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Literacy is a luxury that many of us take for granted. That is why SADAG created SPEAKING BOOKS and revolutionized the way healthcare information is delivered to low literacy communities.

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When Chris Stacey's allergist suggested she start getting allergy shots regularly, Ms. Stacey didn't just nod and smile.

"Shots are a long-term investment, and an expensive long-term investment," Ms. Stacey, 36 years old, recalls thinking. At the time, several years ago, she felt that oral allergy drugs were more convenient and less costly than shots. Plus, she was moving from employer health coverage to an individual policy that she had to buy herself, and she worried that her premiums would go up if she were perceived as an expensive patient.

When Ms. Stacey told her doctor she didn't think shots were the right step for her, the doctor didn't change his mind, she says. So she got a second opinion from another allergist who, she says, ended up sharing her view.

Insurers want more patients to be like Ms. Stacey -- unafraid to ask their doctor questions about a course of treatment, not to mention its cost. Despite the fact that patients are often reluctant to sound like second-guessers for fear of irritating their doctors, insurers are arming patients with the tools and the techniques that the insurers have honed to help them press the point on clinical options and costs.

In February, Lumenos Inc., a unit of health insurer WellPoint Inc., intends to start offering a service that lets its patients enter the names of drugs into their cellphone Web browsers, which in turn will shoot back a list of comparable drugs, ranked by how much they cost under Lumenos's plans. That way, patients can ask their doctors about cheaper alternatives while they're still at their appointment, the company says.

An increasing number of insurers are sending letters directly to patients suggesting that they talk with their doctor about certain treatments, tests or medications that the insurers say might be appropriate or less costly for the patients. Others are making suggestions within financial statements2 they're sending home, or listing "questions to ask your doctor" on their Web sites.

Meanwhile, Cigna Corp. intends in the next few months to start telling patients typical prices of different types of doctor visits, including details such as what types of services typically would be provided and how many minutes of face time the patient normally would get with the doctor, based on the price charged. Cigna says it's not pressing patients to challenge their doctors over their bills, though it would be natural for some to scrutinize the charges.

The goal of keeping health costs down is nothing new for insurers. For long insurers have wrangled with doctors over costs, setting up, and then scaling back, unpopular rules that require doctors to get permission to provide certain treatments or drugs. But now more than ever before, they are enlisting patients in the effort to check health-care providers.

"It starts with the notion that you should certainly have a right to question," says Robert Laszewski, a consultant to health insurers. "I think that's different from not having confidence in your doctor, but what you're encouraging people to do is to make them explain it."

The results could mean lower costs for insurers. Insurers also say the tools help patients at a time when they're increasingly bearing more of the costs of their care. Also, certain tools can help doctors keep track of how individual patients' insurance plans work, insurers say.

"We want to empower the member and we want to educate the member," says Constance L. Williams, an associate medical director for UniCare Life and Health Insurance Co., a WellPoint division headquartered in Chicago, which started sending letters about treatments and costs to patients in Massachusetts in a pilot program in late 2003, and now is expanding the program.

Still, it's unclear how vigorously patients respond to insurers' prods, if they do at all.

Susan Rebello, 51, received a mailing from UniCare suggesting that she ask her doctor about taking a drug called an ace inhibitor, based on her health history, which included heart failure and diabetes. Ms. Rebello, of Three Rivers, Mass., says she hesitated to bring the subject up with her doctor.

"We just had a good rapport," she says. "It's like, geez, how am I going to go to him and tell him that my insurance company is suggesting that I be on a medicine? ... I really didn't want to embarrass him."

She decided to "kind of soften" the subject by telling her doctor that her insurer was "trying to play doctor now," and showing him the letter, she says. It turned out the doctor thought she was already on an ace inhibitor, and he apologized and prescribed the drug, she says.

The letter and others like it were developed by Resolution Health Inc., a Columbia, Md. company that provides the letters to clients including UniCare, Blue Shield of California and Horizon Blue Cross Blue Shield of New Jersey. This month Resolution Health added PacifiCare, recently acquired by UnitedHealth Group Inc., to its client base. Resolution Health has sent similar letters to doctors, but the doctors often receive information about several patients at once and then don't see the relevant patients soon after the notes arrive, the company says. So in the past couple of years, the company started focusing on patients too.

"I think it's easier to get the doctor's attention through this mechanism," says Earl Steinberg, Resolution Health's chief executive. "When the patient is raising some issue, it's sort of harder for the doctor to just dismiss it or ignore it."

UniCare has gauged doctors' and patients' reactions to such mailings -- finding mixed results. In addition to sending letters to patients, the company faxed copies to the doctors of 481 patients, including a survey asking doctors for their thoughts about the letters. Seventy six doctors replied, some sarcastically.

UniCare surveyed 2,700 patients who had received the letters, and it received 316 responses, most of them showing satisfaction. The majority of respondents showed the letter to their doctor, UniCare says. Some 40% of respondents didn't show the letters to their doctors at all.

"We still have some work to do with helping people feel comfortable about saying to the doctor: 'What's up with this?'" says Dr. Williams of UniCare. "I think that we need to give patients tools and training to make sure that their concerns are heard."

Some doctors say that patients already ask them more questions about cost than they used to, in particular attempting to reduce their drug expenses. But many patients still don't raise cost-related matters unless they're under major financial strain, doctors say.

"Historically, that was something that, for whatever reason, was not a large part of the patient-physician relationship," says Thomas Kintanar, a family physician in Indiana who says he fields a "small number" of cost-related questions.

David Hagan, a family physician in Gibson City, Ill., notes that it can be convenient for a patient to raise cost issues in the office. If a patient is going to realize at the pharmacy that they have to pay a lot for a drug, "I'd rather find out now, rather than get a phone call two hours later, after the chart has been put away," he says. But some doctors question the likelihood that a patient will pull out their cellphone to check on drug costs in the middle of an appointment.

"If I've got to sit there and wait for them to look something up on a cellphone, that takes up their time and my time," says Larry Fields, a family physician in Ashland, Ky. and president of the American Academy of Family Physicians.

"It's kind of a silly solution," Dr. Fields says, "but the premise is not bad."

 

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