My new health insurance plan, issued by Anthem Blue Cross, covers certain preventive care services. One is an annual eye health screening. I just had my annual eye exam done by my eye doctor who is an in-network provider. So I’m eligible to order more contact lenses, I am required by law to have my eyes examined once a year.

Yesterday I received a phone call from my eye doctor’s office. They submitted my claim for my eye exam and let me know that Anthem Blue Cross denied it. I was told that annual eye exams, according to my health insurance company, are “eye chart vision screenings” performed by my primary care physician at my annual well-woman visit.

Really?

At age 52, I am only entitled to have my PCP tell me to look at a chart and read the letters with one eye covered.

Are you kidding me?

I called Anthem Blue Cross this morning and asked why my claim was denied. I was told the same thing as what my eye doctor explained and in addition that “eye chart vision screenings,” performed by a PCP, are considered adequate screenings for eye health.

Not according to the American Optometric Association.

The AOA’s website explains that, “Periodic eye and vision examinations are an important part of preventive health. A comprehensive adult eye and vision examination includes an evaluation of eye health, such as depth perception, color vision, muscle movements, peripheral vision or side vision, Keratometry, Refraction and more. These are performed by “eye care professionals.” See their website for info http://www.aoa.org/eye-exams.xml

Does a vision-screening test performed by my PCP qualify as a “comprehensive eye and vision exam”?

No.

According to the AOA, an eye health examination is “external examination of the eye includes evaluation of the cornea, eyelids, conjunctiva and surrounding eye tissue using bright light and magnification.” This recommendation also includes measurement of the pressure within the eye.  

Is your PCP equipped to perform these tests in your annual exam?

Probably not.

According to the Affordable Care Act, we are all entitled to certain preventive care services. On July 14, 2010, the ACA “helps make preventive care affordable and accessible by requiring health plans to cover recommended preventive services without charging a deductible, co-payment or co-insurance.” See link here http://www.healthcare.gov/law/features/rights/preventive-care/index.html 

Apparently, the ACA left out qualified eye health exams by optometrists and ophthalmologists even though the American Optometric Association reports that “periodic eye and vision examinations are an important part of preventive health care.”

A comprehensive eye exam can detect signs and symptoms of vascular diseases such as diabetes and hypertension. The Centers for Disease Control and Prevention (CDC) reports that, “taking care of your eyes also may benefit your overall health. People with vision problems are more likely than those with good vision to have diabetes, poor hearing, heart problems, high blood pressure, lower back pain and stroke, as well as have increased risk for falls, injury and depression.” 

Note that the National Eye Institute recommends “comprehensive dilated eye exams”  and those exams must be conducted by an “eye care professional.”

Apparently my health insurance company disagrees with the National Eye Institute and thinks my PCP is an “eye care professional.”

Your health plan may state it covers eye health exams but in reality they may not. Check your plan for the details. 

For more information about patient empowerment, visit www.thetakechargepatient.com

I woke up this morning at 7am to my husband standing in the hallway dressed in his bathrobe, holding his left hand wrapped in bandages.

“Are you okay?” I was sleepy and it hadn’t yet registered that he’d had a very late hockey game the previous night and hadn’t come to bed.

“Got hit with a puck.”

I went to him. As I got closer I saw the bloody bandages. “Jamie, what happened?”

In his usual “it-not-a big-deal” kind of way he said, “I was holding my hockey stick and the puck hit my hand. It split open my finger.”

I remained calm. Maybe it was the pre-coffee stupor that numbed my response. Jamie had been through a number of hockey injuries over the years as he plays on a local league. He loosened the gauze to reveal his ring finger and blood oozed from the cuts and dripped onto the floor. The wounds were angry, swollen and deep.

“You need a doctor,” I said. My brain lit with adrenalin now, I shifted into high gear. Which doctor were we going to see? We had to get dressed quickly. Maybe we should go to the emergency room. No doctor was in until 9am.  

Still standing in the hallway, he said, “Nah, it’s fine. I’ll wrap it up, use some of the stuff in the first aid kit.”

But it wasn’t fine. The cuts looked nasty, primed for infection. “No way.”

“Let’s go downstairs. I know we have gauze pads. We’ll wrap it up. Maybe put on Neosporin.” I stopped myself on the first step. “No, not Neosporin.” I envisioned Neosporin seeping into those deep cuts. I prattled on, my anxiety goosing my obsession with medical information.

As we made our way downstairs and into the kitchen, Jamie described how he’d come home at midnight and had iced his hand, wrapped it in gauze, and had slept in the guest room because he knew if he’d woken me up I’d have insisted that we go to the emergency room. The only thing Jamie hates almost as much as emergency rooms is my reaction when he crawls into bed stinking of beer and sweat, especially if he’s bleeding.

“Jamie,” I said, “next time, wake me up.”

In the kitchen now, we found the gauze pads and medical tape. I started to help him but I wasn’t doing any good. My nerves were getting the better of me.

“Let me do it,” he said. He wrapped his finger in fresh gauze. And then another. The blood just wouldn’t stop. I started to feel light headed.

“Dr. Pullen’s out of the office today. We’re going to an urgent care center.”

Jamie started to protest but I insisted.

I grabbed my laptop and began researching urgent care centers. I read reviews on Yelp, scared by some truly terrible reviews posted by dissatisfied patients. I then searched for urgent care centers that were attached to physicians’ offices, places that were members of The Urgent Care Association. Researching urgent care centers might not be something many would do but since I had written a chapter on them in my new book, The Take-Charge Patient, I knew that some were a lot better than others.

Brentview had a waiting room filled with patients. On the wall was a hockey stick signed by Wayne Gretsky. Jamie turned to me and said, “We’re in the right place.”

Of all places, we’d stumbled upon an urgent care center whose physicians loved hockey. It was kismet.

Dr. Darvish was great. He had in fact treated Wayne Gretsky many years ago and Jamie and he chatted about hockey and the Kings, L.A.’s hockey team. Jamie seemed calmer in the face of the doctor. Darvish explained that wounds like his needed to be stitched up quickly to keep the swelling and possible infection at bay.

Much to my relief, Dr. Darvish seemed to know what he was doing. After he cleaned and inspected the wound, apologizing to Jamie for causing pain, he explained that Jamie’s wedding band would have to come off because he’d have to inject his finger with anesthetic right where the ring was.

Jamie tried to pull the wedding band off but the swelling was a hefty gatekeeper.

Darvish said, “We’ll have to cut it. I’m sorry.”

A male nurse brought in a portable saw just for such a situation. But he didn’t know how to use it. Placed on a tray table, he fumbled with its parts, trying to get it to work.

Jamie looked at him and said, “First time?”

The nurse nodded.

“I can do it.” Jamie grabbed the machine.

Sure enough, my skilled husband put that device together and began sawing at the wedding ring I’d given him 25 years ago. Jamie has built motorcycles from scratch and knows his way around just about any type of machine.

Looking a bit sheepish, the nurse held the finger straight so Jamie could get at it. The scenario just made me laugh so I took a photo of it. Who would believe that a patient would take over with a mechanical device and saw his own ring off so the wound could be stitched?

11 stiches later, we were out of Brentview. The doctor had done a great job. As we left the exam room, he said he was sorry for us having to wait for so long as they were unexpectedly understaffed.

It was an easy healthcare experience. One doesn’t often say “easy” and “healthcare” in the same breath. Brentview was pleasant, the doctor was good, and Jamie is going to be okay.

But next time, he’s waking me up. 

The story in The Los Angeles Times, Patient is out of network, out of luck,  describes a patient, Jalal Afshar, 58, with a rare disease who, despite Kaiser Permanente’s denial to pay for treatment, found the appropriate treatment for himself and is now cured. He is suing Kaiser for 2 million, the sum total of his medical treatment that saved his life.

If this isn’t the most perfect example of a take-charge patient, I don’t know what is. Jalal’s doctors at Kaiser admitted to never having treated a case of Castelman’s Disease and offered hospice to him. Jalal did his own research to find a specialist in the treatment of Castelman’s disease at the University of Arkansas for Medical Sciences in Little Rock.  Kaiser authorized the referral to see Dr. Fritz van Rhee for preliminary tests but ultimately denied payment for treatment. If Kaiser approved the referral to see the specialist, why then did they disallow the treatment?

Perhaps Kaiser Permanente’s pre-certification process rendered the proposed treatment as medically unnecessary, not appropriate, or not at the level of care or effectiveness in keeping with Kaiser’s standards. 

 Boy, were they wrong.

Why would Kaiser deny treatment that ultimately saved Afshar?

Money.

If their review of the proposed treatment for Castleman’s disease was considered too much of a financial risk, they probably declined payment on that basis.

With an HMO like Kaiser, treating patients like Afshar boils down to making money and saving it. According to The New York Times article, The Face of Future Health Care George C. Halvorson said, “We think the future of health care is going to be rationing or re-engineering,”

And rationing is right. Afshar’s case is the perfect example of rationing of care and right in keeping with the mission of HMOs.

The journal, Radiology, (University of California, Irvine Medical Center, CA) reported on a case where a woman’s appendix ruptured while she had to wait 8 days for diagnostic tests for abdominal pain. The court decided in favor of the HMO, stating that “rationing health care is intrinsic to the design and mission of HMOs.”  See article here http://radiology.rsna.org/content/217/3/626.full

Jalal Afshar took it upon himself to research effective treatment for his disease, something Kaiser Permanente should have been willing to do or at least authorize. After all, Kaiser is the only HMO to earn a four star rating for overall quality of care in the HealthCare Quality Report Card from the California Office of the Patient Advocate.  

People have asked me, “What is the value of being a take-charge patient if you’re a patient at Kaiser, which has some of the best integrated data systems in the country?” I’ve told them that being a member of Kaiser does not obliterate the necessity for becoming an active participant in one’s health care. Successful, quality outcome of care isn’t just about closed, integrated systems. It involves a number of things, one of them being an empowered and engaged patient who is willing to do his or her own research and pursue treatment options when necessary.

An HMO like Kaiser wouldn’t have helped me one bit when I received 10 misdiagnoses from 11 physicians of differing specialties for a severe, chronic pain condition that lasted 16 months. I didn’t give up. I kept pursuing answers even after several doctors suggested that I adjust to a life of chronic pain. I found my own diagnosis in The New York Times article, In Women, Hernias May Be Hidden Agony.  The surgeon and hernia specialist (at a major Los Angeles teaching hospital) who was interviewed for The New York Times article, performed surgery on me to fix hernias with nerves passing through the holes.

I’ve been pain free for two years.

If patients think that closed, integrated systems like Kaiser Permanente, Cleveland Clinic, or Mayo Clinic, are going to solve all of their health care problems, they are sorely mistaken. Electronic Health Records are very successful in decreasing fragmented care, preventing certain types of medical errors and more. But patients still have to be engaged, empowered, and invested in their care. They have to be willing to do some of the work. 

Just like Jalal Afshar. But patients like him are now being asked to shoulder the risk when HMOs are unwilling to assist.

I understand why HMOs like Kaiser are becoming popular and are encouraged by The Affordable Care Act (ACA.) The U.S. far outspends other countries on health care, dedicating more than 17 percent of its gross domestic product (GDP) to health care compared with 12 percent or less in all other countries. We have to do something about our country’s overspending on health care. But is rationing care to a 58-year-old male fair? Are HMOs the way we want to go?

I welcome your comments.

 For more information on The Take-Charge Patient, visit www.thetakechargepatient.com

A recent article in the Wall Street Journal reported on doctors’ lack of communication skills and how that affects quality of care, healthcare costs and patient lawsuits. No surprise there. Doctors’ communication skills are a current hot topic. But I think we’re forgetting that a physician’s communication skills are only one piece of the puzzle. The doctor-patient relationship is the heart of good healthcare. That relationship includes communication, and it affects quality of care, patient satisfaction, treatment adherence, patient safety and more. (U.S. News&World Report) 

Physician communication skills have been part of the curriculum for medical students for years but a successful medical encounter isn’t just about a doctor conducting a good patient interview, taking a thorough history, or explaining medical information in a way that a patient understands.

It is also about the quality of the doctor-patient relationship.

The relationship between a physician and patient does involve successful communication from both parties, but let’s not forget that a personal connection or bond enhances trust on the part of the patient. A doctor can be a good communicator and the patient can still not trust her. That lack of trust impacts treatment adherence, patient satisfaction, patient safety, and a willingness to return to the doctor.

For trust to develop with a patient it involves more than the obvious; a doctor’s good credentials, experience, reputation and communication skills. A doctor has to be a good listener, and good listening involves the ability and willingness to focus on a patient’s story and tune out distractions and time pressures. Actively listening means not only replaying key elements of what the patient has shared but conveying empathy. For a patient to trust a doctor, she has to feel heard and cared for. According to Health Affairs, patients have to believe that doctors are acting in their best interests. 

I can tell you that during my 16-month chronic pain condition, it was the doctors I connected to personally who won my trust, whose advice I followed, and with whom I lived up to my end of the bargain as an engaged and empowered patient. I saw plenty of physicians who were good communicators but who left me out of the equation and therefore failed to incite my trust, my confidence in them, failed to enlist my commitment to their proposed treatment plans. It was the doctors who looked me in the eye, who treated me with respect and who collaborated with me in my care, who won my allegiance.

The importance of looking a patient in the eye can be overlooked by many doctors who are tied to their iPads and laptops with the onset of EMR requirements, according to The British Journal of General Practice. Glancing up from the keyboard or computer screen and establishing eye contact with a patient can help facilitate an effective relationship and engagement with the patient. Eye contact implies respect and emotional connection.

Speaking of engagement, the relationship between patients and physicians can facilitate patients as partners in their care. Communications skills alone can’t do that. But a personal connection, in concert with successful communication and patient engagement, stands a much better chance.

A successful relationship between doctor and patient includes shared decision-making. Creating a working alliance with patients has many benefits. According to The New England Journal of Medicine,  shared decision-making includes the patient’s preferences, values, cultural orientation and beliefs. Doctors can include the patient by using a variety of decision aids such as written materials in the patient’s language, videos, visual models and even hand-written drawings. For shared decision-making to be successful the doctor must have good communication skills and create a personal connection with the patient. Not all doctors have the time or desire to do that.

Change takes time.

I welcome your comments.

An article in today’s Los Angeles Times, Social isolation increases risk of early death, reported that seniors who are socially isolated are more likely to die prematurely. The article was based on a newly published study in the Proceedings of the National Academy of Sciences.

I’ve written before on loneliness in seniors  and how that contributes to poor health but this new study got me thinking and I began some research on what might help seniors combat isolation.

According to an AARP Foundation survey , seniors are having trouble staying connected with family, friends and neighbors. The reasons aren’t necessarily what you might think. The fact that families are now spread out all over the country might be anyone’s first guess, but there’s more to it. 

Seniors might be coping with their own illnesses/medical conditions or those of a spouse or partner. They might be struggling with lack of mobility or may have lost their job. Maybe they live alone, have fewer friends than they used to, or are caregiving for a loved one, and more. It’s easy to see how a senior might become disconnected, overwhelmed or stranded—any of these can contribute to isolation.

I’ve witnessed this first-hand with a close relative who is retired and now copes with chronic medical conditions that contribute to him being fairly homebound unless friends and caregivers take him out. Just the other day in a phone call he said, “Retirement is awful. If I hadn’t had to retire because of my physical problems I never would have.” It didn’t take much prompting for him to continue. “Martine,” he said, “getting old is not easy.”

I feel for him, especially because he lives across the country and my regular phone calls, books and treats that I send him don’t make up for not flying there often enough. Besides, he has few family members and friends now that he’s retired and 81 years old.

I also know other seniors who are retired and who long for a sense of connectedness to a group of people, something they once had with their jobs. They don’t necessarily miss the jobs they retired from but sorely miss the connections they once had, and in particular the sense of self-efficacy they felt in the world.

Recently, I talked with a few friends who are worried about their retired parents who have become isolated and have developed a sort of inertia when it comes to connecting with the community. They shared that their parents don’t know where to go to make the first step or simply lack the motivation. So, I decided to do some research to see what I might come up with in terms of resources for seniors that might serve as a lift back into the community.

Much to my delight, I came across MyMentorAdvisor   As I read about this organization, I grew excited for the seniors I care about and the possibilities that could come from connecting to this organization. MyMentorAdvisor is “a website developed to match people that may be retired…who have a specific talent or skill and want to share their knowledge with others who have a need or interest. It’s about people helping people.” I contacted the founder, John Young, to find out a little more. He established phase 1 of the website five months ago and is in the process of establishing an initial network of mentors. I passed this information on to a retired CEO friend of mine and he said, “I’m fascinated. I’ll let you know of my progress.”

I was also delighted to uncover a number of organizations that also focus on connecting seniors with professional experience to businesses and individuals as a way of sharing a wealth of knowledge with those who need it. SCORE.org offers mentors to businesses of all types. Their website states that “Volunteering at SCORE is a way for you to give back to your community, connect with fellow business owners and pass on your knowledge and expertise to the next generation of entrepreneurs in your community.”

Equally as exciting is ExecuBrainTrust  which “places highly experienced retired executives for corporate consulting engagements and temporary executive assignments.”

Who knew these organizations existed?

Another organization, WISE & Healthy Aging (Santa Monica, CA), is simply one of the most wonderful organizations for seniors which “enhances the independence, dignity and quality of life of older adults through leadership, advocacy, and innovative services.” I was a moderator for a WISE & Healthy Aging event at RAND Corporation  a few weeks ago. I didn’t realize until now that not only do they provide a comprehensive resource center for the over 50 set, but they also offer Peer Counseling,  a program within WISE that trains older adults to counsel their peers. They’ve been featured on the TV shows “20/20,” 60 Minutes and others.

Perhaps we’re all familiar with senior centers and religious institutions that provide opportunities for seniors to get involved, connect to others and volunteer. My own godmother, Martha, was very involved in her local senior center and it kept her involved, active and stimulated. But senior centers and churches might not be for everyone. Check out AARP and the above links and see if they are a fit. If not, Google “senior resources, combat isolation” and you’ll come up with a number of articles which list resources and links to organizations.

The key to combating isolation in seniors, according to AARP, and Richard J. Leider, author of The Power of Purpose, is to find a new purpose or reinvent your purpose in life. It’s about “what gets you up in the morning and what energizes you and brings passion to your life.” Leider is also the founder and chairman of The Inventure Group  a coaching and consulting firm in Minneapolis.

Connecting to purpose is important for all of us. Purpose drives us into the community to make new friends and business connections, to give back, and increases a sense of fulfillment. Maybe for some it’s recreating purpose and for others it might be tending to grandchildren, volunteering in the community or creating a book group. Whatever it is, I hope the conversation continues about what we can do to assist our seniors.

I welcome your comments.

DISCLAIMER: I am not recommending any of the organizations listed. Please do your own research.

 Please visit my websites: The Take Charge Patient and Critical Conditions.