Health Care Systems - What happens when facing a chronic condition?

Most people consider themselves healthy. However, the federal government has data to show that the average American has 1.7 conditions. This may sound surprising, but chronic conditions include hay fever, migraine headaches, and astigmatism that requires eyeglasses. Most people only consider more serious conditions to be chronic, like asthma, diabetes, arthritis, and heart problems. A chronic condition is any health problem that lasts a long time or recurs frequently. A chronic condition can be treated but cannot be completely cured.

The first step to ensuring excellent health care is to fully understand the chronic condition: When do attacks occur? How long do they last? What are minor symptoms vs. intense symptoms? What are successful treatments for the condition? Are there preventative measures that can be effective?

The second step is to find a health care plan that provides all the options and services to successfully treat the condition. Under managed care, a primary care physician and a specialist will care for a person with a chronic condition. The primary care physician will coordinate the overall treatment and is responsible for giving the patient the needed referrals to see the specialists. It is important to pick a primary care physician who is knowledgeable about the chronic condition and is easy to talk to.

Treating a chronic condition successfully, and quickly, can depend on the managed care organization's rules for seeing a specialist. Sometimes the rules and restrictions for seeing a specialist can be complicated, time-consuming, and frustrating. It is important to follow these rules, however, to ensure the highest amount of coverage from the health plan.

People need to ask some hard questions of their health care plan about their own specific chronic conditions. For example, fill in the blank with the name of the chronic condition:

• Does the plan contract with doctors, hospitals, and community-based health care providers with a track record of serving —— patients?
• Can a physician with experience in —— be the primary care physician?
• Does the plan have a drug formulary (a list of drugs and classes of drugs preferred by the health care plan for use by its members)?
• If so, are off-label drugs and new drugs for —— included in the formulary?

Other questions to ask when dealing with a chronic condition include (adapted from AIDS Action Foundation, Medicaid Reform and Managed Care, undated):

• How and how often is the formulary revised to include new and more effective drugs as they become available?
• What information does the plan have on the health outcomes of chronically ill people, including those with ——?
• What are the plan's policies on specialist referrals?
• What are the plan's policies on new drugs, new treatment rules, and participation in clinical trials?
• Many plans have consumer boards or advisory committees. If the plan has one, are people with —— and providers with —— expertise included?

Referrals with Chronic Conditions

Referrals are the most complicated factor in dealing with chronic conditions and managed care. The process and rules for referrals vary from plan to plan. Some questions to ask the health care plan are:

• How does one get a referral, and for how long can it be used?
• How often can the referral be used before having to get another one? Is it one referral per specialist visit or does one referral cover a series of visits?

Referrals cover not only specialist visits but laboratory tests. Unless a patient has a condition that is life-threatening, the tests may not be performed on the same day as the doctor visit.

Prescription Drugs and Chronic Conditions

Some chronic conditions require no medication while other conditions require medication only during flare-ups, or when the condition is actively bothering the patient. Still other conditions require the long-term use of a prescribed medication. All health care consumers should understand the terms formularies, generic substitution, and therapeutic substitution.

FORMULARIES. Formularies are lists of prescription drugs preferred by the HMO for its members and are common in managed care. Plans develop the formularies on the basis of drug safety, effectiveness, cost, and cost-effectiveness. Formularies can be restrictive and can potentially impact the care a person receives. Managed care has been criticized for taking improper savings on drug use at the expense of consumers' health, even to the extent that illnesses and deaths could have been prevented.

People with chronic conditions need to pay special attention to their health plan's formularies. A doctor's knowledge of formularies is not dependable because a doctor may deal with numerous health care plans. In an open formulary, a patient should be able to get any drug, with some drugs requiring an additional co-payment. In a closed formulary, a patient who wants a specific drug may have to wait for the doctor to seek prior authorization, or approval, if the drug is not on the approved formulary list. If authorization for the nonformulary drug is not granted, the patient can file an appeal or even explore legal action.

GENERIC SUBSTITUTION. Generic substitution is the substitution of one medication with another drug that contains the same active ingredients in the same amount and dosage, but sold by a different company. Generic drugs are common because they cost much less than brand-name drugs. In changing from a brand-name drug to a generic drug, or vice versa, a patient may experience some side effects.

THERAPEUTIC SUBSTITUTION. Therapeutic substitution is the replacement of a prescribed drug with an entirely different drug in the same pharmacological or therapeutic class. These substitutions can pose more danger to the patient than generic substitutions. Different drugs, even those in the same class, can have significantly different effects on people. Pharmacists or hospitals should inform the doctor of any therapeutic substitutions, but they do not always do so. Consumers should check any differences between what was prescribed and what was received.

Emergencies and Chronic Conditions

Sometimes chronic conditions can be so severe that hospitalization is required. It is the patient's responsibility to learn about the chronic condition, including how to know when an episode is mild or serious and what to do about it. The primary care physician or the specialist can provide a list of symptoms, including recommendations for when a patient will need to go to the emergency room.

Disease Management

Some health care plans have disease management programs for people who suffer from chronic conditions like asthma, diabetes, or arthritis. A call to the plan's advice line or member services department will provide information about what is available. These programs focus on care for the whole patient, not just the symptoms or conditions associated with the disease. The disease management program may include patient education or behavior modification (a change in habits and lifestyle) classes, long-term monitored drug use, or the assignment to a case manager, who can recommend treatments and services that might not normally be covered under the plan. The case manager will coordinate the overall care of the patient.