Navigating Healthcare

By Diane L. Marolla, LICSW

“Fundamentally, the answers to our challenges in healthcare relies in engaging and empowering the individual.” -Elizabeth Holmes

Each month, when I contemplate which topic I want to discuss with the readers of The Smithfield Times, it is always a hard decision for me. I choose a topic, but when my writing deadline approaches, I will encounter a consumer with a personal healthcare crisis or there will be a current new story that will change my mind. This month, it was a consumer with a healthcare crisis that prompted me to write about why it is important that individuals are engaged in their treatment, and the importance of care coordination.

Last week, I received a call from a small business owner whose employee was having a health crisis. Whereas I have made a choice to focus my healthcare career on solving the problems with healthcare and have put my clinical work on hold for now, I am always willing to help guide a consumer in getting good clinical care. When I spoke with the individual by phone, I learned that she was a 25-year-old single female who is having a sudden onset of problems with her vision. She was scared and confused, and had an appointment to see a specialist in Boston. I also learned the following:

She was seeing an optometrist for issues with her vision. Her optometrist is the one who recommended she go to Boston for treatment.
She hadn’t seen her primary care physician (PCP) in years. Her optometrist advised her to see her PCP.
She has a neurologist who treats her for chronic migraines. It was unclear to me whether her optometrist knew that she suffered from migraines or that she was under the care of a neurologist.
She sees her OB-GYN annually. Per her report, her OB-GYN does not do any annual blood work on her.
The Boston specialist (who has never met this individual) said she needed an MRI before her appointment, and advised her to have her PCP order the MRI.
She had no idea if an authorization or a referral was needed for the MRI.
She had no idea what her insurance would cover.

As I guided her on what to do next, I realized yet again why our healthcare system remains a maze for consumers, and why it is so expensive. Nobody was assisting this individual in coordinating her care. (Care coordination simply means there is health care professional who is assisting a consumer in navigating the healthcare system.) In addition to her care being fragmented and uncoordinated, nobody was having the discussion about her insurance and what would be covered, and if she would absorb any of the costs.

Here are some points I would recommend to all consumers for getting good medical care:

Good clinical care and treatment always starts with a consumer having a relationship with their primary care physician (PCP). You should see your PCP every year for your annual exam so that they know you and your medical history. Your PCP is always there for you should you need to be seen for a medical problem that may crop up in between your visits. Should you need a specialist, your PCP will work with your specialist(s) and share your information with that specialist.
If you are a female, do not automatically assume that your OB/GYN will take the place of your PCP. Be sure to have a conversation with your OB/GYN to see if they want to take on that role and if your insurance company will pay them to manage your primary care as well.
If you have what is called a chronic condition (examples of chronic conditions are diabetes and migraines), it is important that your team of medical doctors/therapists are coordinating your care. It is also important that no matter what your visit is and who it is with, that they know you have a chronic medical condition. In the example of this young lady who suffers from migraines, her optometrist and her dentist should be aware that she has this chronic condition and if she is taking medication for it.
If you see more than one doctor or therapist for your care, make sure you read through your benefits, so that you know what your costs will be, if authorizations are required, and if you can go out of state for treatment.
If you are admitted to a hospital, ensure that the hospital is coordinating your care with your outpatient medical doctors and therapists. Your outpatient doctors and therapists should know that you are in the hospital, when you are being discharged, and if they are making changes to the medications that you are on.
Know and understand your health benefits. If you don’t, it will cost you with medical bills that you are not prepared for. Review your healthcare policy and call your insurance company. Always keep notes of who you spoke with at your insurance company, the date, the time and what they said to you. All calls with your health insurance company are recorded, therefore, they can’t “deny” that you called them if you have the information on when you called and who you spoke with. This information will help you should your insurance company choose to deny your claim and not pay your doctor for the care you received.
Always be honest with all of your doctors and therapists about what conditions you have, who you are seeing, and what medication you are taking.

As I always try and remind folks, our health is everything. Never be afraid to ask questions of your treating physicians, your therapists or your insurance companies.