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Asthma care and the health system

Asthma care is important chapter.Earlier chapters have offered information about understanding, controlling, and treating your child’s asthma. But as parents of children with chronic diseases know all too well, there’s more to caring for a child than giving medicine and getting to doctors’ appointments. There’s also a sea of bureaucracy—the “health care system” of insurance forms, referrals, specialists, bills, copay’s, deductibles, prescriptions, medical devices.

Caring for a child with asthma may sometimes feel like a journey across unfamiliar waters. Your primary care provider’s office may serve as a home base, but other important ports of call may include sub specialists, visiting nurses, medical supply companies, and other providers. Unfortunately, the coordinates for this journey are not mapped out clearly for you in advance. Our health care system is complex and ever-changing. Financial and bureaucratic obstacles still prevent many children from receiving the care they need.

Asthma care important guidelines get free
Asthma care important guidelines get free

Asthma care important guidelines get free

Social workers can help families work through these challenges. You are fortunate if a social worker is playing an active role on your child’s team. If not, an experienced social worker has contributed information to this chapter that will give you insight into successfully navigating the health care system of asthma care. You can use this information to help create a team that includes your child’s doctor and other health care professionals. Parents should not have to carry the burden alone.

PRIVATE HEALTH INSURANCE OF ASTHMA

Asthma care and medicines are expensive, and obtaining the right health insurance is an important first step in accessing the health care system. Recent changes in the law provide the opportunity for virtually every child in every state to qualify for some form of health insurance. The rules and steps involved are complex, however, and may leave many gaps in the asthma care that is provided. Gone are the days when parents could assume that any type of health insurance would pay for all the care that a child with asthma requires.

If your child has private insurance through your employer, you need to explore what it covers. Inpatient (in-hospital) and outpatient (office) benefits may be treated differently and may include copay’s and deductibles that come out of your pocket before the insurance coverage starts to pay. Some insurance plans provide full payment only to providers who are within the plan’s own “network.” If this is the case, it’s important to be sure that the network includes your child’s primary care doctor or pediatrician, nurse practitioner, and other health and asthma care professionals. A referral from your primary care provider may be needed for the insurance plan to cover fully any specialists, such as allergy or pulmonary doctors.

With the increasing costs of medicines, most insurance companies have cut back on prescription plans. Many plans include copay’s, prior authorization, or require the use of a mail-order prescription company. Generic forms of some asthma medicines are available and may result in lower costs if prescribed by your doctor or nurse practitioner. By and large, generic drugs for asthma care work just as well as name brands.

If your insurance does not cover prescriptions, there are other options to consider. Some pharmaceutical companies offer assistance plans;information can be obtained by contacting the individual company directly. Clinical research trials also will sometimes cover the cost of medicines. Information about Clinical trials can be obtained through drug companies, your physician, or through an Internet site set up by the National Institutes of Health (www.ClinicalTrials.gov). Durable medical equipment, such as nebulizer and other home care needs, are covered differently by insurance plans. Some forms of equipment, such as spacers, can be ordered at low-cost from organizations such as the Allergy & Asthma Network: Mothers of Asthmatics (www.aanma.org or 1-800-878-4403).

Asthma care public insurance

If you do not have private insurance, several options are available for public insurance. These programs use funds from the federal government but are organized differently in each state. You can learn the specific rules for your area by calling your local county Board of Assistance. Medical Assistance (also known as Medicaid) offers coverage to children under the age of nineteen based on income, residency, and other requirements. Many state Medicaid programs involve managed asthma care plans that have rules about specialty care similar to private insurance plans.

In 1997, the federal government established the Children’s Health Insurance Program (CHIP) to expand the availability of health insurance coverage to working families beyond what Medicaid provides. The federal government funds the states to help pay for this program. Since the program is administered by each state, the specific rules may vary in your area. In most states, children from a family of four, with earnings up to $34,100 per year (in 2002), are eligible. More information about the CHIP program can be obtained by calling 1-877-KIDS-NOW.

Some children with chronic diseases like asthma care may be eligible for Supplemental Security Income (SSI) as determined by financial and medical criteria. There are strict guidelines, but an eligible child may receive cash assistance as well as medical insurance. Information about SSI can be obtained through the Social Security Administration at 1-800-772-1213 or through your local Social Security office.

PRIMARY ASTHMA CARE

Primary asthma care is an important of every child should have a primary asthma care provider for well-child checkups and immunizations. With a chronic disease like asthma, it is particularly important to see consistently the same physician, nurse practitioner, or other professional over time so the primary care provider can get to know your child well. This primary asthma care provider will play the lead role in assessing your child’s asthma, prescribing medicines, and making referrals for other services or specialty care if needed. Primary asthma care providers differ in many ways, including their training background (for example: family medicine, pediatrics, and nurse practitioner programs), the structure of their offices (private office, hospital, or public clinic), and the size of their practice (a single provider or a large group).

Choosing a primary asthma care provider is a personal decision, but several factors are important to consider when your child has asthma.

  • Experience with young asthma patients: The provider should be familiar with treating asthma in the pediatric age range. Children have many unique needs that require a treatment approach different from that for adults.
  • Access:  Since asthma flares can occur at unpredictable times, you should always be able to reach someone for advice. Many offices are open for evening and weekend hours, which can be very convenient for working parents.
  • Support systems: Last but certainly not least, the other staff and support services are important. A friendly, accessible office staff and a well-organized system for teaching about asthma, refilling prescriptions, and following through on patients’ needs can add a great deal to your child’s care. Some offices may have specifically trained staff, such as social workers or case managers, available to  help with obtaining services. A team approach to primary care has the most to offer.

Specialty Asthma care

Specialty asthma care can be confusing because each type of provider may have a different focus. Pediatric allergists specialize in the reactions of the immune system to common environmental allergens, such as pollens, dust mites, or pet dander, that can play a key role in asthma. Allergists use skin tests to detect allergies and may, in some cases, treat allergies by giving repeated small doses of the allergen (see former chapter). Pediatric pulmonary medicine physicians (also known as pulmonologists) specialize in lung diseases in children. These physicians perform lung function tests and procedures such as bronchocopy, where a small camera is used to look inside the lung. Both allergists and pulmonologists treat asthma with the conventional medicines that have been described in this book. In specific cases, however, they may have a somewhat different approach to diagnosis and management of asthma care.

Whether your child needs to see a specialist is an individual question to be discussed with your primary asthma care provider. In most cases, mild asthma can be managed successfully by your regular physician or pediatrician. But a specialist can be very helpful if your child does not seem to be responding well to treatment or if your primary care provider has specific concerns and suggests that further testing may be needed. Beyond having added experience and training, specialists usually schedule extra time to delve into the specifics of more difficult cases. Since they focus on asthma, they may also have educational material, support staff, and other resources that can be very useful to you and your child. Visiting a specialist may pose some potential problems. With more than one provider now treating your child, there is the potential for con-fusion and miscommunication. It’s important to make sure that information flows well between the specialist and your primary care provider, who will continue to prescribe your child’s medicines and see your child for acute illnesses.

Specialty care is expensive and can pose financial hardship if not covered by insurance, so it’s important to make sure that referrals and other needed forms are completed before seeing a specialist.

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