Wednesday, November 18, 2009

A Medical Home?

Way back in August, I was looking at our calendar and noticed an appointment missing. Nolan's two year old well-child visit had never been set up by our pediatrician's office, and I didn't realize this until I flipped the calendar over and realized there was no appointment scheduled for the little guy's two-year old well child visit.

I called the pediatrician's office, and they told me that if I wanted to see our regular pediatrician, we would have to wait until November for an appointment. Because Nolan has so many issues, I really wanted to see our regular pediatrician- it was worth the wait. We last saw the pediatrician for a well-child in March, which means that Nolan's posterior urethral valves, gastric motility issues, and severe gastro-esophageal reflux disease (GERD) were all additions to his medical file since that visit.

I walked into the pediatrician's office today, and in walks... a random nurse practitioner. Not our regular pediatrician, as I had requested. This meant I had to go through Nolan's general history with her, including his hearing loss, urology work-ups, failure-to-thrive, and GERD. She didn't have a "feel" for his history, so she spent a lot of time worrying about his language development (this isn't our primary concern at the moment, which our regular pediatrician would have known).

All of this underscores the importance of a child's "medical home." For children who have multiple medical specialists, the medical home is a central location for all of the various medical records, and a physician who is aware of the entire scope of medical and developmental issues at play. In our case, we have an audiologist, an ENT, a GI specialist, and a urologist who all submit records to our medical home (the pediatrician's office).

When you don't have the same physician on a routine basis, however, the medical home becomes useless. Perhaps for children who have no underlying issues, a random "doctor of the day" is fine. For us, it is a rather big waste of time, since all of the appointment time is spent doing "catch up" work rather than discussing current concerns and growth. Frankly, I feel like we are medically homeless.

At any rate, the nurse practitioner listened to Nolan's heart, weighed him, measured him, and ordered a Hepatitis A shot and a flu shot. The H1N1 vaccination is still not available in our area, so we were out of luck in that department.

The current stats are (at almost 27 months of age):

Weight: 23 pounds, 12 ounces. A slight decrease from his weight at the GI doctor's office in August (he was 24 pounds then). This is right at the 3rd%.

Height: 34 1/2 inches. This is just above the 25th%. His growth rate in height has actually decreased (he used to be in the 50th%), but he's on the charts in a healthy region, so there is no real concern. We'll keep an eye on it, but it shouldn't become a problem.

Head Circumference: 50cm. This is in the 75th%. No matter what, the boy has a lot of brains!

The nurse practitioner wanted to see him in six months, because they typically do a check-up at 2 1/2 years. I collected my howling children (Nolan, indignant because of the shots, and Matthew, indignant that he didn't get his choice of sticker) and headed for the front office.

There, I was informed that our insurance wouldn't cover a check-up in six months. So we'll see them again in a year. I wanted an August appointment, so that we'd be closer to Nolan's actual birthday. I was then informed that insurance mandates that the well-child visits be one year and one day apart. So even though we were almost three months late in getting to see the pediatrician, we can't set the appointment closer to his actual birthday. This is going to cause a problem for school immunization requirements when the time rolls around- he won't be allowed to have his immunizations until after school starts, all because of insurance company bureaucracy.

I'm not too worried, because we'll just use his specialists as his "medical home" if need be. Because in some strange philosophy of being "penny wise and pound foolish," the insurance company allows us to see the specialists whenever we want. Go figure.


terena said...

how annoying! Insurance companies really are a mystery, aren't they?

susannah said...

i know-those insurance companies are ridiculous. i love that he has big brains! ;) i feel you- so frustrating when you have to recap all of this info that your regular ped would just know!!!

Julia said...

Wuh?!? Any chance you can change pediatricians? Might not change the insurance situation, but it sounds like the one you're seeing is not being very accomodating, to put it mildly. If they're serious about seeing Nolan in 6 months, they can arrange it -- call it a six month follow-up rather than a well-child visit. Heck, with a file like his, it shouldn't be hard to justify pretty frequent check-ups.

Loudest Mom said...


I'm sorry insurance makes life so difficult (same for us!). Jake is due for his 6 year check-up now (and he'll be 7 in December, that's how "off" we got...)

leah said...

I am extremely frustrated. There is another pediatric group in the area, and I believe they only have two pediatricians. We really need someone who can remember Nolan's case history and keep an eye on him. Luckily our ENT has been consistent and our GI doctor is sent from heaven above (I really like her that much). At least we're taken care of in the two most important areas!

rouchi said...

M y heart goes out to you for so many issues that need to be looked into.I wish you all the very best. Hey Nolan is a brainy guy, no doubts about it!

rouchi said...

M y heart goes out to you for so many issues that need to be looked into.I wish you all the very best. Hey Nolan is a brainy guy, no doubts about it!

Herding Grasshoppers said...

Oh how aggravating!

Do you really like the "regular" pediatrician you've been seeing?

When we had similar (but much more minor troubles) with our doctor's office/staff I made sure HE knew about it. I think it's pretty common that the actual doctors don't know what kind of shenanigans the staff is pulling.

And if the office is that buggered up... I'd take a look elsewhere. Maybe it's not feasible with his medical issues, but sometimes a Family Doctor is a good option, rather than restricting yourself to a pediatrician... at least it opens up the field.

Just a thought,


leah said...

I had actually planned on having a family doctor when we moved here from California, but would you believe it- no family practitioners here! The doctor Dennis and I see is an internal medicine guy and only treats adults. Rural communities can be funny things sometimes. There are two very independent pediatric groups, though, and I've been talking to people in our community about them. It seems most of the people who have children with medical needs go to the other group (where they are not pawned off onto any random doctor). SO I may really need to switch.

I like our primary doctor, but there is no way to guarantee that we would get to see her. It's hard, because I'd rather stay where we are and see OUR pediatrician, but I don't think that's possible.

I also forgot to mention that Nolan's left ear is full of wax, and the nurse practitioner wouldn't have it removed. He has a hearing test on Monday, and his normal pediatrician would have removed it. Instead, we get to go for a hearing test and will probably get sent to the ENT, then have a repeat hearing test. Sigh... (I would use a wax removing OTC kit, but this is the ear with the intact PE tube, so we're not supposed to mess with it at home).