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Jacques Chambers, CLU, Benefits Consultant
Although they are not as popular as they once were, Health Maintenance Organizations (HMOs) and their close relatives, Exclusive Provider Organizations (EPOs) and Point of Service (POS) Plans, still provide coverage to the majority of people with health insurance.
While these plans have generally worked well for people who are usually healthy and have only temporary or minor medical problems, they have been a real challenge for persons dealing with chronic or catastrophic medical conditions, such as HCV.
Health care from an HMO does not have to be inferior. In fact, it can be excellent care. Thanks to the public outcry about HMOs skimping on care to increase their profits, Congress and many state legislatures have tightened regulation of this industry. Publicity by the media of problems with care from HMOs and the frequency of large jury awards have forced HMOs to make an effort to improve the quality of their care, or at least improve the image of their quality of care.
The basic principal of HMOs is that, in return for a flat fee called capitation or premium, they will provide all your medical needs in return for nominal co-pays for services. However, to make sure you get the “quality of care you need,” and, coincidentally avoid “unnecessary” and expensive “over-utilization,” a Primary Care Physician (PCP) must coordinate all your treatment. Regardless of what treatment you may need, you must first go to your PCP, who will usually be a general practitioner, possibly an Internist or Family Practice specialist.
This Primary Care Physician is also called the “Gatekeeper”—an extremely descriptive title. If you believe you should see a specialist, it is the Gatekeeper that decides whether or not you get to see the specialist, and, if so, which specialist you will see.
Remember the game of “Simon Says?” In the HMO world, it is “PCP Says.” Unless the PCP says you need a specialist, you will have to rely on the PCP to provide your care, whether it is something he/she is familiar with or not. Keep in mind that the fewer doctor visits, tests, and treatment you undergo, the bigger an HMO’s profits and the more the doctor/clinic will earn.
With a set-up like this, it makes you wonder if anyone ever gets good care from an HMO. Yet, it is possible to get excellent care through an HMO. Part of this is due to the doctors and other medical providers who still care about providing care to people who need it. However, the key to the quality of the care you receive is you and how actively you participate in the decisions about your healthcare.
There are a lot of excellent and caring medical providers working with HMOs, but you will have to seek them out. You will also have to make sure they continue to focus on your medical care, despite the bureaucratic barriers built into the HMO system.
In reality, the HMO is not that different from any other type of healthcare delivery system. You are the person who is ultimately responsible for seeing to it that you get the best care available. It is up to you to know the level of care you are actually receiving and to determine what quality of care you should be receiving.
It is up to you to take control of your medical care, and, to do that, you need to become more knowledgeable about all areas of your medical condition and its treatment.
Know your medical condition. Thanks to sites like this and others on the web, there is a lot of information about hepatitis C and its treatment. Thanks to the Internet, you can stay current on new treatments, clinical trials, and new diagnostic methods.
HCV is a relatively new discovery. There is a lot of information available about it, and there is a lot of research being done to learn more. It would be nice if everyone could find a physician whose practice consisted only of HCV patients, but that is not possible. You can become one of your physician’s sources of new information about HCV treatments and trials.
You should feel free to print out information, cut out articles and take them to your physician. Hopefully, he/she is already current, but you may be providing new information. If your doctor is not the type that welcomes such input from the patient, you may be seeing the wrong doctor.
Find a knowledgeable Primary Care Physician. The Centers for Disease Control states: “Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C.” Following this statement means that in an HMO, your Primary Care Physician should be “knowledgeable and current” in HCV and its treatment.
Within virtually all HMO networks, you are able to select your own Primary Care Physician. Your selection of a PCP will determine not only who provides the majority of your care, but will also determine which specialists will be utilized when needed.
However, the HMO directory will only give you only minimal information about your choices, and it won’t tell you which PCPs frequently treat patients with HCV or stay current about it. Clearly, you will need to do some research.
If you attempt to call the HMO itself, it will not provide much information either as they are prohibited from “steering” patients to particular clinics or doctors, even if it means better health care. You may have to call several doctors’ offices to learn more. Some questions you may want to ask include:
- What is the doctor’s specialty? Is he/she board-certified? Many PCPs are internists, which may give them more experience with HCV.
- What chronic medical conditions does the doctor treat most frequently?
- Does the doctor treat other patients with HCV? How many? What percentage of their practice is HCV?
- What has been the doctor’s experience with pegylated interferon? Do not hesitate to ask very specific questions, referring to treatments and using terms you have learned about in your research on HCV. If they don’t know what you’re talking about, scratch them off your list and move on.
- Who are the gastroenterologists, hepatologists, infectious disease specialists, or other HCV knowledgeable specialists that the doctor works with and refers patients to? You may want to talk to their offices as well.
- How willing is the PCP to make a referral to a specialist who knows more about HCV? How often will they refer you to a specialist?
- How long does it take to get a referral once the PCP requests one?
Some PCPs even have the ability to permanently refer you to a specialist for treatment of chronic conditions such as HCV. In those cases, the specialist effectively becomes your PCP. Ask your prospective PCPs if this is a possibility. This is particularly important if you can’t find a PCP knowledgeable in the treatment of HCV.
These are a lot of questions, I realize. However, neither the HMO nor your physician has as much at stake as you do in your medical care. This is your health and your life you are protecting, so spending some time and energy on this now can give you piece of mind and better healthcare later.
Medical office personnel are not always as helpful to prospective patients as you may need. One alternative is to learn as much as you can about your PCP choices, select one and schedule an appointment. Then you can ask the doctor directly and decide whether you want to stay with that PCP or switch to another. That will give you an excellent idea of how well they listen to you, how much time they are willing to spend with you, and their general “bedside” manner as well as their knowledge and experience of HCV.
Another advantage to meeting the doctor face-to-face is that you will be able to get a clearer picture of how closely he/she will adhere to the rules imposed by the HMO at the expense of your care.
Know your plan and your rights. You should spend some time with your Plan Document, the coverage booklet that describes the provisions of your HMO coverage. While it is important to have a good idea of what is and isn’t covered, it is even more important to understand your rights under the plan. Not everything you need to know about your plan will be in the document. You may have to talk to a representative at the HMO itself or at the state regulatory agency, either your state’s Department of Insurance or Department of Managed Health Care, for information. Things you should know about your plan include:
- How do you change your PCP and how often can you do it? Be aware that if you are totally dissatisfied with your PCP, an HMO will often accommodate your request for a change regardless of their “rules.”
- What right do you have to appeal the denial of a referral or of a particular course of treatment? What are the time limits on such appeals? How does the appeal process work?
- What is the timeline for an expedited appeal if medical treatment is being withheld pending the appeal? Many states have enacted laws which require such appeals to be handled within 24 or 48 hours.
- Does the HMO offer Nurse Case Management for patients with chronic diseases such as HCV? Case Managers have an underlying purpose of saving the HMO money, but most of these case managers are trained nurses, and can be a valuable source of information about the HMO’s policies and rules and may even an ally for you when “fighting the system.”
- What rights do state insurance laws give you with respect to denials of treatment, delays in treatment, and appeals?
- When can you complain to the agency about an HMO’s decision? Many states require that you exhaust all internal appeals first.
The days are long gone in any healthcare delivery system when the patient could put themselves in the doctor’s hands and rest assured that they are getting the best and latest treatment. However, in the HMO system of healthcare, where the providers can increase profits by withholding care, it becomes even more important that you stay actively involved in your medical care. To do that, you must find knowledgeable medical providers who not only know about HCV, but who will listen to you and answer questions candidly about the input of the HMO in determining the direction of your care.
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[Jacques Chambers, CLU, and his company, Chambers Benefits Consulting, have over 35 years of experience in health, life and disability insurance and Social Security disability benefits. For the past twelve years, he has been assisting people with their rights, problems, and other issues concerning benefits and disability. He can be reached at firstname.lastname@example.org or through his website at: http://www.helpwithbenefits.com.]
Copyright June 2003 – Hepatitis C Support Project - All Rights Reserved. Permission to reprint is granted and encouraged with credit to the Hepatitis C Support Project.