Specialty Care Requires Special Attention

Although I’ve spent years working inside “the system,” even I became frustrated trying to manage my mother’s health care back in 2005. At the time she complained of pain in her knees that precipitated a referral to an orthopedic knee surgeon. She was diagnosed with osteoarthritis and began conservative treatment with physical therapy. As her knee condition deteriorated, she also developed severe back pain. When she described her symptoms to the orthopedic surgeon he recommended a total knee replacement.

But my mom’s back pain was actually worse than her knee pain and when she asked whether the surgery would help with both, the surgeon was unclear. “Maybe you should see a back specialist,” he said. Maybe? My mom felt frustrated, a bit helpless, and worst of all, she did not feel heard.

This is a great example of the specialization of care inherent in our healthcare system. While it’s helpful to have physicians with advanced training in a specific area, a huge void exists when a person has multiple concurrent medical conditions. Who’s in charge? Who’s looking at the big picture? Sadly, the answer is most often no one.

At this point, I suggested mom see a specialist in the field of physiatry for a more comprehensive evaluation. The evaluation identified osteoarthritis in both knees and a condition called spinal stenosis. Treatment would eventually require multiple surgeries. Now she had three issues to deal with: Two knees, one back and three different doctors.

In the midst of all of this, I discovered mom’s Medicare managed care plan offered no coverage in the state of Massachusetts where her surgeons practiced. I identified new health insurance options and was able to enroll her in a new plan that did not require referrals and offered 80% coverage outside of her home state. We confirmed and re-confirmed her coverage levels and yet we were consistently questioned by every physician’s office and hospital in which she received care. This forced us to repeatedly supply written documentation and make additional phone calls.

The lesson in this story? Specialty care requires special attention. If you or a member of your family is receiving treatment from multiple providers and hospitals, it’s imperative that you empower yourself with knowledge. Seek second opinions whenever necessary. Understand your insurance coverage and most important, encourage communication among your entire healthcare team. Never be afraid to speak up or ask questions.

Here are a few more things to consider when seeking care from a specialist:

696afc68-d9f3-4d8b-a997-b4b5fca9d92a1. Be sure you understand why your primary care doctor is referring you to a specialist and what information he/she hopes to gain from that visit.

2. Do you fully understand the requirements of your health insurance? Are you required to obtain a referral or approval for specialty care? If so, verify that the appropriate paperwork is completed and sent to the specialist. Ensuring administrative issues are in order will prevent future claims payment issues and a lot of frustration.

3. Did your primary care doctor communicate relevant information to the specialist in writing? This should include a review of your medical history, current medications and dosages and the reason for the referral. It should also include all relevant diagnostic testing results. If you had X-rays or a CT scan, you may need to pick up the images on CD and hand carry the disk to your appointment. Ask your primary care doctor for a copy of the referral letter and take it with you to your visit.

4. Be sure you have a follow-up visit scheduled with your primary care doctor to discuss the treatment recommendations of the specialist. Remember, your primary care doctor knows about all of your medical conditions, the treatment plan for each of them, all your medications, dosages and drug interactions. New recommendations require integration with your current plan of care.