Today, more than two-thirds of Americans are enrolled in some form of managed health care. And when the name of the game is cost containment, "quality care" can be tough to get.
The squeeze starts with the insurance companies, which are forcing affiliated physicians to see more patients in less time, while rationing resources such as lab and diagnostic tests, says Dr. Harvey Kugel, a board-certified internist and author of "Talk Medicine," a book designed to help patients take control of their own health care by communicating better with their doctors.
And many managed-care doctors are "encouraged" to follow clinical practice guidelines, written procedures designed to treat particular diseases for the least amount of money.
HMO doctors can recommend treatment not outlined in the CPGs, and they can spend more time with you during office visits. They can even prescribe brand-name drugs and can order costly diagnostic tests if they feel you need them. "But HMO doctors can't do this for everybody," explains Kugel. "You have to make yourself stand out."
With this in mind, here's what you can do to increase your chances of receiving the highest-quality service in today's managed-care climate.
Be sure that you find an HMO that has been awarded a full three-year accreditation status from the National Committee for Quality Assurance. This award of three-year accreditation is the NCQA's highest distinction for managed-care organizations that demonstrate excellent programs of continuous quality improvement.
Read your member handbook.
It sounds obvious, but according to a recent in-depth survey by Yankelovich Partners, only 17 percent of Americans spend more than one hour reviewing their health plan's information. Yet these are your HMO's guidelines to policies and procedures. They tell you what's covered, what isn't and how long you have to file a claim. Plus they can help to keep you from getting lost in the system.
When selecting your primary-care physician, you need to keep in mind that "board certified" (which means that the doctor has passed the board exam) is better than "board eligible" (the doctor hasn't yet taken this important accreditation test). But even the most credentialed PCP might not be right for you.
"Choosing a doctor involves a gut response that starts when you call for an appointment," says Dr. James Kvale, professor of family and community medicine at the University of Texas-Houston Medical Center.
Clues that you're in good hands: The doctor's staff is professional and concerned about your well-being. The doctor's office is clean. Your waiting room time is rarely more than 30 minutes. Your doctor listens to your concerns and answers your questions.
Seek out specialists.
Referrals to specialists are usually authorized by your primary-care doctor. But if you want to go to a particular specialist your doctor doesn't know and, for some reason, doesn't want you to see, you can get around it by working backward. Call the specialist and tell him or her you're interested in becoming a patient, and ask if there is a relationship with other PCPs in your plan. (Offer to fax the list from your HMO's physician directory.) Then switch to the PCP he or she suggests. (You can always switch back later.)
If you believe that you are not receiving satisfactory care and your physician isn't being helpful, call your HMO's member services department. In many cases, they can help you get the benefit you need. Or you might want to work through the human resources department at your job. You might also consider filing a formal grievance with your HMO (check in your member handbook for the grievance process).
Or send a letter directly to the HMO's medical director and the head of its member services department. Ask him or her to respond to you within a specified time, and say you'll seek regulatory or legal help if necessary.
If the problem isn't resolved, you can ultimately file a grievance with your state's HMO regulatory agency. Call your HMO's member services department for this agency's address and telephone number. Remember, it's the squeaky wheel that gets the grease.
Know your legal limits.
If you receive a bill from your doctor for a covered service because your HMO hasn't paid the doctor on time, send the invoice back to your doctor. Include the note, "I'm not responsible for this bill. I'm covered by managed care," advises Dr. Harvey Wachsman, a medical doctor and attorney in Great Neck, L.I., who specializes in managed care. When your HMO fails to pay your doctor, says Wachsman, it's breaching its contract with the doctor.
"Let the doctor go after the HMO," Wachsman advises.
"Is this covered?" and "What is this going to cost?" are two relevant questions to ask your doctor, who may recommend a treatment that's not covered by your HMO. If your doctor isn't sure about your coverage, double-check your managed-care contract before consenting to any procedures.
Do your homework.
To understand your condition and become a decision-maker in your own health care, do your own research (www.medsearchinc.com, a medical research Web site designed for the layperson, is an excellent place to start). By being informed, "you may get better care and you'll feel more in control," says Kvale. If you discover a new treatment your doctor hasn't recommended, there's a good chance it's not yet covered by your HMO. But that doesn't mean it can't be.
When speaking with HMO customer service representatives, be sure to jot down the date of your call and the name of the representative you speak with. Question denials.
If your claim is denied because the treatment you received was deemed "not a covered service," "not medically necessary" or generally "unauthorized," ask your doctor to write a letter to the HMO requesting to have the claim reconsidered. Or call your plan's member services department for an explanation.