Author Archives: Dianne Savastano

Health Care Decisions: Black and White vs. Gray Areas

Black and white scenarios are simple. They usually involve just one decision and there is some predictability in their outcome.

Gray areas, on the other hand, involve several, often interconnected decisions and vary based on the preferences of the people involved as well as their particular circumstances. These scenarios are often unpredictable and can be confusing or stressful. They may, at times, even feel unfair.

Consider the case of my client, Jim. He was approaching 65, planned to remain working and had health insurance through his current employer. His wife, also 65, was retired and had access to retiree medical benefits for both herself and her spouse. Jim had to choose among the following options:

  • Stay on his employer-sponsored plan
  • Access traditional Medicare and its suite of associated products
  • Revert to his wife’s retiree medical coverage

He was confused.

Another client was diagnosed with a blocked cardiac artery. He also had three options presented to him:

  • Take several cardiac medications and be closely monitored for symptoms
  • Have a cardiac catheterization procedure that could involve insertion of a stent to open the blocked artery
  • Consider the need for open heart cardiac surgery as a possibility if stenting was not appropriate

He wasn’t sure what to do either.

A third client, Barbara, was caring for her spouse at home. He had Alzheimer’s Dementia that had now progressed to the point where caring for him alone was becoming unsafe for Barbara and her husband. Her options were as follows:

  • Share caregiving responsibilities with her children
  • Hire private help in the home to assist her
  • Research and possibly move her husband to a Memory Unit in an Assisted Living facility

All of these options posed dilemmas for her.

How to sort through the choices available

Clearly, and in all three of these examples, the decisions to be made are in that murky gray area of “it depends.” How then, does one decide? Here are a few suggestions to help you and your loved ones through the process:

  • Gather as much information as possible


    For the gentleman choosing his insurance, a spreadsheet that compared benefits and the cost of each option helped him decide.For the man with cardiac disease, a long discussion with his cardiologist, during which she outlined the risks and benefits of each choice based on the scientific literature, was helpful.For the woman caring for her husband, a discussion with her children about their availability to help, as well as researching the cost of in-home care or a move to a Memory Unit was invaluable.

  • Don’t go it alone

    These are big, potentially life-altering decisions; there is no reason you need to make them alone. As I’ve mentioned in previous newsletters, there is tremendous value in having a Care Partner who can attend physician appointments, acting as another set of ears, a scribe, and a helper.A Care Partner is equally useful within these gray areas of decision making. They can help by:
    • Listening
    • Helping you to identify all the options available
    • Helping you think through the implications of each decision
    • Helping you reach a decision you can live with
  • Superimpose your preferences on the options availableThe man facing an insurance decision liked his employer-sponsored plan and was not looking forward to a change that might impose an administrative burden on him.The man with the artery blockage wanted to resume all his activities and did not want to be held back by symptoms of angina that might occur.Barbara had a preference for caring for her husband at home.

  • Listen to your intuitionOnce you’ve gathered information from as many sources as you feel comfortable with, listen to your gut about what the best decision – for you – may be. We’re all different; intuition is about acquiring knowledge and then making decisions through emotions. So ask yourself: “Is what I am about to do in keeping with my values?”In the insurance example, Jim valued an outcome in which he would pay no more than was necessary for what he thought was beneficial. He felt that his current plan was very valuable.For the man with the cardiac issue, he valued independence and vibrancy. He wanted a solution that would restore that.In Barbara’s case, she valued the commitment she and her children had made early on after her husband’s diagnosis: to care for him at home if it did not place any undue burden on her or her children.

  • Do the best you can; recognize that decisions are often iterativeJim had the option of continuing on his employer-sponsored plan for now and putting off a decision between traditional Medicare and his wife’s retiree benefit when he retired two years later.The man with the artery blockage wanted to have the catheterization and hoped a stent could be inserted. If need be, he will embark on surgery.Barbara decided to care for her husband with the help of her children and outside assistance. If the time comes where a move to a Memory Unit is needed, she will cross that bridge then.

Conclusion

As you and your families are presented with health care choices, always remember that clear cut, black and white decisions may not be possible.

Learning to live within gray areas of decision making by using some of the suggestions above can help you make choices that are both sound and comfortable.

Our Health Care Is Our Own Responsibility

Dianes DadIt all began two years ago, when my dad noticed a growth under the skin of his upper right arm. This “lipoma” (a benign, fatty tumor) didn’t bother him and so we, in collaboration with his physician, decided to do nothing about it.

Eighteen months later, he started to complain of a strange, sporadic tightening sensation in the right arm followed by an odd feeling in his head (“a sort of lightheadedness”) that would go away when he rested for a few minutes.

We went back for a re-evaluation and, thinking the lipoma was now pressing on the artery of his arm, had the tumor removed.

But the problem didn’t go away. Both my dad’s primary care physician and the surgeon who had removed the lipoma continued to speculate it was a vascular issue rather than cardiac, since his symptoms were on the right and not the left.

Finally, after a thorough evaluation and medical record review, a vascular surgeon suggested that maybe it was cardiac, even though the symptoms were “on the wrong side.”

One cardiology evaluation, two stress tests and an angiogram later, it was determined that my dad had two coronary artery blockages and would require bypass surgery, something that was performed successfully earlier this month.

Whew! My dad is home now and recovering beautifully. Still, I don’t mind telling you that when the ordeal was over and I had some time to think, I found myself feeling more than a little bit embarrassed.

Why had it not occurred to me to pursue a cardiac evaluation earlier? After all, the signs were all there: Shortness of breath when walking; lightheadedness that resolved immediately with rest; pain in the upper arm.

And while my dad’s cardiologist tried to soothe my feelings by asking me when I had become a cardiologist myself, I couldn’t help but wonder how I had missed the obvious.

Anchoring Mistakes

According to Dr. Jerome Groopman, fifteen percent of all people are misdiagnosed as a result of “errors in thinking” by physicians.

He explains that within the first 18 seconds of meeting with a patient, a physician will generate an idea in her mind of what’s wrong, often interrupting the patient’s story in the process. This “anchoring mistake” may cause the physician to fixate on that snap judgement.

This judgement might be based on…

… the first thing the patient says;

… something in the medical records that somebody else concluded previously;

… not listening effectively;

… some combination of all three.

In my dad’s case and given that, as the cardiologist explained, “he had an atypical presentation of a very common disease,” it’s easy to see why, initially, we were all led down the wrong path.

That’s why Dr. Groopman wants us, as patients, to understand how physicians think and to encourage our doctors to think more broadly. Specifically, he suggests asking two critical questions when given a diagnosis:

  1. “What else could it be?” This can help prevent the anchoring described above.
  1. “Could two things be going on simultaneously?” This may encourage a thought about the possibility that there is more than one answer for a common symptom.

Lessons learned

Over the past two weeks, I’ve relived every conversation I had with my dad and his doctors, going way back to the appearance of his first symptoms. Here then are some suggestions to help you and your loved ones act as your own best advocate when you suspect something may be wrong:

  • Pay close attention. Write down when symptoms occur, including what else might be going on when you experience them (e.g., “It happens when I walk and goes away when I stop.”). This may help in identifying a pattern you can share with your doctor.
  • Try not to self-diagnose. Let your physician do her job, asking questions, listening and assimilating information.
  • Gather all relevant medical records. This is especially important if you receive care in multiple health systems that don’t communicate electronically with one another. It also helps any specialist you see be more efficient and may prevent duplication of a diagnostic test.
  • Share your entire story. If your physician interrupts too soon, state that you are not sure she is listening to the whole story and you want to be sure she has as much information as you do about your body.
  • Ask Dr. Groopman’s questions. If a hypothesis is developed or a diagnosis made, and a plan of care is outlined, ask the questions Dr. Groopman suggests: What else could it be? Could two things be going on simultaneously?
  • Speak up and walk away if necessary. If you don’t feel heard, muster up your courage to politely say so: “I’m not feeling totally comfortable that you’ve heard all I want to tell you. I’m unclear as to why you’ve come up with this diagnosis and plan of care. Can you help me to understand more fully?” If you continue to remain uncomfortable, pursue another opinion.

Conclusion

My experience with my dad – something that occurred despite the talented group of physicians with whom we worked as well as my own professional focus – reinforced for me the importance of acting on our own behalf, pushing back when things don’t seem right and looking beyond the obvious.

I am forever grateful for those professionals who listened, evaluated, communicated and came up with the right diagnosis in time. I, for one, will be more vigilant in the future!

Taming Healthcare’s Administrative Barriers (and the Frustration that Accompanies Them)

As healthcare consumers manage illness or chronic disease, and as they access diagnostic testing or treatment, they often experience anxiety and fear about the potential of pain and the uncertainty of the future.

On top of that, they are forced to live within the confines of their insurance policy, something which – often for the first time – requires them to pay close attention to what’s covered, what’s not, and what the parameters are in accessing care (e.g., referral requirements, staying within a network of doctors and hospitals).

Ideally, consumers would pay close attention to this when they enroll in an insurance product. But let’s be honest with each other … reading the details of an Evidence of Coverage document is not all that exciting.

And that’s why, at the intersection between accessing care from providers and living within the confines of insurance coverage, that frustration begins to bubble up.

A frustrating summer with long, long periods of time on the phone

When my parents became snowbirds, their change of address necessitated a change in theirMedicare Advantage Plan. Because they spend five months of the year in New England and come home for the major holidays, I purposely chose a national company that had a “Passport Program,” something that would allow them to access in-network care while home so that they could maintain relationships with physicians who’d treated them for years, and I could continue to accompany them to appointments.

And so as we planned for my dad’s total hip replacement this past June and some specialist care for my mom, we knew what we needed to do to enact their Passport Program. And yet it took at least an hour on the phone, per parent, to make this happen. We specifically asked if any referrals were required and were repeatedly told no. We were also told that no prior notification or authorization was necessary as we planned for dad’s surgery.

Despite that knowledge, I still had to make more phone calls and spend at least another five hours on the phone with various entities, one of which was a member of the administrative team from my dad’s surgeon’s office. Not only did I have to convince her of the requirements of the plan, continuously reiterating that a referral and prior authorization were not necessary, I had to deal with the threat of cancellation of his surgery if I did not obtain a referral.

We got through it, the surgery was not cancelled, dad is doing well, and all the bills have been paid.

My point, however, is that even with the knowledge and experience I have, the administrative barriers are sometimes so onerous that it can take hours of your time and lead to feelings of frustration.

Taming the administrative beast

Here are some things you can do to prevent frustrating experiences of this type:

  • Pay attention to what you’re buying

    As you enroll in employer-sponsored plans, Medicare plans, or buy insurance on the open market, be sure to pay attention to what it is you are purchasing. A great way to educate yourself is to call the insurer ahead of time and state you are contemplating buying a particular plan but, before you do, you want to know how it’s going to work in real life. Present a situation such as, “What if I need knee surgery in the year ahead that may include having an MRI and staying in the hospital for a day or two? How will the plan work?” Specifically ask what you need to do, what the provider needs to do and how you can expect claims will be paid.When I’m reviewing policies, I focus on the items listed below. If you review the same things when purchasing a plan, you’ll be ahead of the game.

    • The premium
    • The deductible
    • The out-of-pocket maximum
    • The network I have to live within
    • How big-ticket items like hospitalizations will be paid
    • Whether any out-of-network benefit exists and at what level those claims are paid
    • Are my doctors and hospitals in the network
    • Are there referral requirements
    • Are there prior notification rules
    • Are there prior-authorization rules
  • Pick up the phone and call

    The realist in me knows that even if you did a comprehensive job when purchasing your plan, you may not remember when you go to access care. So I suggest you do the following:Ask the business office representative in your provider’s office what their understanding is of how your plan works.

    They often know when a referral is required or prior notification or authorization is needed. Bear in mind, however, that they may not always be right. As noted in the story about my dad, the representative was insistent upon certain things that were not necessary (because of his Passport Program). And while she later acknowledged that this product was not one she was familiar with, in the meantime, she caused me a great deal of angst the morning of surgery when she said we might need to cancel. (I did not share that with my dad as I spent yet more time on the phone; he had enough to worry about that day.)

    Using the information you get from the provider’s office, call to verify.

    When you call, have your Evidence of Coverage in front of you and ask the representative to reference the page and paragraph that addresses your question. That way, if you are in disagreement with what your provider thinks, you can reference the actual paper policy.

    If there is disagreement, arrange a three-way call between you, the insurer and the provider’s representative.

    This isn’t always easy to pull together, but I must compliment the insurance company representative who helped when I was troubleshooting for my dad. She was amenable to getting the provider’s representative on the phone and we finally got things cleared up.

Conclusion

Although insurance policies do not make for the most interesting reading, be sure to pay attention to what you are buying and to the rules you must follow when using the plan to access care.

Remember, should the administrative process fall apart, you are the one who will feel the impact. Being pro-active in this regard can save you a ton of time, effort, phone calls, and frustration in the future.

Medicare Open Enrollment – Two Reasons To Reassess Your Plan Each Year

Medicare Open Enrollment occurs each fall, lasting approximately seven weeks, from mid-October through early December, with coverage taking effect on January 1st. There are a number of important decisions to be made and for most people, this first time enrollment is a big event, as it should be.

Unfortunately, many older adults (and the children who help them through the process), fail to reassess their specific plans and coverage on an ongoing, annual basis. Instead, they simply allow last year’s decisions to roll over for another year.

There are two reasons why this can have negative consequences:

First, your healthcare situation may have changed.

When I help someone to enroll in Medicare, I begin by asking the following questions:

  • What medical conditions are you managing?
  • What specific medications do you take, including dosages?
  • What’s your current utilization level of the healthcare system? For example, what is your frequency of physician visits and hospitalizations?
  • What’s your anticipated use of the healthcare system? Will you be having any diagnostic testing or elective surgical procedures in the next year?
  • Where do you prefer to access your care?

Answers to these questions can then be superimposed on the Medicare options available,helping one understand how their insurance will work as they use it, as well as what the associated costs for premiums and out-of-pocket expenses will be.

But here’s the wrinkle: your situation may have changed.

For example, maybe when you initially enrolled, you were managing minimal medical conditions. Today, however, you may be planning for two, total knee replacements over the next calendar year. With that in mind, you’ll want to reassess and review the options available.

When you do, carefully consider these additional factors:

  • Your monthly premiums
  • Your deductible, if there is one (because you’ll be paying it)
  • The hospitalization benefit (because you’ll be using it). How many days are covered and at what level? Is there a daily co-insurance and, if so, for how many days?
  • The skilled nursing facility benefit, in case you need it. How many days are covered and at what level?
  • The cost for diagnostic testing and, in particular, X-Rays, CAT Scans and MRIs
  • Is a referral required? If so, you must follow the rules to receive any coverage.
  • Does a specific network need to be considered? If so, is your doctor and/or hospital in that network? If not, are there any out-of-network benefits and how much will that cover?

As you can see, upcoming health-related events can have a significant impact on the Medicare coverage you’ll need. What you had before may no longer be what is best.

Second, your healthcare plan may have changed.

Although insurance companies are required to notify you if your plan has changed in any way, I find that most people pay little attention to the written notifications they receive during the course of a year. It’s easy to ignore paperwork and think that if you don’t do anything, you’ll be re-enrolled.

That’s true. But if you don’t pay close attention, you may be quite surprised by your “new” coverage.Benefits may change and you could find yourself with out-of-pocket expenses you had not anticipated.

For example, a new client called me when she found herself paying $100.00 more for each MRI, a diagnostic test she requires fairly often to manage a medical condition. She also discovered that her co-pay for two different medications she takes regularly is now $95.00 instead of the previous $50.00. Yet another medication was no longer even covered. Lastly, she now had to pay higher out-of-pocket expenses for the hospital at which she routinely received her care (she could pay less if she switched hospitals, but that’s not what she wanted to do).

All changes that resulted from modifications to an existing plan in which she was re-enrolled.

So what should you do to guard against such changes? Here is what I suggest:

  • Revise your list of medical conditions and your comprehensive medication list.
  • Consider the care you will need in the upcoming year and identify which benefit will cover it. Investigate what the coverage level is for that benefit.
  • Check to see if your doctors and hospitals are still in the network. Be sure to ask about your specific plan and not just the company. Although a physician may take Tufts or Blue Cross, they may not take the specific Medicare Advantage Plan you have or are considering from that company.
  • Use the Medicare website. Go to Find Health and Drug Plans and enter your data. The algorithm will sort plans for which you are eligible to enroll, from the lowest cost to the most expensive. But don’t stop there; pay close attention to specific benefits and coverage levels.
  • If you are interested in a specific plan, go the company’s web site and search for the following, specific documents for that plan. Then read them carefully, keeping your individual needs in mind:
Note as well that different insurance companies may refer to these documents using slightly different labels and not every company publishes this detail online. If you can’t find what you need, call and request it.

Conclusion

I find insurance and Medicare to be very confusing to the average consumer. It’s even confusing tome, and I work in this area every day and have done so for many years.

Overall, be sure you pay close attention and ask lots of questions specific to YOUR needs. If you have an older individual in your life, check in with them to be sure they are adequately covered and that they understand the products in which they are enrolled. The devil is definitely in the details; time and effort spent up front will hopefully result in smooth sailing in the year ahead!