We all know that insurance and other financial incentives drive many health care decisions, but for a doctor to flat out, dispassionately admit to a private patient advocate that insurance was what was driving his medical decision-making? It was shocking.

The sad reality is that this happens all the time in our healthcare system. Insurers - private as well as Medicare and Medicaid - make decisions about what treatments they will cover, how long a patient can be covered in a hospital or skilled nursing facility, what medication can be prescribed, and more. Some of the common ways this is done is through prior authorization for procedures and step therapy for medication. Note that the decision of an insurer not to cover something doesn’t mean you can’t get it, it means that your insurance company will not pay for it. Yet the reality is that most people cannot afford to self-pay for expensive treatments. 

What can you do about this?

Know your insurance policy. Your insurance policy is a contract between you and the insurer. Of course it’s a unilateral contract that you have no ability to change - or even look at before enrolling, but it is a contract. It’s not fun reading, but you should know what it says. Use the language from the policy to make your argument for why something should be covered.
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Know what your rights are as a patient. The American Medical Association (AMA) has published physician and patient rights and responsibilities. Medicare beneficiaries have legal rights, including related to hospital discharge. Most major healthcare organizations have their own set of patient rights and responsibilities; you should be able to find this online. I recently worked with a family and the case manager at the facility was giving them the run-around about setting up a family meeting with the physician; after some back and forth, I ended up quoting directly from the facility’s patient rights document and - like magic! - a Zoom meeting was set up for later that afternoon.

Be persistent. I like to say that insurance companies are bigger and badder than us and are counting on us to feel overwhelmed, intimidated, and just give up. Stick with it. Know the facts: what does your policy say; what is considered best practice and what peer-reviewed evidence is there; what are your rights as a patient/member.

Advocate for yourself. Use the above tips to advocate for yourself or a family member. Be polite but firm and persistent. Enlist the assistance of your healthcare providers. Go up the chain of command. 

Please contact me if I can help

Regarding being prepared, think about these two questions:

• If you’re alone in the hospital, can you speak for yourself?
• Does anyone else know enough about your health to speak for you?

I’ve blogged before about the importance of creating a health information binder. It’s critical to do so AND to make sure that someone knows where it is so they can access the important information and advocate for you.
Communication is different as you may have to rely on phone and video communication when your loved one is in the hospital. Key points include:

• Ask about communication protocols - when is the best time of day to call? Who should you ask to speak to? When are shift changes (don’t call then!)? 
• Designate someone in advance to be the point person - generally, the staff at the hospital will only take calls from one person per patient. Figure out ahead of time who that person will be so that you can avoid family disagreements during a health crisis. (This is also a good reason for getting your Advance Care Directives done!)
• Have the information you need readily available when you call (this is why the health information binder is helpful) - allergies, names of specialists, medical history, medication list, etc. 
• Technology - make sure you and your family members know how to use FaceTime or some other video app. It’s literally a lifeline for staying in touch, being able to see how someone is doing, and allows you to see facial expressions and body language when speaking with doctors and nurses.
• Write everything down - keep all your notes in a notebook. Write down questions that you think of so you don’t forget to ask during your daily phone call with hospital staff.
• Find out the medication schedule - this is a good time to check in with your loved one so you can make sure they are getting the correct medication and can keep track of what medications they are taking.
• Discharge planning - many hospitals will allow someone to come in for the discharge planning meeting even if they don’t allow visitors. Be sure to take this opportunity. A lot of important information is provided during discharge and someone other than the patient should be there to listen to everything and ask questions.​

Choosing the right health insurance plan can be overwhelming. It may be tempting to just keep the plan you currently have rather than look at spreadsheets and dense, hard-to-decipher descriptions of coverage options.

That’s a mistake. Whether you’re over 65 and inundated with advertising about Medicare open enrollment options or getting your insurance through the Marketplace or working for a company whose annual open enrollment is taking place this fall, it’s imperative that we review our current plan and see what our options are for 2021.

Here are some things to keep in mind regardless of where you get your health insurance:

• It’s not all about premiums. To get a sense of how much you may spend during the year, you need to look at all costs including deductibles, co-pays, co-insurance, out of pocket maximums. Click here for an article that defines these and other key health insurance terms.
• The provider network may or may not matter to you. It’s a personal decision whether you want to trade lower costs for having to switch doctors, travel further, or have a smaller network to choose from.
• Look at the health care services you think you’re most likely to need and try to find a plan that meets your specific needs. For example, if you know you’re going to need a lot of physical therapy (PT) next year, it may make sense to pay more in premiums for a plan that provides better coverage of PT visits.
• Do you have a second home in another state? Provider networks will be important in this scenario.

Medicare
Medicare Open Enrollment started October 15 and you can’t watch TV these days without seeing commercial after commercial about different Medicare insurance options. During Medicare Open Enrollment you can:

1. Switch from Original Medicare to Medicare Advantage
2. Switch from Medicare Advantage to Original Medicare
3. Switch from one Medicare Advantage plan to another Medicare Advantage plan
4. Switch from one Part D (prescription drug coverage) plan to another Part D plan

​A few tips:

• Be sure to check the formulary (list of covered medications) in your current Part D plan and any Part D plans you are considering to make sure your medications are included. You can do this on Medicare Plan Finder.
• If you’re in a Medicare Advantage plan, be sure to check whether your providers will still be in network next year.
• You can download the Medicare Open Enrollment guide from the Medicare Rights Center.
• This article, 3 Ways to Prepare for Medicare Open Enrollment, has helpful advice. 

Health Insurance Marketplace and Employer Health Plans

• Open enrollment for the Health Insurance Marketplace/Exchange is from November 1 - December 15.
• Open enrollment timing and options for employer-based plans vary. 
• For either, here is some helpful advice about Choosing A Health Plan from FAIR Health.
• More general advice about open enrollment for health insurance and other benefits can be found here and here.

Bottom line: Be sure you understand your options, get your questions answered, and know your preferences (cost, access, convenience, willingness to accept risk, etc.) before you make a decision. Contact me if I can help answer questions or conduct an analysis for you. 

Medicare is complicated. There are a lot of “parts” as well as rules, enrollment periods, etc. I’ve started making 1-2 minute videos to explain different aspects of Medicare including what is open enrollment, what isn’t covered by Medicare, Parts A, B, and D, what is IRMAA, and more. I'll be adding to this "Medicare collection" periodically so subscribe to my YouTube channel to stay up to date.

Thank you Betsy Phillips, Realtor, Baird & Warner, for having me on your "Let's Chat" series to talk about patient advocacy!

Medicare's annual open enrollment period starts this month and that means there are A LOT of commercials urging people to switch plans. Here are some of my thoughts after seeing yet another one of those commercials...
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Since the beginning of the pandemic, I’ve received many calls and heard many stories about how difficult the visitor restrictions continue to be for hospitalized patients, residents of senior living communities, and family members. As the pandemic continues, more and more organizations and individuals have been voicing concern about the isolation of seniors in assisted living and skilled nursing facilities, as well as the lack of advocacy for hospitalized patients. While exceptions for end-of-life or compassionate care visits have been available throughout (for patients without COVID), they often require families to make painful, difficult choices about who can say goodbye in person. Rules for all of the above scenarios have changed, loosened and also vary based on geographic area and facility. Be sure to check the most recent policy of the health care facility or community in question. 
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Please use the information below to understand the issues as well as to advocate to visit your loved ones.

Hospital/healthcare settings:

The Beryl Institute recently released Patient and Family Recommendations for Addressing Visitation Policies during COVID-19. This policy statement emphasizes the importance of allowing a “care partner” to be in the hospital or any healthcare setting with patients. Anyone who has been in the hospital or had a loved one in the hospital knows how critical it is to have someone there with you: it’s usually difficult to understand and remember what the doctors are saying and ask meaningful questions when you are in a health crisis. Care partners also provide important information to health care providers that patients, due to physical illness, cognitive issues or just being overwhelmed, tired, or scared, may not remember to share on their own. While these recommendations include that “All patients must have the option to have a care partner present in the healthcare setting,” they also set out guidelines and responsibilities for care partners to keep healthcare personnel safe. The photo below shows some of the recommendations:

Please see my previous post about having an “In Case Of Emergency Kit” prepared - this will make it easier for your care partner!

Long term care settings:

The Centers for Medicare & Medicaid Services (CMS), has issued guidelines to states  regarding visitation of residents of long term care facilities. They note:

     While CMS guidance has focused on protecting nursing home residents from COVID-19, we recognize that
     physical separation from family and other loved ones has taken a physical and emotional toll on residents.
     Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions
     of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other
     ongoing changes related to COVID-19 confusing or upsetting. CMS understands that nursing home residents
     derive value from the physical, emotional, and spiritual support they receive through visitation from family and friends.

The guidelines address indoor and outdoor visits as well as compassionate care visits and visitor testing. See the photo below for some of the guidelines for indoor visits. Check the guidelines from your state and the long term care facility you wish to visit for more specifics.