Our Health Revolves Around Insurance

Insurance has become a VERY widely discussed topic over the last few weeks. And in most cases those conversations are not good conversations. It seems in the last several years insurance companies have really grown and have total control over a patients treatment! They have the ability to deny procedures that the patients physician deemed necessary. They also have the power to say that patients can’t use certain medications. Whether that’s by actually refusing to pay for them, requiring the patient to try several other medications first or making their “coverage” of the medicine so poor that no one can afford to take it. Some will argue that this has been happening since the Affordable Care Act was instituted, and that may be true. But my purpose today is not to talk about or fight the political side of things. My point is to share the struggles that many Americans, especially the chronically ill are forced to face head on due to their insurance on a daily basis. As well as giving a few pointers on dealing with issues with your current & potentially future insurance carrier.

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It’s no secret that medicine as a whole has drastically changed over the last few years. And definitely not for the best in most cases. The costs for medical care has skyrocketed and a big part of that is the insurance companies, who seem to be paying less, charging us more and dictating what procedures, treatments and medications we can or cannot have. I know that I am NOT the only one who is unhappy with the state of our current medical system. Or with the fact that the insurance companies have been allowed to dictate most care.

Many that I have spoken to in the chronic health community about this topic conveyed their frustration to me. Most felt frustration due to what seems to have become the norm. The issue I am speaking of is the “HURRY UP AND WAIT” mindset that has now become modern medicine. Nothing is more frustrating than being told that you could potentially have x, y or even z, only to then be told then that a pre-authorization will be required for the test or procedure needed to diagnose the problem. Getting approval from any insurance company could potentially take weeks. That is IF you are lucky enough to be approved the first time for said test or procedure. Many will be denied once, twice or more by the insurance company requiring anything from very specific documentation, to trying other treatment options. Sadly, even if you do what they ask you may still be denied. If you are approved the tests may be booked for three weeks out. So you could potentially be looking at months before any possible diagnosis could be given. I have discusses this topic with many chronically ill and they feel the same way. The fact that insurance is now controlling medicine(both actual medications and also other treatment options) is not  okay. And the fact that they are also requiring outrageous co-pays and premiums is totally unacceptable! And makes carrying insurance for many just plain impossible.

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I did a little research and found that depending on your location monthly health insurance premiums vary greatly. The premium costs for a healthy 21yo range depending on location from $180 monthly to over $400 monthly. That’s not great but when you add age and any health issues the statistics show a dramatic difference in the monthly premium costs.ValuePenguin, shows how the monthly cost will increase with age. A 30yo will pay 1.135 times more, a 40yo 1.3 times more, a 50 yo 1.786 times more and a 64 yo will pay 3 times the cost of the 21 yo’s premium.  And these  rates are just a simple policy. There will be an added cost for mental health coverage as well as if you are sick and will require more care.  These number just absolutely blow my mind.

I know what you may be thinking, “Amber, you are a nurse and have worked in medicine for most of your adult life, you know how this process works.”  Yes, that is true I do know. Well, I knew how the process worked prior to the Affordable Care Act was put into place. But that has changed dramatically. The fact that insurance companies now have more control than our actual doctor in regards to what medication we can have, or what procedure will be approved totally blows my mind and makes me so angry. What ever happened to the day when you and your doctor have the final say. Or the time when a doctor could order a test and it could be done in a day or two with no fight from the insurance company. I do understand that in the long run the insurance companies “GOAL” is to reduce the number of unnecessary tests that are being done that could potentially harm the patients. And they are trying to prevent medical errors bred by disjointed or fragmented care! Some say that the insurance companies are trying to keep a look out for the patients. While that may be true the way they are going about it makes it hard for most people to understand that.

After speaking with several fellow spoonies about what they feel are the biggest struggles when it comes to insurance. The top three that were brought up were as follows:

For me the biggest issues has been having their “doctors” override the recommendations of my own dr and not approving the treatment plan that my doctor feels is in my best interest. – Jane

The insurance company won’t pay for meds that the dr prescribes unless your try X number of medications first. They should pay for all medication. -Mindy

COST!!! Private insurance is more than a house payment for some. I am a couple of years away from not being able to afford it anymore. If you don’t pay high premiums you pay high out of pocket costs. – Valerie

Tim Gouw, PayPal.me/punttim

After speaking to many from the chronically ill community the above topics were three that came up again and again. Leading me to believe that those truly are the biggest issues. What kind of government & companies think that it is okay to charge people premiums that cost more than a house. Simple, because they know they will pay it because their health conditions require some kind of medical insurance. The sad part is that many people have no idea how insurance companies work or how they can work along side their insurance in some situations to move along the process of getting tests or procedures approved.

I would like to give you FOUR TIPS for dealing with your insurance provider.

1. If you feel like the prior authorization, whether it be for medication or a procedure, go ahead and make a call yourself to the insurance company. They should be able to tell you what the hold up is. And if they require more documentation from your provider always ask what exactly they need so you can give that I formation to your provider.

2. Please know that if you are talking to your insurance company about it’s benefits regarding a procedure, test or medication you need and you don’t feel like it is going as well as you would like. You have the right as the patient to ask the insurance company to make a conference style call to your physician.

3. This may sound cliche but finding a doctor who is on the same page as you and will stand up for your patients rights is ESSENTIAL in the insurance fight. If you have a dr that you feel wouldn’t do those things for you it is totally 100% for you to start looking for a provider who will stand up for you and your rights.

4.  As far as the costs of premiums & co-pays go I would HIGHLY suggest that you start looking into options for the following year way in advance of the last day. This will give you plenty of time to really look into each plan, what the costs are and what is covered. I would also suggest talking to others with similar conditions and see what plans they have. By doing this you are becoming an educated shopper which gives you the information you need to pick the best options for you.

Sadly, it doesn’t look like the cost of the insurance is going to be changing anytime soon. So we as the chronically ill need to find a way to deal with the problems at hand. In the insurance game we have to be strong and not be afraid to stand up for our rights when it comes to speaking with insurance providers. We also NEED a physician on our side that will not be afraid to do the same. We also need to educate ourselves as I mentioned before. We need to make sure that we know everything we can about the options of plans we have.  By doing this you will be able to make the decision that suits you and your family best.  Chronic illness is a battle no matter how you look at it. But when you throw the insurance bone into the mix it creates many unnecessary problems. So in closing, you should always take your time choosing physicians and your insurance plan. If you and the physician aren’t on the same page then there is no way you can ever become a united front to face the insurance company.  So ALWAYS make sure you have a good physician in your corner.

I hope some of you will find this useful!

With Love,

Amber

What You Should Know About Allergies

Most would agree that some years are worse than others, and this year Nany feel like their allergies are going to get the best of them. Even though we have seen just about every kind of weather possible this “spring,” (I won’t call it spring yet!) everything seems to be blooming already. That means that for those who suffer with allergies and chronic sinus infections, this time of year (and fall) can be very frustrating and miserable. Allergies are not classified routinely looked at or classified as a debilitating illness. However, like many others i have talked to this spring, I am starting to feel like it possibly could be in that classification. I have been doing some research on this topic the last week or more, so I wanted to share a few of the things I’ve learned.

It seems that the best place to start this article is to start with a few definitions. I want to provide knowledge for those who may not suffer or those who may not be aware of what allergies are or can be! So let’s start with what an allergy is. By definition- an allergy is when a person’s immune system reacts to some kind of foreign substance, that is know as an allergen. An allergen could be things that can be eaten, inhaled into your lungs, touched, or injected into your body! Specific response can cause anything from sneezing, itchy eyes, a runny nose all the way to severe reactions that cause hives, low blood pressure, trouble breathing and even death! Examples of possible allergens are dust, mold, trees, grass, ragweed, pollen and food allergens such as milk, egg, soy, wheat, nuts it fish proteins.

How many people suffer from allergies every year?!? Any guesses? I was shocked to find out that allergies have been found to be the SIXTH leading cause of Chronic Illness in the US alone. This can lead to an annual cost healthcare costs of an excess of $18 BILLION dollars. It is estimated that 40- 50 MILLION Americans have allergies of some kind every year!! People of all ages can struggle with asthma, allergic rhinitis, food allergies, and eczema. Asthma is said to affect more than 24 million people in the US, including more than 6 million kids.

I’m just guessing that everyone could probably name at least 5 people right off the top of your head if you were asked who you know that suffers from allergies!! One would think that due to the fact that so many million people suffer with allergies that is would be easily treated by any medical provider. While that may be true for the every day Joe who suffers from seasonal allergies. But for those who have severe allergies that don’t respond to the over the counter meds and treatment, or has allergy based asthma, a specialized doctor is necessary. A doctor who specializes in allergies and asthma would be the best person to see. Simply because these providers received specialized education and training in these conditions. They are able to perform allergy testing, accurately diagnose your symptoms, and develop a personalized diagnosis for your specific allergies and conditions.

There are two key steps in diagnosing your allergies. One would be to take a full and thorough medical history, and the the second would be doing actually allergy testing. You are probably wondering why a full medical history would be important. That’s simply because when it comes to HUMAN allergies the person’s medical history is just as important as the actual testing. The history provides a link between the test results and the actual allergies. The history can help the provider to see what allergies your family might have and to see what certain medications, in or outside settings or food seems to make your symptoms worse. While the provider is taking your history you might be asked about the following:

  • Your overall health
  • Your symptoms and if your immediate family have asthma or allergies such as skin rashes, eczema, hives or hay fever.
  • Your symptoms. They provider will most likely want to know when your symptoms occur( what you are doing and where you are at), how often they happen, what brings them on and what if anything makes your symptoms better. The allergist may also want to know about your home and work environments and eating habits to see if they might lead to your exact allergies.

After the provider has taken a very thorough history, testing will most likely be done. Allergy testing has become the gold standard in the diagnosis of allergies. Blood and skin tests are used to detect a person’s sensitivity to common allergens. They can show allergies to things like pollen, dust mites, animals, ragweed, certain foods, latex, certain trees or plants. In most cases skin tests have proven to be the most accurate and preferred way to diagnose a person’s allergies. Blood tests are generally ordered less often, but they could be used in cases of severe skin rashes, or if the person can not stop a medication that can possibly interferes with the skin testing. Allergy tests basically give reliable results that confirm information that the provider gathered while taking the medical history.

After you’ve had a positive allergy test and you and your provider are aware of what allergens you react to, it is time to develop an individual plan of care. According to the Allergy and Asthma Foundation of America there are many options for treatment depending on the specific allergy and the severity of the allergy/reaction. The foundation states that the treatment of allergies can include: avoiding allergens, medication options and immunotherapy (which can be given as a shot or a tablet placed under the tongue.

You may be thinking what I was when I read through my research, HOW ON EARTH DO I AVOID ALL ALLERGENS THAT IMPACT ME?!?!? That being said the AAFA says that the best way for a person with allergies to prevent allergy symptoms and decreased the required amount of medications is to AVOID your allergens as often as possible. They say that doing this can include removing the source of allergens from home and other places you spend large amounts of time. So if you are allergic to pet dander either remove said pet from the inside of the house or look for hypoallergenic types of animals. They also suggest routine nasal washings to help reduce symptoms brought on by airborne allergens. This can be done by doing a nasal saline rinse using a squeeze bottle or Neti Pot. (Side note if you are going to do nasal rinses you should always use only bottled water or boiled tap water. Never tap water that hasn’t been boiled)

If the avoidance technique does not work for you, there are medications available. Not everyone is okay with taking anything for allergies, simply because they don’t think it’s a big deal. However, not treating your allergies can turn into much bigger and more painful issues like sinus & ear infections. Below you will find a list of classes if medication that can be taken to help with allergy symptoms.

  • Nasal Corticosteroids, aka nose spray- Work by reducing swelling which can cause a stuffy, runny, itchy nose. This option is the most effective for those suffering from nasal allergies.
  • Antihistamines- Do just what the name says. They block histamine which is a trigger for allergic swelling. This type of meds may reduce sneezing, itchy runny noses and hives. These meds come in a variety of forms, and often time can be found over the counter as pills, liquids, melting tabs, creams or nose spray.
  • Mast cell stabilizers – This classification of meds work by keeping your body from releasing histamine (that is a cause of allergies). By blocking the production it helps with itchy, watery eyes, or an itchy, runny nose! This group is available as eye drops or nose sprays.
  • Decongestants – This group of meds works by reducing stuffiness by shrinking swollen membranes in the nose. One has to be cautious with these meds. As they can, if used more than prescribed, cause the stuffiness and swelling in the nose to worsen.
  • Corticosteroid creams &/or ointments – These products relieves itchiness and can prevent rashes from spreading.
  • Oral Corticosteroids- This type of medication has to be prescribed and may be used to reduce swelling and stop severe allergic reactions. These medications do have well known side effects so be sure to talk to your doctor or your pharmacist.
  • Epinephrine – This comes as pre-measured and also self injectable devices. This is the most important medicine to give during a severe allergic reactions (aka anaphylaxis). For this medicine to work properly it must be given/taken within minutes of the first sight of a serious allergic reaction. If you know you have a severe allergy to food, any kind of stinging insect, latex or medications, you need to make sure you always carry EPI pen with you. And that friends/family know how to use it if you are unable to.

Another method of treatment for allergies is Immunotherapy. Currently there are two types of immunotherapy that can be used to treat allergies. They are allergy shots and sublingual immunotherapy (SLIT)

  • Allergy Shots- This method of treatment involves giving injections of allergens in increasing doses over a long period of time. By doing this the person receiving the shots progressively becomes less sensitive to the allergens given in the shot! Allergy shots work best for those who have allergies to pollen, pets, dust, bees and other stinging insects and asthma. However, those who have allergies to food, feathers, hives or eczema will not likely to respond well to shots.
  • SLIT – This is another method for treating certain allergies without injections. When using this modality for treatment, an allergist will give patients small doses of an allergen under the tongue. Over time the exposure will improve tolerance to the the allergens thus reducing symptoms. This method overall is fairly safe and effective for treating nasal allergies and asthma. Currently SLIT is only available for the treatment of dust mites, grass and ragweed!

I don’t know about you but I am feeling a little overloaded at the moment. I have provided you with lots of information on allergies. I hope that my research has provided you with more information about allergies, treatment and diagnosis. I know I learned a lot. I must include this disclaimer, the information provided in this article is just for self education and gaining knowledge about allergies. That being said you should never start a new treatment method without first speaking with your doctor or getting a referral to an allergist. It is a fair assessment that many people will suffer from some kind of allergy during their lifetime. However, like most medical conditions everyone’s journey with their allergies will be different. And what treatment works for you may not work for Your kids. While doing research for this article I came across The American College of Allergies, Asthma and Immunology. They have a fabulous website that provides so much great information and is easy to understand. Click the link above if you want to learn more.

If you have any questions or comments on this post feel free to share them in the comment section below. And feel free to share with anyone who might benefit.

With Love,

Amber