Dr.Joe's Data Base

Getting High Quality Medical Care
in a Changing Healthcare Landscape
When searching for good medical care, it used to be that the hunt
focused on whether the physician was the best in his or her
profession, had a good bedside manner, was conveniently located and
referred patients to the hospital with the most up-to-date
equipment.
But nowadays, rules imposed by insurers for scheduling and receiving
care can sometimes place roadblocks between you and the physicians
and hospitals you prefer.
For people with diabetes, this new health care environment can be
especially disconcerting. In an effort to save money on the
spiraling cost of medical treatment, employers can decide to switch
health care insurance options they offer employees -- and all of a
sudden you may discover that visits to your family doctor or
diabetes doctor are no longer covered, and you need to seek out a
new physician or physicians to provide your medical care. For people
with diabetes, this can mean learning new philosophies and methods
of care which may differ from lifelong established systems that the
patient has successfully used to manage the disease.
So, what do you do in this new health care world?
Here's some general guidelines to follow:
Understand what's going on in healthcare these days, so you can
better understand and work with the changing roles of health
care providers, and the different pressures they are facing.
Be knowledgeable about your own diabetes so you can ask
questions and pinpoint areas where you and your primary care
physician need to focus extra attention -- and perhaps get
additional help from a specialist -- to keep your diabetes on
track.
Be your own advocate. Know what preventive care and screening
the American Diabetes Association recommends, and ask your
physician when it is time to have these various aspects of your
care provided. Try to find an insurer that supports (i.e. pays
for) getting these preventive measures done. Don't hesitate to
call or write your health insurer and provide them with a clear
and compelling argument as to why you need them to pay for some
aspect of your healthcare that they don't cover -- a referral,
or an educational program for example. Include in your arguments
any research that supports your need for the referral, and be
sure to note that the insurance company will benefit if a needed
referral will decrease your risks of developing more costly
medical problems down the road.
Choose your primary care physician wisely. Look for someone who
is both knowledgeable about diabetes and who seems interested in
working cooperatively with you.
Make sure your primary care physician will, and more importantly
can refer you periodically to a quality diabetes or other
specialist, or to education programs for help with hard to
manage problems.
If possible, be prepared to pay for some things out of pocket,
particularly diabetes education, and an occasional second
opinion from a physician who may not be covered by your
insurance.
When possible, choose the health plan that enables you the
greatest freedom to see different physicians and pays for the
care you need.
Don't hesitate to express concern if you have questions about
the quality of your care.
The changing roles of physicians
Today's world of medicine is very specialized, yet efforts to
contain costs are placing increasing burdens on primary care
physicians -- the traditional family physician -- to provide as much
medical care to patients as possible, because their care is the
least costly. Yet, in caring for your diabetes, it is likely that
your medical needs will require both a primary care physician and a
team of health-care professionals who can back your primary care
physician up when needed. "If at all possible, you should find a
medical setting where your diabetes is cared for by a team of
pressionals, each an expert in a particular aspect of your total
care," notes Dr. Richard S. Beaser and Joan V.C. Hill, R.D., C.D.E.,
in their new book, Joslin's Guide to Diabetes Care. This team should
include the primary care physician, a diabetes expert who is usually
an endocrinologist, a dietitian, nurse educator, exercise
physiologist and someone who will provide psychological counseling
and support when needed. Other team members may be added as needed
to treat or prevent complications.
Your desire to have your diabetes treated by a team of specialists
-- and your insurer's desire, in many cases, to have as much care as
possible provided by a primary care physician -- may seem to be at
odds. "Some believe that those two needs are in conflict," notes
Joslin President Kenneth E. Quickel Jr., M.D., president of Joslin
in Boston. "But in fact, the best, most cost-effective care in the
long run will occur for people with diabetes when the primary care
physician and the specialty care team work in collaboration with
each other."
Physician as traffic cop
Your primary care physician is trained to care for you as a total
person and treat a wide range of medical problems, from colds and
the flu, to checking your cholesterol levels and checking your
diabetes care. This person serves as a traffic cop, in many ways,
coordinating your overall medical treatment.
But in addition to acting like a traffic cop, this physician also
serves in many health insurance settings as a gatekeeper, managing
day-to-day health needs and regulating the flow of patients to more
costly forms of care. In essence your primary care physician works
on your behalf and the insurer's behalf to be sure that you are
receiving care for your medical needs in the most cost-effective way
possible. Frequently, payments to primary care physicians from
insurers are tied to how effectively they can reduce the use of
expensive tests and services -- and the physician may be penalized
for a perceived over-use of specialists and expensive tests.
"Back in 1916 Elliott P. Joslin wrote that 'the number of cases of
diabetes is so great that it at once becomes evident that their care
must rest in the hands of the general practitioner. It is ridiculous
to expect that the treatment of diabetics should all be under the
supervision of a specialist,'" notes Dr. Quickel. "So, while this
role of 'gatekeeper' is just a fact of life today, in fact it has
always been important for the primary care physician to work with
the diabetes specialist. Picking an excellent primary care physician
is as important for people with diabetes these days as it is to pick
an excellent diabetologist or endocrinologist, and being certain
that they can work together is essential.
Diabetes specialists as primary care physicians
In some health insurance programs diabetes specialists are
registering as primary care physicians, as well as diabetes
specialists, to enable patients to pick a diabetes expert to serve
as their primary care physician. This is due, in part, to the fact
that most diabetologists are first trained in general internal
medicine or pediatrics before they receive additional training in
diabetes and endocrinology. But they are also doing this because the
line where primary care ends and diabetes care begins can be very
blurred. In the Boston market, most of Joslin's diabetologists are
enrolled as primary care physicians in some health plans for this
very reason. "Joslin physicians have frequently served as primary
care physicians for patients over the past 50 years or more, because
diabetes is a lifelong disease that affects so many aspects of a
person's health, " notes Dr. Quickel.
Other insurers don't allow diabetes specialists -- even though they
are certified to practice general internal medicine -- to enroll as
primary care physicians. In some cases, they may even insist that
specialists associated with a medical school be classified as
'tertiary care physicians,' which severely limits your ability to be
referred to them. The insurers do this because the insurance company
perceives these specialists and the institutions they hospitalize
patients in as exceptionally high priced. So the same Joslin
physician may be enrolled as a primary care physician in one health
plan, and a tertiary care specialist in another.
"In the perfect world, our preferred role is to serve as the
diabetes expert, and to leave the primary care to the primary care
physicians," notes Dr. Richard Jackson, a senior physician at
Joslin. "But because patients sometimes want and need more from us
than insurers will allow them to get if we enroll in these health
plans as specialists only, we do in some cases enroll as primary
care physicians."
The ideal
The ideal scenario is that you identify a primary care physician who
is knowledgeable about diabetes, has an interest in the disease --
and knows his or her limitations and will refer you for additional
care when needed, irrespective of any disincentives insurers may
place on making the referral. "Most physicians aren't going to let
the insurers get in the way of making a referral for a patient who
really needs it simply because of some small financial incentive,"
notes Dr. Quickel. "But a primary care physician has to know a lot
about a mind-boggling number of different diseases and conditions.
He or she may not be as immediately up-to-date on new thoughts in
diabetes care as a diabetes specialist, whose role is to know a lot
about one disease or group of diseases and their complications. What
this means is that the primary care physician can manage most of
your medical issues -- including many of those surrounding your
diabetes. But at a certain point, the primary care physician may
need to seek a specialist's advice if things aren't going as well as
they need to."
"What we're really advocating is a holistic approach, focused on
preventing problems," notes Dr. Jackson. "By focusing on preventing
problems rather than acting upon them when they occur, we can
actually lower the cost of healthcare by limiting the amount of
money patients need to spend on specialists to treat costly
complications like artery disease, a heart attack, stroke or other
problems."
Be knowledgeable about your disease
How can you as the patient know if the diabetes portion of your
medical care is going as it should? "By being a knowledgeable
patient," says Hill, who is director of educational services at
Joslin.
Below are some key questions you should know the answer to in
assessing both how your diabetes is going and how your primary care
physician and diabetes health care team's combined management of
your disease is fairing. "If you don't know the answers to these
questions, ask the person who provides the bulk of your diabetes
care (whether that is a primary care physician, a Joslin specialist,
a nurse practitioner, or a diabetes specialist elsewhere) the
answers to these questions at your next visit," Hill says.
These are also good questions to discuss with a new primary care
physician or diabetes specialist that you may be switching to as a
result of a change in health plans, notes Jackson.
Be your own advocate
If you don't know the answers to all of these questions, discuss
them with the clinician most involved in your diabetes care over the
next couple of visits. Then ask yourself how you felt while you were
asking your physician some or all of these questions. If you felt
increasingly comfortable as the conversation continued, this may
suggest that the physician was a good listener, and didn't send out
"bad vibes" suggesting that he/she didn't like being questioned
about his medical practices. If, on the other hand, you felt that
you needed to stop asking questions fairly quickly, was that because
the physician -- either overtly or covertly -- was sending you
signals that he/she didn't like being questioned about his knowledge
of your disease? Or was it just your own discomfort with questioning
a traditional authority figure?
"You're paying for your health insurance -- get what you need and
are paying for," says Dr. Jackson.
What to do if you are uncomfortable
Many people will find it difficult to discuss these questions with
their physician. "Many of us have been raised to believe that we
can't question the parish priest or the doctor, that they will take
care of us and it's just as well not to ask too much," says Hill.
"But as research like the Diabetes Control and Complications Trial
(DCCT) increasingly shows us, the results of careful blood sugar
control will reduce complications risk. It becomes increasingly
important to make sure that all the members of your health care team
know what they are doing -- and that includes you. You, the patient,
are the most important member of the team managing your disease. You
have every right, as a result, to know that the other members of the
team are working with you, and have the skills to make your life
with diabetes as manageable and risk-free as possible."
What do you do if your are genuinely uncomfortable with your health
care provider, and your choices are limited to the physicians
enrolled as provider for your insurance company?
"Ask around," recommends Hill. "Go to meetings of the local diabetes
association, and try to find other people with diabetes who have
found good primary care physicians and/or good diabetes
specialists-primary care physicians who may be covered under your
insurance. Check out the primary care physicians of friends who
don't have diabetes, but who say their physician is approachable and
seems knowledgeable about whatever medical conditions they have.
Perhaps such a physician will also be knowledgeable about diabetes
-- or perhaps if he/she isn't, at least he/she will be willing to
refer you to someone who is for your diabetes care, and continue to
provide your overall non-diabetes medical care."
Can your employer help?
You may also want to consider letting your employer's human
resources or benefits department know if you are uncomfortable with
the quality of the care you are receiving under your health plan,
particularly if the health coverage has been recently changed and
you feel your health care is suffering because of it. While
insurance companies, on average, will have an individual as a
subscriber for three years or so before the subscriber either
switches insurers or switches jobs, statistics show that your
employer will, in all likelihood, have you as an employee for much
longer. Poor health care can result in poorer performance on the
job, lost work days and lost productivity, not to mention higher
insurance costs in the long run if you develop complications. Your
employer is likely to be very interested in knowing if you are
concerned about the quality of your medical care as a result of a
change in health coverage. And the insurance carrier may be more
likely to listen to the voice of an employer who is paying for
insurance for hundreds or thousands of workers, rather than
listening to you, who is the voice of only one.
Perhaps even more importantly, your employer may be interested in
knowing of ways that they can continue to offer a lower cost health
plan that meets the needs of most of their employees, while offering
some additional work-site programs to help meet the needs of their
workers with diabetes, or others with problems such as obesity, high
blood pressure, high blood fat levels, etc. Perhaps you can talk
with your employee benefits department about providing on-site
nutrition counseling free of charge to people with these kinds of
problems; or perhaps offering a fitness benefit or weight loss
program in addition to the basic health plan, which might enable you
to develop an exercise or weight loss program at lower cost to help
manage your diabetes; or perhaps a stress management program free at
work to help lower blood pressure.
Be prepared to pay out-of-pocket
People need to recognize that increasingly, having health insurance
does not automatically entitle you to have all your medical care for
free. People with diabetes have long had to pay for diabetes
education out-of-pocket -- and in some cases have balked at doing
so. "Part of being an educated consumer is having a good diabetes
education," notes Hill. "And you will probably have to pay something
for that."
In addition, a change in health insurance coverage and a resulting
change in health care providers may leave you longing for your
former diabetes health care team. You may find that advocating for
yourself to get the referral you want to see your former team just
isn't working. Or the effort of managing your diabetes and all the
other things going on in your life may leave you without the
emotional energy you may need to do all the spade work required to
get that referral. Or, admit it, some people just feel too
uncomfortable to complain on their own behalf. Or the environment at
your workplace may make you feel uncomfortable about calling
attention to your medical issues with your employer's benefits
department.
If any of these situations is the case for you, then perhaps, if
possible, you should simply plan to spend $500-$1000 per year out of
pocket for a good diabetes-specific medical evaluation (doctor
visit, lab tests, diabetes education, eye exam) with your former
diabetes specialists at Joslin, even if they aren't covered under
your health plan. See it as augmenting the care you are receiving
and getting covered by your insurer. "After all, to make sure your
care is running smoothly you would spend $500-$1000 a year on
tune-ups, oil changes and other things which are over and above your
warranty," says Dr. Jackson. "Why not do the same thing for your
body?"
This can serve two useful purposes -- first, it can help reassure
you that your diabetes care is on track, and provide you information
about how you can improve your overall diabetes care. Second, if
problems with your existing medical care are uncovered, you can use
this information to go back to your own physician and health plan
and seek improvements. Or perhaps you can parlay the information
into an out-of-plan referral to the physician team you wanted to see
in the first place, or some additional action (i.e. specialty
referrals) within the plan to physicians who may be categorized as
super specialists, only to be referred to in the most dire of
circumstances.
How do you choose your insurance wisely?
Despite changes in the market place most people covered by insurance
at work still find that they have some choice in health coverage.
What should you look for when the annual opportunity to make your
health plan selection comes along? What should you look for in
health insurance coverage if you are going to change jobs and
someone in your family has diabetes? How do you minimize upheaval in
your health care team coverage? Here's some questions to make sure
you know the answer to when considering health plans:
Are the physicians I currently see covered under the insurance plan?

If they are, how easy or difficult is it to gain access to these
specialists I am seeing? How easy, in general, is it to get a
referral?
Just seeing the name of your physicians on a list of providers may
suggest that you'll be able to see them whenever you wanted, just as
in the past. This may not be the case, however. Some plans, for
example, list certain physicians as part of their health network.
But they are as tertiary care providers, which means that you can
only be seen by one of these physicians if your primary care
physician recommends it and the medical director of the health plan
OKs it. "Getting this approval is a long process and your request
will often be rejected. Instead, the plan will offer to cover you
seeing a 'secondary care specialists in the local area' -- an
endocrinologist in the community not associated the physician you
want to see, even though the physician you want to see may be in
your local community."
So, before signing up with a new health plan, don't just check with
the health plan's provider book to see if your specialists are
covered under the plan. Also check with your specialists themselves
to see how difficult it is to get a referral under the health plan
you are considering.
Other questions to know the answers to include:
What co-pays and deductibles are required in the health plan I
am considering? How do these differ with physicians I may see
who are "out-of-network?"

Does the insurance plan cover such things as diabetes education?
Weight loss programs? Fitness programs? One-on-one counseling
with dietitians, certified diabetes educators, etc.? Can the
costs of these services be included in your deductible? Does the
insurance plan cover costs associated with these programs at any
institution, or only at certain places?

What coverage is provided for medical supplies such as blood
sugar monitoring equipment and supplies? What does the drug
benefit include? Are insulin and syringes covered?

What is the mental health benefit? Will it cover such things as
a diabetes-related support group or one-on-one counseling. How
difficult or easy is it to get a referral to such a program
through your health plan?

If the person with diabetes to be covered under the health plan
has a diabetes complication, what rules governing pre-existing
conditions may limit how much money your insurance will cover to
pay for those complications? Or for diabetes care itself?

Is the person to be covered under the plan who has diabetes
planning on becoming pregnant? If so, will the health plan cover
the more frequent testing and doctor visits required. Who are
the specialists in diabetes and pregnancy covered under the
plan? Where will the baby be delivered and what are the
neonatology services available?
Keep in mind that each insurance plan has numerous different
subplans that it sells to employer groups. The only way you will
know for sure if your care at Joslin is covered, for example, is to
check with your insurance carrier.
"Getting health care just isn't what it used to be," notes Hill.
"People just have to be prepared to be more aggressive consumers to
get the care they used to simply get by paying their health
insurance premiums and their doctor bills. It takes a lot of work.
But now, more than ever, an informed, intelligent consumer who is
willing to be a little aggressive will get the best healthcare."
Questions about your diabetes care to ask your doctor

* When was the last time my hemoglobin A1c was tested? What were the
results, and what did they mean? How often does my physician do such
testing?

Hemoglobin A1c (or Hemoglobin A1) is a measure of diabetes control
over the past 2 months. There is some lack of standardization in the
testing, so a result at one lab using one test can mean something
different from the test results provided at another lab. Recent
research at Joslin has shown that HbA1c test results at or near 8.1
percent (as measured in the Joslin labs) can greatly decrease one's
risk of certain diabetes complications, but results significantly
higher than that lead to greately increased risk of complications.
The Diabetes Control and Complications Trial suggests that even
lower results may decrease complication risk if achieved safely.
Your physician (primary care physician or diabetes specialist)
should be ordering an A1c test at least twice per year and more
often if you use insulin. If your results are over 8 your physician
should be discussing with you potential changes in your treatment
plan to improve your diabetes control, because your risks of
developing diabetes complications are much higher. If you are
suffering frequent low blood sugar (hypoglycemic reactions), you
health care team should be discussing possible changes in your
treatment plan to lower your risk of low blood sugars while keeping
your HbA1c as low as safely possible.
* When was the last time I had a "lipid profile" done? What were the
results and what did they mean? How often does my physician do such
testing?

This test measures the level of blood fats in your blood. People
with diabetes are prone to higher levels of blood fats in their
systems -- which puts them at increased risk of heart and blood
vessel disease. You should have these tests done at least once a
year. Your total fasting cholesterol should be less than 200. Your
levels of HDL (so-called good fats) should be greater than 40. Your
levels of LDL (so-called bad fads) should be less than 130, and your
triglyceride levels should be under 150. If you have heart or blood
vessel disease, these levels may have to be even lower to prevent
more problems. If your test results don't fall in these ranges, your
physician should be referring your to a dietitian for help with
lowering the overall fat content in your diet, and help in losing
weight, if that is a problem. He/she should also encourage you to
begin an exercise program -- and should recommend an exercise
tolerance test before you embark on an exercise program if you are
over age 35 or have any diabetes complications. If you have any
diabetes complications, he/she should be referring you to an
exercise specialist (usually an exercise physiologist). These are
usually the first courses of treatment for a lipid problem. He or
she may also prescribe lipid lowering medications, if you have found
that these changes aren't having the desired effect.
* How frequently should I be testing blood sugars at home? What
should my target blood sugars be?

Patients and their physicians should work out an individualized
testing program that works well for them. For patients who are not
on insulin, Joslin clinicians still encourage daily blood sugar
monitoring at least twice a day. Patients on insulin should be
testing their blood sugars at least four times per day, (before
meals and at bedtime). Additional testing should be done before and
after exercising, and if you feel like you are having a low blood
sugar. Normal fasting blood sugars for a non-diabetic are under 126
mg/dl. Although people with diabetes can't be expected to hit these
target levels all the time, they are the goal to strive for. If your
physician recommends a higher target goal for blood sugars, ask why.
There may be circumstances associated with your overall medical
condition -- such as frequent hypoglycemic reactions, an inability
on your part to be able to identify low blood sugars, etc. -- why a
higher target is better for you. For information on target blood
sugar goals at various times during the day, click here.
* Can I eat foods with sugar in them? What dietary guidelines should
I be following?

"If the only dietary advice you have is a pre-printed meal plan, or
if you believe that to manage your diabetes you need to just avoid
foods with sugar in them and lose some weight, you are misinformed,"
says Hill. Recent American Diabetes Association guidelines have
loosened restrictions on the use of foods containing sugar in the
diet of someone with diabetes as long as the person is incorporating
them as part of an eating program tailored by their diabetes
treatment team. Many people with diabetes have a specially tailored
meal plan that takes into account their lifestyle, eating likes and
dislikes, medication requirements, their need to lose weight or cut
back on fat in their diet, and more. Unless you are absolutely clear
about what your diabetes meal program is, and have had your meal
plan updated in the past year, you should probably ask your
physician for a referral to a dietitian. If your medical plan will
not pay for this, the investmant of about $70 for an hour's
consultation may be well worth it to improve the variety of foods
you can eat.
* When was the last time I had my feet examined? Are there any
problems with my feet?

At each visit, your physician should be looking at your feet.
Symptoms of foot problems (primarily the result of poor circulation
and/or nerve damage) can include decreased feeling in your feet,
cramps that occur when walking but go away after resting, slow
healing cuts and scratches, redness of your feet when sitting, or
whiteness when they are propped up on a stool or chair, lack of
normal hair growth on the legs and feet, or pain in your feet or
legs. Even if you don't have any of these problems, your physician
or a member of your health care team should instruct you on how to
care for your feet, and impress upon you the importance of
inspecting your feet daily. If you have any of these problems, you
may want to discuss whether it would be appropriate for you to be
seen by a specialist, such as a vascular surgeon or podiatrist.
* When was the last time I had a dilated eye exam by an
ophthalmologist? What were the results? How often should I have a
dilated eye exam?
People with diabetes need yearly eye exams in which drops are put in
their eyes to dilate the pupils, which will enable the
ophthalmologist to see inside the eyes clearly to detect signs of
possible eye disease. Having your primary care physician look in
your eyes during your regular physical is good to do, but the
dilated exam is vital. People with diabetes are more prone to eye
complications, specifically retinopathy, macular edema, and
cataracts, among other problems. If your physician or eye doctor has
mentioned that you have any of these conditions, ask what treatment
is being recommended. Frequently laser surgery or other types of
surgery are needed for more advanced eye problems. But if you have
eye disease, early detection and treatment can minimize the risks of
severe sight loss.
* When was the last time I was tested for microalbuminuria (the
earliest benchmark for kidney disease). What were the results? How
often does my physician order this test performed? What should I do
if I have microalbuminuria?

If you do not have any signs of kidney disease, your physician
should be ordering microalbuminuria testing at least once a year. If
you have signs of kidney disease, you should see your physician more
frequently for evaluation, including regular blood pressure checks.
You will also want to discuss whether you should be taking blood
pressure lowering medication and/or making adjustments in your diet
to slow further kidney deterioration. You may also want to discuss
whether you should see a kidney specialist (nephrologist) for
ongoing follow-up.
* What's my blood pressure? Is it OK? If not, what should I be
doing?

High Blood Pressure increases the risk of stroke. People with
diabetes are at an increased risk of having a stroke, so high blood
pressure is important to treat. Have your blood pressure checked at
least twice a year. If your blood pressure is over 130/85, (a lower
target than for people who do not have diabetes) ask your doctor
what you should do. Weight loss, following a low sodium diet,
increasing your exercise, and/or taking blood pressure medications
should be discussed.
* What other diabetes complications do I have? What should I be
doing about them?

If you have any complications, such as blood vessel disease, a
recent heart attack, eye problems, any signs of early kidney
disease, neuropathy, etc., you may want to ask for a referral to the
appropriate specialist to have the complication checked out further.