Make Your Doctor Your Health Ally
How to team up with your provider to enhance your care
Spending a day at the pool or riding her BMX bike shouldn’t have been cause for concern after Victoria Bryson was diagnosed with type 1 diabetes in 2013. But the 8-year-old was repeatedly missing the warning signs of hypoglycemia in the hours following physical activity, a condition known as hypoglycemia unawareness.
When Victoria’s endocrinologist, Susan Phillips, MD, recommended she start using a continuous glucose monitor (CGM) in addition to a pump, Victoria’s mother didn’t need to be convinced. The benefits of the device, which records and displays glucose readings in real time, were obvious. “To really fine-tune my daughter’s diabetes management, it made sense to have a CGM as an additional tool to monitor the lows and the highs,” says Polina Bryson, who lives with her husband and two children in San Diego. “We could improve control and quality of life.”
But before Victoria could get the device, Bryson needed to clear an enormous hurdle: cost. The particular CGM recommended by Phillips was a few months shy of being approved for pediatric use by the Food and Drug Administration. That meant Phillips would be prescribing the device for off-label use, possibly hindering insurance coverage. And the Brysons couldn’t afford to buy a CGM out of pocket.
The obstacles seemed insurmountable, Bryson says, until she teamed up with Phillips, who wrote what’s known as a “letter of medical necessity” to the insurance company. Phillips detailed how Victoria Bryson could benefit from using a CGM, citing research studies and including Victoria’s blood glucose logs, which showed that she was having lows and that they were pervasive.
“You have to make a case for using whatever device, documenting the safety and efficacy of it, and explaining in detail the risk that the patient is suffering due to the lack of intervention,” says Phillips, a pediatric endocrinologist at Rady Children’s Hospital–San Diego and an associate professor of pediatrics at the University of California–San Diego School of Medicine.
The strategy paid off: Not only was the CGM covered by insurance, saving the Brysons thousands of dollars, but it happened in a timely fashion. “Our endocrinologist knew what to do,” says Bryson. “She knew what language to use, what data to include in the request to document medical necessity.”
Joining forces with your primary care provider or specialist can lead to improved diabetes management. But some people, particularly those newly diagnosed, may not realize the power of partnering with a provider to boost their quality of care.
“Your physician is there to collaborate and be your partner because you’re the one who—day in and day out—is making the decisions and figuring out what’s working and what’s not,” says Martha Funnell, MS, RN, CDE, FAADE, associate research scientist in the Department of Learning Health Sciences at the University of Michigan Medical School. “Having a provider who’s open to that type of relationship is absolutely critical because this is a long-term chronic disease.”
Forming that relationship begins with listening, says Phillips. “If you do that enough, patients believe you and trust that you’re going to help them the next time something comes up,” she says.
Keep reading to see how your provider can help you get the treatment you need when you find yourself in challenging situations.
Situation: Your doctor recommends a pump to help with better blood glucose management. You’re familiar with the basics, but you’re not entirely comfortable using the device.
Strategy: Your doctor might not have the time or the detailed knowledge needed to help you learn about all aspects of self-care. That’s why it’s important to work with someone who can refer you to another provider without delay. “Diabetes is a team sport,” says Funnell. “There are lots of other people you need to be working with: the educator, the dietitian, the community pharmacist. Part of making your provider your ally is about saying, ‘I understand you’ve only got 10 minutes, but I want to learn about this. Who else can I talk to?’ ”
Situation: Your doctor suggests a CGM to help you manage your diabetes. But you’re on Medicare, which generally doesn’t cover the device. (Medicare recently announced it would cover one brand of FDA-approved CGM for making treatment decisions; however, it’s not yet clear when coverage will begin.)
Strategy: “Continuous glucose monitoring has evidence-based benefits for people with diabetes, and yet access to these technologies is limited for many people,” says David Kerr, MD, FRCPE, director of research and innovation at the William Sansum Diabetes Center in Santa Barbara, California. His advice: Don’t take “no” for an answer. If your insurance plan doesn’t cover a CGM, ask your provider to write a letter of medical necessity to your insurance company explaining why you need the device. If you’re denied, ask your provider to appeal the decision with what’s known as a “peer-to-peer review”—typically a phone conversation between your physician and a physician at your insurance company.
If that still doesn’t do the trick, craft a letter of your own. “I can make the case, but it can be much more powerful coming from the patient,” says Veronica Brady, PhD, MSN, FNP-BC, BC-ADM, CDE, a nurse practitioner at the University of Nevada–Reno. Ask your provider for a copy of the original letter sent on your behalf so you can address yours to the same person and include any peer-reviewed studies it mentions. Add a copy of your blood glucose logs to prove your case. Then personalize your letter with details from your own experience.
Situation: Your doctor recently prescribed insulin to help you manage your type 2 diabetes, but you skip doses on more occasions than you care to admit. You’re afraid you’ll gain weight, or perhaps it’s the injections that scare you, so you’re less than honest with your doctor.
Strategy: Fudging about any aspect of your treatment doesn’t do you or your provider any good. If you’re not able to stay on track, it’s important to be honest so you can reassess your goals.
“Patients worry you’ll be upset that they didn’t take their medicine or didn’t stick with whatever plan you set as a goal,” says Neil Skolnik, MD, professor of family and consumer medicine at Temple University School of Medicine and member of the American Diabetes Association’s primary care advisory group. “Whenever you put two people together—and this is true whether they’re longtime friends, or doctors and patients—there’s value in saying, ‘What are we trying to accomplish together?’ Once you clarify the goals, it’s easier to move forward.” Your doctor isn’t there to judge you, but to help you find solutions.
Another thing to remember: Honesty is a two-way street. For your provider to be your ally, he or she will need to deliver the cold, hard truth. “You want a provider who will hold up the mirror and say, ‘This is what’s going on. I’m going to give you the information. What choice are you going to make?’ ” says Morrison.
Take Harold Young. He weighed 465 pounds when he was diagnosed with type 2 diabetes at age 27. But it wasn’t until he began seeing a new primary care doctor five years later that he fully realized he needed to do something about his weight. “He didn’t sugarcoat anything,” says Young, manager of team development at the American Diabetes Association. “At that first appointment, he said, ‘You’re going to die earlier than you need to if you don’t get a handle on your weight.’ ”
Young spent the next few years trying to shed pounds and improve his blood glucose levels through diet and exercise, but with limited success. Finally, his doctor recommended bariatric surgery. By then, doctor and patient had developed enough trust for Young to confide his misgivings. “My fear was that I’d go through this major surgery—then what?” says Young, now 41. He was also worried about pain. His doctor referred him to a surgeon who alleviated his fears with straight talk. “He said, ‘Initially, I’ll give you pain meds, but then you’ll have to learn to deal with it,’ ” recalls Young.
Now, four years later, Young has lost more than 200 pounds and he’s met his A1C goals. The lesson? “You are the steward of your own health, but you have to trust your doctor,” he says.
Situation: You’re curious about a new treatment you’ve heard of, but you leave your doctor’s office without getting around to asking about it.
Strategy: “Go in with an agenda,” says Tyree Morrison, CRNP, CDE, a nurse practitioner with Frederick Primary Care Associates in Frederick, Maryland. That’s how Susette Langston approaches her doctor visits. Diagnosed with type 2 diabetes 14 years ago, she arrives for appointments armed with a small notebook detailing her blood glucose readings, blood pressure and other test results, as well as a file of things she wants to discuss with her doctor, such as magazine articles related to some aspect of diabetes she’s unclear about.
“I don’t want to forget anything that’s important to me,” says Langston, who lives in Rochester, New York. “I jot down questions as they occur to me and keep them with my blood glucose readings so I will have them handy for my doctor visit.” She tries to save time early in a visit so she can spend it asking questions later. “While you are waiting for your doctor to come into the exam room, take off your shoes and socks so you’re ready to have your feet examined, as they should be at each visit,” she says. (For more tips, see “Make The Most of Your Doctor Visit,” below.)
Situation: You’re having trouble paying for your insulin. Or maybe you’re curious about a new drug you’ve seen advertised on TV but you’re worried about the cost.
Strategy: Let your doctor know you’re having trouble financially. He or she may be able to revise your prescriptions by suggesting an equally effective but less expensive medication, or recommend coupons and assistance programs to help you cover the expense. Also ask your pharmacist for information that you can share with your doctor, whether that’s about cost or medication facts.
Make the Most of Your Doctor Visit
Fifteen minutes. That’s how much time you’re typically allotted with your health care provider. Here’s howto make the most of it.
Prep for Your Visit
Bring a detailed blood glucose log; a list of your medications—not just the names, but also dosages and time of day you take each; and any other health forms or documents. Make a note of when you last had your eyes, feet, and blood pressure screened. If you cover the basics and your urgent needs quickly, you’ll have more time for an open conversation.
“Between visits, write down the things that are of concern to you,” says Veronica Brady, PhD, MSN, FNP-BC, BC-ADM, CDE, a nurse practitioner at the University of Nevada–Reno. Put a star next to the questions you feel are the most pressing, such as: Should I be concerned about the tingling or numbness in my feet?
Review everything that was covered in your exam, as well as next steps. “If your doctor is referring you to another [provider], ask for a copy of any correspondence so you’ll have a record of what’s being said about you,” suggests David Kerr, MD, FRCPE, director of research and innovation at the William Sansum Diabetes Center in Santa Barbara, California. “It will move the clinician to use language that’s understandable.”
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