So what should you do with this new health system?
Understand what is happening in the health system now, so that you will better understand and know the procedures of the health firms that are constantly changing along with the pressures they are subject.
Know your condition so you can ask and focus on areas where you and your doctor should focus his attention and soon to seek help from a specialist-so you can control your diabetes.
Be your own lawyer. Meet the recommendations of the American Diabetes Association for preventive care and active search, and ask your doctor when it is time to follow those recommendations. Try to find a health care provider that supports (pay for) monitoring of these recommendations. Do not worry if you need to write a letter to your provider arguing why it is necessary that they will pay any procedure that you require and that they do not cubren- transfer to another physician or an educational program for example. Include in your argument any research that supports the need for the transfer, and be sure to mention that the insurance company will benefit if the referral to another doctor decrease your risk of developing medically more costly long-term problems.
Choose your doctor wisely. Find someone who is knowledgeable about diabetes and who are interested in working with you to control your disease.
Make sure your general practitioner is able to periodically refer you to a diabetes specialist or other specialist, or educational programs to help with more complicated problems.
If possible, be prepared to pay for some things out of pocket, particularly diabetes education, a second opinion given by a doctor who is not in the health system.
When possible, choose a health plan that allows greater freedom in choosing their doctors and to pay for the care you need.
Do not worry if you should express concern when he questions the quality of care offered.
The Changing physician performance:
Currently, the world of medicine is very specialized, however, efforts to keep prices are putting pressure on general practitioners - family physicians traditionally to provide the greatest care possible to patients because their care it is the least expensive. However, during the care of your diabetes may require medical needs a primary care physician and a group of professionals who work with their knowledge when needed. Dr. Richard S. Beaser and Joan VC Hill, RD, CDE described in the book " Joslin's Guide to Diabetes Care" "If possible, patients with diabetes should seek a medical environment where the disease is controlled by a professional team, including experts in important areas of their overall care. " This team should include a general physician, a diabetes expert who is usually an endocrinologist, a dietician, an expert nurse educator, an exercise physiologist and someone who will provide advice and psychological support when necessary. Other members may be added as necessary to treat or prevent complications.
His desire because diabetes is managed by a team of specialists-and the desire of his insurer, on many occasions, that most care is offered by the doctor generally can be contradictory. "Some believe that these needs are in conflict," describes Kenneth E. Quickel Jr., MD, president emeritus of Joslin in Boston. "But in fact, the patient with diabetes receive the best and most effective long-term care when the general practitioner and the team of specialists work as a team."
The doctor as traffic officer
Your general practitioner has been trained to treat you as a person of integrity and to treat a variety of medical problems such as colds, flus, monitoring cholesterol and control diabetes. This person works as a traffic officer, in many ways, coordinating their comprehensive medical treatment.
But besides acting as a traffic officer, this doctor also works in many health insurers as the gatekeeper, handling day to day health needs and regulating the flow of patients to the most expensive forms of care. In essence, the general practitioner works on his behalf and that of your insurance to ensure that you receive the best medical care in a way that does not lead to higher costs. Often, the insurance payment to general practitioners is limited to how effectively your doctor may reduce the use of expensive tests and services- and the doctor may be penalized for an abuse of specialists and effective testing.
"Elliott P. Joslin In 1916 wrote that" the number of cases of diabetes is so great that it is clear that their care rests in the hands of general practitioner. It is ridiculous to expect that treatment of diabetes is under the constant supervision of a specialist. Dr. Quickel. Notes, while the role of goalkeeper is a reality, has always been important that the general practitioner working closely with specialist diabetes. The selection of an excellent general practitioner is so important for a patient with diabetes as choosing a diabetologist or endocrinologist excellent addition to ensure that the two can work together.
Diabetologists and general practitioners
Diabetes programs of some health insurers, specialists are registering as general practitioners and diabetologists as to allow patients to choose a diabetologist as your general practitioner. This is due, in part, to the fact that most are trained diabetologists first general internal medicine or pediatrics before receiving their training in diabetes and endocrinology. Another reason I do this is because the dividing line between general medicine and diabetes is not clear. In medical practice in Boston, some of the Joslin diabetologists are recorded as general practitioners in some health plans for this very reason. "Physicians Joslin served as general practitioners for patients over the last 50 years or more, because diabetes is a disease that lasts a lifetime and it affects many aspects of a person's life," notes Dr. Quickel.
Other insurers do not allow diabetologists -a despite having certification to practice general internal medicine register as general practitioners. In some cases, they insiten that specialists associated with a medical school are classified as "tertiary care physicians," which limits patient referrals. Insurers perceive that these specialists and institutions where they hospitalize patients are expensive. Thus a physician at Joslin be classified as a general practitioner in a plan and as a specialist third level on another system.
"In a perfect world, our primary function is to serve as experts in diabetes and leave the primary care general practitioners," said Dr. Richard Jackson, a senior physician at Joslin. "But because patients demand and need sometimes more of us than insurers provide them if we only we affiliate specialists, we also we affiliate as general physicians."
The ideal
The ideal scenario is that you identify a general practitioner who knows the management of diabetes, is interested in sickness and knowing their limitations refer you to other experts to receive additional care when needed, despite the penalties that this will Truck with the insurer when the doctor made the reference. "Most doctors will not allow insurers to interfere when a patient needs to be referred only because they offer a small monetary reward, says Dr. Quickel. "But the general practitioner should know a lot about a no-number of diseases and different conditions. He or she can not be updated with the most recent management protocols as can be, the diabetologist, because their role is to know much about this disease and its complications. This means that the general practitioner can handle most of your medical problem - including many of those around the diabetes-. But at one point the general practitioner should seek help from a diabetologist if management has not been efficient as it should be.
"What we're looking for is a holistic approach, focused on preventing problems" says Dr. Jakson. "If we focus on preventing problems rather than acting on them when they occur, we can really lower the cost of health care by limiting the amount of money that patients need to spend in specialists who must treat costly complications such as arterial disease, heart attack, a stroke or other problems. "
Understanding Your Disease
How do you know that your diabetes is being managed properly by your doctor? "Knowing their disease," says Dr. Hill, who is the director of educational services at Joslin.
Here we present a number of important questions you should answer when you are evaluating the management of their diabetes in general and as has been the interaction between general practitioner and specialist in diabetes in managing their disease team. "If you do not know the answers to these questions, ask the person providing him with most managing your diabetes (either your general practitioner, a specialist at Joslin, a nurse practitioner , or ólogo diabetes another EU institution) the next time you have medical control, "says Hill.
Also provided are good questions to discuss with your general practitioner or the New diabetologist if you are going to change doctors because of changes in your health plan says Jackson.
Be your own lawyer
If you do not know the answers to all these questions, discuss them with the clinician more involved in the care of their diabetes during future visits. Then ask yourself how you felt when I was asking these questions. If you felt comfortable as the conversation continued, this may suggest that the doctor was listening to their concerns and not let him know he was upset because he was being questioned about his medical practice. If, on the other hand, felt he should stop asking as soon as it started, it was because the doctor either openly or secretly - he was sending messages because suddenly he felt uncomfortable when questioned about his knowledge about diabetes? or because it bothers you question a traditional figure of authority?
When shopping for health-insurance "make sure you receive the services for which they are paying" - says Dr. Jackson.
What to do if you feel uncomfortable?
Many people feel uncomfortable when they have to discuss this with your doctor. "Many of us have been brought up to believe that we can not ask the pastor or doctor, they take care of us and it is better not to ask a lot," says Hill. "But studies such as the Diabetes Control Test and show its complications (DCCT) results that careful control of blood glucose levels reduces the risk of complications. At this point it is very important to ensure that members of the diabetes management team know what they are doing-and that includes you. You, the patient, is the most important team member handling your illness. As a result, you have a right to know that the other team members are working with you, and who have the skills to make your life with diabetes is manageable and is free of risks as much as possible ".
What to do if you feel unhappy with your health care provider, and your options are limited to physicians associated with your insurance company?
"Ask," recommends Hill. "Attend association meetings local diabetes and try to find other patients with diabetes who may have found a good general practitioner and / or a good diabetologist that may be covered by your insurance. Interview general practitioners of his friends They do not have diabetes but said that their doctor is accessible and seems to have knowledge of a number of medical institutions. it is possible that such a doctor is knowledgeable about diabetes- or has- not be willing to refer you to a specialty was, and will continue to give general care unrelated to diabetes "
How can you help your employer?
You may consider express the human resources department where he works on his disagreement with the medical care they are receiving under the health plan offered, particularly if the health coverage has recently been changed and you feel that your care is suffering from this reason. While insurers, on average, have a customer enrolled for three years before this individual change insurer or change jobs, statistics show that your employer will use it for much longer. Poor delivery of health services results in the impoverishment of their job performance, absenteeism and low productivity, not to mention the high costs for the insurance if you develop complications. Your employer will probably be interested to know if you are concerned about the quality of your medical care as a result of changes in health delivery. And the insurance will be more interested in hearing the voice of a quiene employer is paying for health insurance for hundreds or thousands of workers, rather than listen to you, who represents one person.
More importantly, your employer may be interested to know how they can continue to offer health plans at low cost that meet the needs of most of its employees, while offering additional programs at work, which will help meet the needs of workers with diabetes, or other problems such as obesity, high blood pressure, high blood lipids, etc. You can propose to the human resources department to organize days of nutrition in the workplace and free of charge to people with such problems; or to offer weight loss programs or exercise in addition to the basic health program, which will help you develop an exercise program or weight loss at low cost and it will help you manage your diabetes; or even better a stress management program to help workers to lower blood pressure.
Be prepared to pay out of pocket
People should know know what, having health insurance does not involve a complete health service free. Patients with diabetes must always pay for their education in diabetes-and in some cases they end up frustrated at the end. "An important component to be an educated consumer is to have a good education in diabetes," says Hill. "While insurers have increased coverage of educational programs in diabetes, you probably have to pay some of the cost."
Also, if insurance should be changed, this change in the provision of health may make you want to have the management team their previous diabetes. Surprisingly, you may be at a crossroads where you do not get the transfer you want to see again the diabetes management team you prefer. Or the effort involved in managing your diabetes and all the other things that are happening in your life leave you without enough energy to make all the necessary search for that transfer. Or, admit it, some people feel uncomfortable when they complain in their own name. Or your work environment can make you feel uncomfortable about having to mention the health service that receives the human resources department of your employer.
If you are in any of these situations, then you should, if possible, set aside an amount of money once a year for a good specific medical evaluation of your diabetes- medical examination, laboratory tests, diabetes education, exam vision) with specialists of their choice, even if they do not belong to your health plan. Think of it as increasing the care you receive through your insurer. "After all, to make sure your car always works well you should invest $ 500- $ 1000 a year in oil changes and basic maintenance that exceed the guarantee of their car," says Dr. Jackson. "Why not do the same for your own body?"
This can help you in two ways: first, it can help to reaffirm that diabetes care is where it should be, and can provide information on how you can improve your diabetes care. Second, if problems are discovered even with your current insurance, you can use this information to call attention to your doctor and insurance to improve the service. "Maybe you can parlay the information the information into an out-of-plan referral to the physician team you wanted to see in the first place, or some additional action (ie 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. "
Choosing your insurer?
Despite the changes in the market, most patients insured through an employer think they have options to choose their health coverage. What should evaluate the health insurance plans when to make the annual selection? What should be evaluated in a health plan if you are going to change jobs and one of their insured relatives have diabetes? How minimizes agitation discomformidad in its health insurance? We offer below a series of questions to ensure that you know the answers when evaluating health insurance plans:
Doctors who are managing my disease are included in the health plan?
If they are, it will be easy or difficult to obtain transfers to these specialists? How easy, in general, you can get a transfer ?.
Seeing the name of your doctor on the list of providers may suggest you podráverlos whenever you want, as used to be in the past. This can not happen now. Some plans, for example, publish lists with names of doctors who belong to its health network. But they are providers of tertiary level, which means that you can only see them if and only if recommended by your general practitioner and director of the health plan approves. "Getting this approval is a lengthy process and your request may be denied after all. Instead, the plan will provide coverage locales- an endocrinologist specialists in their community not associated with the doctor you want to see, although the doctor you want to see this in the area.
So before signing up for a new health plan, not just check the book of medical providers to see if their specialists belong to this network service. Also ask specialists directly how difficult it is to get a referral using the health plan you are considering choosing.
Other questions you should know the answer:
How much you must pay copayment and how much is the deductible health plan that will choose? What is the difference when I see a doctor outside the network?
The insurance covers things like diabetes education? Programs for weight loss? Exercise programs? Individual consultations with dietitians, diabetes educators or certified? The deductible includes the cost of these services? The insurance plan includes costs associated with these programs at any institution, or only in certain places?
The plan covers the costs incurred for purchase of equipment for monitoring, lancets, controls, etc.? Which includes drug insurance? Covers insulin and syringes?
Provides support mental health? It will cover things like diabetes support groups or individual counseling? How easy is it to get a referral to one of these programs through this health program?
If the patient with diabetes to be affiliated presents a complication associated with the disease, the rules governing the pre-existence of certain diseases can limit coverage by the insurer in such complications or care of the disease itself.
The patient with diabetes consider the possibility of pregnancy while in this health plan? If so, the health plan will cover the most common tests and medical visits required? Who are gestational diabetes specialists affiliated with this health plan? That clinic is expected that the baby will be born? And what neonatology services are available there ?.
Remember that every insurance plan has a no n umber of sub-plans that sells insured employer groups. The only way you'll know for sure if their care at Joslin obtained will be covered, for example, is asking the insurer directly.
"The search for a health plan is not like it used to be," said Hill. "Patients should be more aggressive consumers so they can get the care that previously was obtained by fee based health insurance and accounts their doctors. This represents a lot of work. But now, more than ever, only the intelligent and informed consumer who decides to be a little aggressive get the best health service ".
By Tonywankha