January 2023 Advice to Be Well From Dr. Mark Bornstein and Dr. Paul Benson

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I am a transgender male.  I want to get a bilateral mastectomy and go to a physician out of state that my friend went to and was very happy with.  I went to my primary care doctor asking for a referral who told me that they would not refer me out of state and would be happy to refer me to a capable compassionate surgeon locally who has experience with transitional top surgeries.  They said it is due to my HMO insurance and receiving care “out of network”.  Can they do that? – DD 

Dear DD, 

The concept of a Health Maintenance Organization (HMO) is to receive care within an organized system of care.  This has good and bad points.  The good point is that care within a group of providers is usually more efficient and less costly, often avoiding duplication of services and easier access.  The bad point is if you want to go out of your physician’s or hospital’s network; it’s not always possible.   

Hospitals and providers accepting HMO’s get paid a small monthly capitation for each patient to provide care whether you receive any services or not each month.  Most medical services to other providers are paid out of that capitated amount.  Capitated providers and hospitals would not want to pay another hospital or provider out of their monthly capitation allowance for services they can provide and are included in the monthly capitation.  It’s not your HMO paying most of these costs, but your provider and their hospital.  Giving out of “their” network referrals with every ask could put individual networks in a negative financial position quickly. This happens more than one would think.   

Most providers will issue an out of network referral if there is a valid good reason and certainly for any emergency.  HMO insurances are not that public with their financial arrangements with providers.  People call their HMO and are told “You can go where you want” as long as you get a referral.  The HMO insurance companies don’t have much financial risk, so they can say that to keep their subscribers happy.  My opinion is that they should change that as it misleads people. 

The short answer is you are best off to accept an in-network referral from your doctor.  If your consultation does not go well, or you have negative feelings about the specialist, you should go back and discuss this with your primary care physician.  For people with little to no known health problems the referral issue is probably not a big deal.  If you have health issues, especially you see several medical specialists, opting out of an HMO may be a good idea to allow you to see whoever you want.  It’s more of a problem for patients having different specialists from different hospital systems, and their insurance changes to an HMO.  Usually, we are able to work this out in a satisfactory manner for all. 

I hope this helps clarify your situation. 

Hi Doc. I am a person living with HIV (PLWHIV) and I am going on a week-long vacation next week. I only have 4 pills left of my HIV treatment, so I will go about 7 days without medications. Should I space them out and take every other day so that I am covered for the entire vacation?

This is a very important question and it is essential that every PLWHIV knows this answer. We DO NOT space out our HIV medications. This is actually quite dangerous and something that can lead to problems in the future. With HIV medications, we typically tell people “All or None”. This means take your medications every day or do not take them at all. Of course, if you miss a day every couple of weeks, it likely is okay although it is of the utmost importance to strive to take medications every day.

The reason for this is that spacing out medications can lead to resistance. When someone has HIV treatment resistance, that means that the HIV virus has mutated so that certain medications will not work on the virus. This limits our options on treating HIV and will increase your chance of having HIV in your body.

To better understand this concept, let’s get into the weeds of the science behind resistance. I promise, it will just be for a moment! The HIV medication must be at a high level in your body to decrease the virus. If there is a large amount of medication in your body, it will be able to suppress the virus. Conversely, if there is zero medication in your body, the virus will thrive as there is no medication trying to counteract the virus and there will be no need for the virus to mutate. The issue comes if there is some virus in the body AND some medication in the body. This is when the virus will be able to mutate and form a more resistant type of HIV. This is why spacing out medications can be so dangerous.

This is an essential concept to understand. Do not space out your HIV medications. Make sure to think ahead and request a refill from your pharmacy before a vacation. If you are truly in a pinch, you can always contact our office at Be Well Medical Center for some samples of medications. We do have a limited supply of most of the single pill regimen HIV treatments. I hope this helps!

Since 1980 Dr. Paul Benson’s Be Well Medical Center has been an inclusive medical center celebrating diversity. Do you have a health related question for Dr. Paul Benson and Dr. Mark Bornstein? Submit your questions to [email protected]. This article is a sponsored editorial produced in collaboration with Be Well Medical Center. Between The Lines’s journalism is made possible with the support and partnership of advertisers like Be Well. Learn more about Be Well here.