Patient Navigator

Long-Term Care (LTC) insurance can be a sensible purchase for folks who expect that they will need caregivers as they grow older.  Unless you are very poor and eligible for Medicaid, or very wealthy and can afford to spend a significant portion of that wealth on caregivers, LTC insurance is worth considering.  Once they’ve paid years of premiums, consumers rightly expect that their LTC insurance policy will pay for this care, whether it is at home or in a facility.

Unfortunately, the vendors of these policies use almost every weapon in their arsenal to avoid paying benefits.  In the past year, I have been working with a family who bought long-term care insurance coverage for both husband and wife many years ago.  They had been paying the monthly premiums regularly.  By the time they needed to trigger the policy for their care needs, they had paid over $100,000 in premiums.

One would expect that the insurance carrier, having been paid so much money, would make it easy for this family and the care providers to obtain the benefits.  Sadly, the opposite was true.

For example, invoices from the in-home care agency were mysteriously “lost.” Multiple times.  The two fax machines that are designated to receive the invoices are over-worked and frequently out of service.  The processing times are so long that it takes months before we can determine if an invoice has even been received.  The ability of Customer Service to actually help solve a problem is inconsistent at best.

I have been told by my client’s in-home care provider that this is not unique to my client, or to their insurance carrier.  This provider has the same problems with most of the carriers, for most of her clients.

Why do insurance providers make it so difficult to navigate their systems to collect the benefits for which consumers have already paid thousands of dollars?

Basically, insurance is about gambling.  The insurance companies gamble that they can take in more money in premiums than they pay out in benefits.  They put low-cost systems in place that make it more challenging for their policy-holders to track and receive all the payments for which they are eligible.

In the case of my clients, the wife passed away mere months after beginning to receive benefits.  By rough calculations, the insurance company collected $60,000 more than they paid out on her case.  In reality, it took months of repeated faxes, phone calls and escalations to managers to actually generate the payments that were finally made.

Thousands of policy-holders do not have the time, mental acuity or energy to persist in their efforts to force the insurance carriers to pay up.  So the most vulnerable – sick, elderly people – are, once again, taken advantage of by the companies that are entrusted with their financial care.  Why are we not surprised?

Become a smart consumer.  For more information, you can download a free brochure from the Society of Certified Senior Advisors as well as other excellent resources in their public library.

Submitted by Debora Harvey, Patient Navigator LLC

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Submitted by guest editor Debora Harvey, Patient Navigator LLC

I went to pick up my hearing aids yesterday.  These are fairly new, only a few months old, yet I have had to send them back to the manufacturer twice so far, and I am not confident that they will work well even now.  The irony is that I paid $3,000 out of pocket for these assistance devices.  They are not covered by my health insurance.  I do have a “discount program” that enables me to go to a provider that has an agreement with my insurance provider, who supposedly charges me less than the current market rate for these devices.  Unfortunately, I am much less than satisfied by both the quality of the hearing aids, and the competence of the “audiological specialist” to whom my insurance company has steered me.

I was in my twenties when diagnosed with a hearing loss significant enough to need amplification. I resisted the need for hearing aids, but the doctor explained to me that, unless I could get the sounds to my brain, my brain would slowly lose the ability to recognize sounds and speech.  Even if my hearing were miraculously restored, I would be unable to understand the words people spoke.

According to the American Speech Language Hearing Association, hearing loss is the number one birth defect in the United States.  Twenty percent of children have some sort of hearing or speech disorder.  Half of the 28 million Americans with a hearing disability are under the age of 50.

Among other statistics, the National Institute on Deafness and Other Communication Disorders (NIDCD) reports that:

• Approximately 17 percent (36 million) of American adults report some degree of hearing loss.
• There is a strong relationship between age and reported hearing loss: 18 percent of American adults 45-64 years old, 30 percent of adults 65-74 years old, and 47 percent of adults 75 years old or older have a hearing impairment.
• About 2 to 3 out of every 1,000 children in the United States are born deaf or hard-of-hearing. Nine out of every 10 children who are born deaf are born to parents who can hear.

Yet many insurance companies significant limit coverage of audiological services, if indeed they cover them at all.   Medicare, the primary insurance for millions of older Americans, does not cover hearing aids or eyeglasses, basic needs for people who are losing the acuity of sight and hearing as they get older.

It is a matter of economics.  In order to keep private or group premiums affordable for individuals or employers, these type of assistance devices are excluded from coverage.  If Medicare were to include this coverage, its budget would be hundreds of millions of dollars more every year; dollars found in tax increases.

ASHA has an active advocacy program working to improve disability benefits in general, especially those relating to hearing disabilities.   Take a look if you or someone you know needs help.

To learn more about hearing loss and other communication disorders, visit the NIDCD Health Information site.

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A recent Washington Post/Kaiser family foundation article offered an alarming look at many Americans’ low level of health literacy, defined by the Department of Health and Human Services as “The degree to which individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate health decisions.”

The article cites a study released in 2006 study by the U.S. Department of Education that found that 36 percent of adults have only basic or below-basic skills for dealing with health material.  This means that 90 million Americans can understand discharge instructions written only at a fifth-grade level or lower. About 52 percent had intermediate skills: they could figure out what time a medication should be taken if the label says “take two hours after eating.”

The remaining 12 percent were deemed proficient because they could search a complex document and find the information necessary to define a medical term.  Adults who were ages 65 and older had lower average health literacy than adults in younger age groups.  Less educated and minority groups generally had lower levels of health literacy.

The Surgeon General of the United States has also tackled this subject.  Because only 12% of Americans have proficient health literacy skills, the majority of adults may have difficulty completing routine health tasks like understanding discharge instructions or diabetes care. There is a strong, independent association between health literacy and health outcomes. These outcomes include emergency department use, hospitalization, self-reported physical health, and mortality.

Interventions to mitigate the effects of low literacy in patients with chronic
conditions have been shown to improve health outcomes. In some cases, the interventions appear to be more effective for low literacy users compared with higher literacy users.  A fascinating January 2011 article in the New Yorker by Dr. Atul Gawande documents this point perfectly.

The Surgeon General concludes:

• First, public health professionals must provide clear, understandable, science-based health information to the American people.  In the absence of clear communication and access to services, we cannot expect people to adopt the health behaviors we champion.

• Second, the promises of medical research, health information technology, and advances in health care delivery cannot be realized without also addressing health literacy.

• Third, we need to look at health literacy in the context of large systems – social, cultural, education and the public health system.  Limited health literacy is not an individual deficit but a systematic problem that should be addressed by ensuring the health care and health information systems are aligned the needs of the public.

In an era when individuals are increasingly required to fend for themselves, health literacy is indeed a public policy issue.  Patient navigators and advocates obviously fulfill a vital need here.  Indeed, we here at Patient Navigator help to educate and empower our clients.  But the problem is massive and the resources small; there is no easy answer.

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There are several important changes on the horizon this year as additional provisions of the health care law are implemented.  Here are a few.

Seniors are affected by several of the provisions. They will get big discounts on prescription drugs.  Prescription drug costs (Medicare Part D) could go down by $700 for a typical Medicare beneficiary in 2011.

Several provisions of the law promote prevention of disease, especially for seniors. Medicare enrollees will be able to get many preventive health services – such as vaccinations and cancer screenings - for free starting in January.

Medicare is increasing up payments for primary care by 10 percent from Jan. 1 through the end of 2015. It’s an incentive for doctors and others who specialize in primary care – including nurses, nurse practitioners and physician assistants – to see the growing numbers of seniors and disabled people covered by the program

Beginning soon after the Food and Drug Administration finalizes rules  in 2011, chain restaurants with 20 or more locations, and owners of 20 or more vending machines, will have to display calorie and fat information on menus, menu boards and drive-thru signs.

Consumers with flexible spending accounts (FSAs), in which pre-tax income can be used for medical purchases, can no longer spend the money on over-the-counter drugs, including ones that treat fevers or allergies and acne, unless they have a doctor’s prescription. The new restrictions, which lawmakers included in the health overhaul to raise more revenue, also apply to health reimbursement arrangements (HRAs), health savings accounts (HSAs) and Archer medical savings accounts (MSAs).

Starting this year, health insurers must spend at least 80 percent of their premiums on medical care, or face the possibility of giving rebates to consumers.  (Editorial note:  don’t hold your breath for any rebates).

For a useful timeline of all the changes coming this year, check the Kaiser Family Foundation website. The U.S. Government’s timeline of what’s changing and when is also helpful.  Bottom line:  Stay Informed!

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Back pain seems to hit many of my friends with regularity.  This can be debilitating, undermining the ability to work and interact with families.  Chronic pain often leads to depression.  There are many different causes of lower back pain, each with its own recommended solution.  Surgery is often an option and can help in many cases.  But it’s worth exploring other, less invasive remedies first.

Recently, I was reading an article in the online Natural Health magazine that detailed some alternatives that are available to those looking for a complementary solution to their pain.

The author compiled approaches to back pain from an orthopedic surgeon, a yoga therapist and a chiropractor.

The surgeon diagnosed the most probable cause of the pain as degeneration of discs due to genetics, injury or too much sitting.  The recommended treatment included rest, alternating heat and cold packs and stretching, for acute pain.  For chronic pain, he recommended avoiding repetitive injury, improving core strength, and stretching.  Surgery would be an option for those who are not helped by these methods.

The yoga therapist indicated that “chronic pain sufferers often are frustrated and depressed; they feel betrayed by their bodies.”  She said that yoga helps these feelings because of the emotional component, which helps sufferers rebuild body confidence.  She recommended gentle yoga, with conscious breathing to calm the nervous system, thus reducing pain-causing inflammation in the body.  Core stretching and strengthening poses help to develop the muscles supporting the spine. Similarly, pilates exercises also help to build core strength and prevent injury.  Regular pilates work frequently restores function and helps to manage or eliminate pain.

Yoga therapists and other complementary medicine practitioners can be found at Alternative Health Directory.

The chiropractor said that back pain can be caused by joints around the spine becoming constricted (by long hours of sitting), creating muscle and ligament tightness.  He suggested that a chiropractic adjustment would stretch tight ligaments to improve joint motion and position. He indicated that an adjustment might not be necessary; that chiropractors also use ultrasound, massage, and electrical stimulation (TENS) to help ease back pain.  One to six visits are generally enough for relief.

To learn more, visit the American Chiropractic Association or to find a chiropractor who treats the children and the whole family, visit the International Chiropractic Pediatric Association.

I would have liked to have seen a contribution from an acupuncturist in this article, as I believe that this treatment offers tremendous benefits in certain situations.  Both conventional and complementary treatments have their place for most conditions.

For good medical summaries of lower back pain, visit the National Institute of Health website on back pain or the Spine Health website.  Another site we recommend is Spine Universe which has excellent information on every type of back pain with recommended treatments.

Prevention  is the key to living a pain-free life, so always stretch, stretch, stretch and try to practice yoga or pilates to strengthen your core.

Contributed by Debora Harvey, Patient Navigator LLC

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Many people experience depression during the holiday season. This is not surprising given that we are bombarded with loud Christmas music wherever we go, incessant advertising and a non-stop drumbeat to shop, buy, spend and create the perfect Hallmark holiday. It is hard not to feel stressed out if you then add the pressure of entertaining, houseguests and a long list of expectations.

Now imagine trying to face all this when you are grieving the loss of a loved one.

It is very hard.  It is painful.  It is unbearably sad.

I lost my mother very suddenly and unexpectedly in May 1990, when she was 63 and I was 31.  I made the decision to skip Christmas entirely that year – no tree, no gifts, no decorations.  I simply could not bear it.  Fortunately, my boyfriend (now husband) understood and supported me, and there were no children to worry about back then. It was the best I could do.

The pressure to go along with the holidays is intense.  Here are my own tips on how to get through them if you are grieving.

1.  Don’t let anyone pressure you or try to tell you what will make you feel better.  Only you know what helps.

2.  Remember your loved one in whatever way seems right – a walk in the woods, a prayer service, watching their favorite movie, setting a place at your table.  You don’t need anyone’s permission or concurrence.

3.  Don’t be afraid to tell people that it really is not a Merry Christmas or Happy Holiday for you.  Let your colleagues at work know that the season is hard for you and ask them to understand if you are distant.

4.  Learn to say no.

5.  Give yourself permission to mourn.  It is normal and necessary.  And then tell yourself gently, over and over, that you will not always feel this way.  And, in time, you won’t.

I’ve learned a great deal over the years about loss and grief.  I’ve learned to grow from each loss in my life, but it has taken a lot of work and faith.  If you are grieving this holiday season, you are not alone.  But please know and believe, with all your heart, that you will not always feel the way you do now.  Time does heal.  Things will get better.

For more information on grief and the holidays, I suggest:

Therese A. Rando, PhD.  Grieving:  How to Go on Living When Someone You Love Dies. (Note:  This book saved me as I grieved the loss of my mother).

Elaine Tiller, M.Div.  When Grief Comes Home for the Holidays, How do you Manage?

Capital Hospice.  Good Mourning: A Resource for Healing.

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Medicare Open Season lasts until December 31.  If you are involved with elderly parents or other seniors, now is a good time to review their Medicare coverage, in particular their Part D Drug Coverage Plans.

Traditional Medicare Part A covers hospitalization, skilled nursing facilities, some home health and hospice. Part B covers physician and outpatient services and requires a monthly premium. Under the new health care law, Medicare will now pay 100 percent of the cost of annual physicals and other kinds of preventive health care, such as cholesterol and obsesity screening.

At this time of year, beware of slick advertising directed at your seniors from Medicare Advantage programs. These Medicare Advantage (Part C) programs are HMOs run by private insurers and carry the same pitfalls as standard HMO plans. They seek to lure seniors out of traditional Medicare with promises of extra benefits. Don’t be fooled. These insurers impose more restrictions on the doctors you can see and the benefits you can receive. The extra benefits they advertise, such as dental and vision care, will be phased out as the government cuts back the subsidies it pays to Advantage plans.

Medicare Part D drug benefits are an important component and require some work to find the right plan. Fortunately, there are excellent tools available tools to help you. The starting point is to develop your list of prescription medications. The variables to consider are brand vs. generic drugs, whether it makes sense to have a lower monthly premium and a higher deductible or vice-versa, the plan’s formulary and authorization requirements, and the plan’s cost.  A great place to start is through the government Medicare site’s Resource locator. You can create a drug list and use it to begin your search.  There is a wide price range among the private insurance companies that offer Part D plans.  The right match for your senior’s medication needs can save thousands of dollars a year.

The final component of your senior’s Medicare coverage is probably a Medigap supplement plan. Medigap is designed to fill the gaps in original Medicare coverage, such as deductibles, co-insurance and co-payments. These plans, also offered through private insurers, offer standardized benefits. However, the price among companies can vary widely.  The government Medicare site also offers a tool to compare Medigap plans.

For more information, you can download the Medicare guide or learn more from the Medicare Rights Center.

This is just the tip of the Medicare iceberg, but Patient Navigator can help you help your senior. Please call or email us for a free consultation about a Medicare review for your loved one.

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Please review our December newsletter.  The topics are:  Medicare Open Season for Seniors; Holiday Grieving – My Tips for Survival; and Food Science Part 3.  Our “Navigator Notes” monthly newsletter is designed to bring you important health topics.  We welcome your feedback.

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The September edition of Navigator News includes articles on:  Understanding Palliative Care; The Fine Print of your Insurance Policy; and Food Science Part 1.   We welcome your feedback!

http://myemail.constantcontact.com/Navigator-Newsletter—September-Edition.html?soid=1103192011442&aid=C2KCCMiqSHU&share=fblike.

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A recent survey revealed that 91 percent of physicians surveyed practice defensive medicine – they regularly order more tests and perform more procedures than are medically necessary in order to protect themselves from the possibility of being sued for medical malpractice.

This survey, by a team of researchers from Mount Sinai School of Medicine, confirms that the fear of being sued is very real and pervasive throughout the entire spectrum of medical practice.

In addition, those surveyed responded that the “overwhelming majority of physicians support tort reform to decrease malpractice lawsuits and that unnecessary testing, a contributor to rising healthcare costs, will not decrease without it.”

Defensive medicine is expensive, inconvenient to both doctor and patient, compromises the relationship between provider and patient, and has no basis in evidence-based medical practice.

Unfortunately, the practice of defensive medicine decreases patient access to health care, and increases costs of healthcare for everyone.  Some patients are left in the lurch as physicians avoid the sickest patients, or those requiring higher-risk procedures, in order to reduce their exposure to malpractice suits.

A 2008 study by the Massachusetts Medical Society found that 83% of its physicians practiced defensive medicine at a cost of more than $1.4 billion annually in that state alone.

To me, $1.4 billion in one state translates at a conservative estimate to at least $30 billion annually throughout the country.

I find the dollar cost of the practice of defensive medicine disturbing.  I find the cost of the doctor-patient relationship, in which the physician views every patient as a potential lawsuit, rather than a person in need of healing, frightening and discouraging.

More medicine is not better medicine.  Evidence-based, patient-centered medicine is better medicine.

Submitted by guest editor Debora Harvey

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