan (PDP) (Part D) or a Medicare Advantage plan (MAP) (Part C)have a chance to change plans for the upcoming year. Common reasons for doing so include:

  • Significant increase in premiums or deductibles
  • Doctors of choice are no longer in-network under a current Medicare Advantage Plan
  • The drug formulary no longer includes certain medication(s)
  • Anticipated better value or more comprehensive coverage

Here are some of the questions we’re often asked during this time.

My medications have changed this year. Should I change my Prescription Drug plan?

If there have been changes to your medications, you should review your coverage to see if your current plan is still the most cost-effective.

You can use the Medicare drug analysis tool on medicare.govto enter your prescriptions and search for the plans in your area. You will see a list of all the options available, including their monthly premiums, deductibles, and estimated drug prices.

Hint: Be sure you pay attention not only to the premium, but to the projected out-of-pocket costs for the year.

My prescriptions haven’t changed. Why should I review my plan for 2021?

Even if your medications remain the same, the coverage and costs for your drugs may be different than last year. It’s important to research this now, before it’s too late. If you don’t, you may find yourself paying a lot more for a prescription than previously. And you’ll have to wait another year to make a change.

Hint: When you conduct your analysis, include competing pharmacies along with your favorite. Pharmacies have different negotiated rates and changing pharmacies may save you money.

I’ve received a notice stating that a new plan from a different company will replace my current one. Is there anything I need to do?

Mergers and acquisitions are common in the insurance industry. If your Prescription Drug coverage is moving to a new plan with a different carrier, don’t assume your costs and coverage will remain the same. It’s important to run a drug analysis to find out what your estimated costs will be under the new plan and whether another option is a better fit for you.

Hint: The notification you receive from the new plan will not encourage you to look elsewhere. You have to do this on your own.

I have a Medicare Advantage policy. What steps should I take to be sure my coverage is still the best for me?

First, as with a standalone Part D plan, it’s worth checking the prescription drug coverage of your existing policy and comparing it to the coverage under a different Medicare Advantage plan.

Second, review the out-of-pocket costs, such as deductibles, copays, and coinsurance, for next year. Some costs may be the same, and others may have increased, or even decreased. Still other plans have added new benefits.

Lastly, review the provider directories to see if your current providers are still in the plan’s network. This is perhaps the most important thing to know if you want to continue seeing your doctors at in-network rates. If your plan is a PPO, you can go outside the plan’s network, but you will pay a higher fee. With an HMO, only in-network providers are covered; if you see a non-network doctor, you will pay the full cost of the visit.

Hint: Just because your provider was in the network last year does not mean he/she is in the network this year. A provider’s status can change, even within a given year.

Should I consider changing my Medigap policy?

Unlike Part D and Medicare Advantage insurance, Medicare Supplement (Medigap) policies are not as restrictive in terms of timing for making changes. Instead of waiting for the Annual Open Enrollment Period, you may apply for a different Medigap plan any time throughout the year. However, after you have passed your Initial Medicare Open Enrollment Period (IEP), you may not be guaranteed acceptance in the new plan.

In all but three states, during your IEP, you’re in a Guaranteed Issue status, meaning that the insurance company must accept your application with no health questions asked. Outside of the IEP, you may apply for a different plan, but will have to answer health questions on the application. Depending on your health history, you could be accepted but at a higher rate or denied coverage altogether if you do not qualify.

Hint: It is rare that we recommend changing your Medigap policy, but it is always worth spending some time evaluating any changes in benefits and cost.

What’s new in 2021?

We follow the industry closely throughout the year, but especially during Open Enrollment, when changes are most often introduced. Here are just a few that we know of so far:

  • Medicare Part B premiums will increase slightly,but the exact amounts will not be finalized by Centers for Medicare and Medicaid Services (CMS) until late 2020. Currently, the standard premium for Medicare Part B is $144.60 per month.
  • Part B Income Related Monthly Adjustment Amounts (IRMAAs) for higher-income earners will increase. The income thresholds that require you to pay an IRMAA may also change for a single person and for those filing joint tax returns.
  • The Part B deductible that is currently $198 per month in 2020 (up from $185 in 2019, and $183 in 2017 and 2018) may increase. The federal government has not yet announced the Part B deductible for 2021, but the numbers from previous years give us a good idea of the ballpark range.
  • The maximum allowable deductible for standard Medicare Part D Prescription Drug Plans (PDP) will be $445 in 2021, up from $435 in 2020. In many plans, the deductible only applies to higher-tier brand name drugs, so if you use generics you may not be subject to a deductible.
  • Medicare beneficiaries with Part D coverage (stand-alone or as part of a Medicare Advantage plan) will have access to low-cost insulin as part of the Part D Senior Savings Model. Approximately one-third of Prescription Drug Plans will offer different types of insulin for a maximum copay of $35.

Summary

Changes are constant and it’s important to separate fact from fiction and avoid taking things at face value.

The only way to know how these changes will impact you is to conduct a comprehensive and detailed analysis of your individual situation, based on how and where you access care, and on the specific prescription drugs you take.

It pays to be an informed consumer, especially when it comes to healthcare!

Insurance Coverage Barriers Matter As Much As Cost

Consider these three recent client examples…

#1. Mr. Smith.

He has significant, chronic medical conditions that require care from a primary care physician and several specialists, one of whom is in a different state than where he lives. He has experienced numerous hospitalizations as a result of his conditions and has a favorite specialized unit in a specific hospital that is very familiar with his case.

In choosing an insurance product, his priority was to have coverage for all these physicians and facilities.

Mr. Smith was considering a Medicare Advantage Plan that was a Health Maintenance Organization (HMO) insurance product. I advised against this. To have coverage under this type of plan, he would be required to stay within a network of physicians and hospitals. Further, he would have to designate a specific primary care physician and obtain referrals to physicians and facilities within the network for specialist care.

Given his care priorities, enrolling in traditional Medicare Parts A and B, and supplementing his coverage with a Medicare Medigap/Supplement Plan along with a separate Medicare Part D Prescription Drug plan, was a much better option, one that would give him more choice and less worry about the future.

#2. Ms. Jones.

She was told that her insurance would not cover an MRI recommended by her physician for an acute back injury. She was in such pain that she decided to pay the $800 out-of-pocket cost for the procedure and appeal the insurer’s decision later. That’s when she contacted us.

Her insurance product denied payment because of the specific clinical criteria they follow to approve such diagnostic testing. The denial stated:

The test should be used when the pain has not improved after six weeks of treatment by your doctor and that treatment should include medications and other forms of therapy such as home exercises and physical therapy. The test was to be used only if it was likely to result in a specific change in treatment and that the change might be related to the need for surgery or a procedure.

As part of the appeal, we asked her physician to write a letter to substantiate his clinical recommendation for an MRI before more conservative treatment was employed.

An alternative for Ms. Jones would have been to wait for the MRI to be approved, following her physician providing up-front, additional clinical documentation to substantiate his recommendation. Such prior approvals are often successful but delays in care result.

#3. Mr. Johnson.

We helped Mr. Johnson overcome numerous delays on the way to being diagnosed with severe sleep apnea. His physicians were optimistic about the good clinical outcomes he might experience from consistent utilization of continuous positive airway pressure therapy (CPAP) to help him breathe more easily when he sleeps.

Unfortunately, his Medicare Advantage Plan only covered a small list of approved medical equipment providers. Of these, the only local one required much additional documentation and was booking appointments 4-6 weeks out. In the end, it took us an additional four months(!) to work through the administrative issues we encountered.

These are just three examples of the kind we experience every day on behalf of our clients. As you can see, the type of plan one chooses plays an important role in determining coverage. Medicare Advantage Plans often appear to be less expensive up front, but the limiting of choice, administrative barriers to accessing care, and out-of-pocket costs as you access that care can be problematic.

Some Practical Suggestions

As much as I wish our healthcare system were easy to manage, it is complicated and something we must learn to live within. With that in mind, here are some ways you can be proactive, taking control where you can and reducing worry.

Anticipate. Every insurance product has administrative barriers. Expect that yours does too.

Learn. Read about your coverage. Call your insurance company before you access care — to verify that providers are in-network, to ensure coverage levels are what they seem, and to fully understand which diagnostic tests and procedures require prior authorization.

Document. Bring necessary documentation with you to your physician practice. Share what you know regarding steps your physician must initiate to assist with authorization for care. During encounters with your physician’s office and insurer, document the date, time, who you spoke with and what they said (this can be very helpful if you experience delays and/or receive inconsistent information and must escalate a concern to a manager).

Identify. In many healthcare practices, there are designated team members who assist with administrative issues and prior authorizations. Identify these people and develop a relationship so that you can follow-up often and directly.

Ask. When buying an insurance product, call the sales department before you purchase. Ask specific questions regarding scenarios you might encounter. For example…

Regarding networks… “I prefer to receive my care from University of MA Medical Center in Worcester MA. If I access care there, will I have coverage? Will that coverage be considered in-network?”

Regarding prior authorization… “I have a condition that might require an orthopedic out-patient surgical procedure in the next year. How will my benefits work?”

Regarding vendors… “I have Type I diabetes and use an insulin pump. What will I need to do to access my supplies and replacement pumps in the future on this plan? Under what benefit will my supplies be paid and how much of the cost will be covered? Are there specific vendors I must use?”

Whew! I know, it’s complicated and it can be frustrating. Fortunately, as the examples and suggestions above illustrate, there are many things you can do to gain control and reduce worry — not to mention time spent and cost!

Recommended Reading: #justdontgetit

#justdontgetit

As I listen to some of the rhetoric about the incidence and the severity of COVID-19 infections in certain demographics, I feel frustrated and find myself constantly saying, “just don’t get infected in the first place.”

Just this past week, Dr. Anthony Fauci said: “From a clinical standpoint, the thing that is the most perplexing to me as a physician is the extraordinary range in spectrum of disease severity.”

I hope these articles about “long-haulers” impact your decision making as we approach the fall and move inside to more confined spaces:

For Some, COVID-19 Symptoms Linger for Months

Long-Haulers are Redefining COVID-19

‘They’re Not Actually Getting Better,’ Says Founder Of COVID-19 Long-Haulers Support Group