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December 29, 2001

Community Resources, Insurance/Costs

Question from Sylmar, California, USA:

I was diagnosed about seven months ago with type�2 diabetes, and my HMO states flatly that there are no circumstances under which they will refer/pay for any nutritional referrals for any condition. I can't even get a copy of the full exchange list! My local ADA office says I should get it from my dietitian, and my HMO refers me to the ADA. Also, my diabetes "team" consists of my HMO primary care provider who freely admits to not having answers to many of my questions, but has been unable to get me anything in the way of a referral. What can I do to get answers to my more technical questions?

Answer:

There are also excellent, affordable booklets and pamphlets that could serve as resources for you from the American Diabetes Association. Visit store.diabetes.org.

If you can commit to reading about your diabetes for one hour a day for a week, you could get a good general picture of the relationship of blood glucose, food, exercise and medications and begin to manage your diabetes. Please look at the website and chose a book that appeals to you. You also may be able to obtain the book you find at the website at your local library or a local chapter of the ADA.

MG

[Editor’s comment: I would discuss a referral to a dietitian with your case manager and also send a letter to the medical director of your HMO stating this need. The latest consensus statement from the American Diabetes Association states:

Because of the complexity of nutrition issues, it is recommended that a registered dietitian, knowledgeable and skilled in implementing nutrition therapy into diabetes management and education, be the team member providing medical nutrition therapy.

For the full text of nutrition recommendations, see Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications.

It also seems that you are in need of diabetes education, so at the same time, I would request a referral to a diabetes team. If your hemoglobin A1c is greater than 1% above the upper limit of normal for the lab, your control is not adequate, and you may also require ongoing management by an experienced diabetes team.

It may help for you to review Standards of Medical Care for Patients With Diabetes Mellitus to use a reference when appealing to your HMO.

SS]

[Editor’s comment: Sounds like your HMO provider, or the HMO plan itself, would also want you to do your own appendectomy if you had a ruptured appendix, too. They’re trying to save money, not help you with your health. Since they are so reluctant, you have several possible choices:

Change providers within the plan if you think it’s the provider who’s barricading the door.
Contact the plan’s “case manager” or whatever title, or the Medical Director, and show them the information mentioned above.
Get out of the plan and switch to another (such as a PPO), if available.
Complain to your employer, if they are funding the insurance. Sometimes, if enough complaints surface, some employers might contact the HMO and have an influence on their behavior. Remember, however, that employers are frequently looking for the cheapest possible plans, so unless there’s a major issue, they are unlikely to be proactive.
Write your state’s insurance commissioner, and send copies of all your prior correspondence.
Write your Congressperson, and send copies of all your prior correspondence.

Don’t give up — it’s your life at stake.

WWQ]