| So, you're thinking about purchasing, or you | | | | make it to the bathroom." After the initial |
| currently have, an HMO health insurance plan. You | | | | onslaught, he says, he passed out by the side of |
| read the nice brochure and the coverage looks | | | | the road and, delirious, he was taken by his |
| like just what you've been looking for. They tell | | | | girlfriend to an emergency room in Summir, N.J. |
| you great things up front, and show you pretty | | | | Jung thought he followed all the claim-filling rules of |
| color pictures of happy people using their plan. So | | | | his HMO, PruCare: He called his primary doctor |
| what could be wrong? Why not purchase their | | | | within 24 hours of his ER visit and left a detailed |
| plan? There are a number of things that they tell | | | | message. Yet a month later, he got a $541 bill |
| you that are 1/2 truths, and the most important | | | | from the hospital and one for $259 from the |
| things they won't tell you at all. If you already | | | | doctor, saying that PruCare had denied it. The |
| have an HMO, compare the 10 points below to | | | | HMO's explanation: The emergency-room visit |
| how you have been treated with your plan. It | | | | hadn't been pre-authorized. |
| should help make sense of it all. If you are thinking | | | | In the end, Jung got reimbursed for the hospital |
| of purchasing one, beware. | | | | charges. But it took five months of phone calls |
| 1. "The less your doctor sees you, the more he | | | | and letters, and, as of mid-January, there was still |
| earns." - One of the great things about joining a | | | | some dispute as to whether PruCare had followed |
| health maintenance organization is the | | | | through on its promise to finally pay the doctor's |
| convenience. You visit the doctor, the HMO pays | | | | bill. Responds Kevin Heine, a spokesman for |
| for it. Most of the time there isn't a single form | | | | Prucare: "When he field his appeal, PruCare said |
| you fill out. But how is your HMO doctor really | | | | they would notify him of the decision. In early |
| getting paid? You might be surprised. | | | | December, he was informed that the facility |
| Sixty percent of all managed-care plans, including | | | | portion would be taken care of and that PruCare |
| HMO's and preferred provider organizations, now | | | | was still examining the doctor portion of the bill. |
| pay their primary-care doctors through some sort | | | | Would we have liked this process to have been |
| of "capitation" system, according to the Physician | | | | quicker? The answer is yes." |
| Payment Review Commission in Washington, D.C. | | | | 6. "Your ignorance is our bliss." - Managed-care |
| This is, rather than simply pay any bill presented | | | | providers are all too happy to tell you about some |
| to them by your doctor, most HMOs pay their | | | | things, like their coverage on well-baby care or |
| physicians a set amount every month- a fee for | | | | their $125 reimbursement for new eyeglasses. |
| including you among their patients. At Chicago's | | | | But for the most part, they treat the really |
| GIA Primary Care Network, for instance, | | | | important information like a state secret. |
| physicians get $8.43 each month for every male | | | | How many patients have dropped out of their |
| patient between the ages of 25 and 44, and | | | | plan in the past year? Are doctors paid on a |
| $10.09 for every female patient between the | | | | capitation system? How good are the doctors? |
| ages of 20 and 24. | | | | We ask these questions of six different HMOs |
| You could argue that these capitation programs | | | | and only two - United Healthcare and Oxford- |
| are an incentive to keep you healthy: Even if you | | | | could provide any answers. "You would like to |
| don't need your doctor, he or she gets paid. But | | | | know that you percentages for surviving a heart |
| what you need to look out for are the additional | | | | attack, based on all the variables, are better with |
| financial incentives that come with some capitated | | | | one plan that another," says Robert Krughoff, |
| payment systems. Some HMOs, such as Oxford | | | | president of the advocacy group Consumers' |
| Health Plans, Cigna and Aetna, have "withhold" | | | | checkbook. "This is exactly the kind of |
| Systems, in which a percentage of the doctors' | | | | comparison shopping you won't be able to do |
| monthly fees are withheld and then reimbursed if | | | | among plans." |
| they keep their referral rates low enough. Others, | | | | About the only place for general information on |
| like U.S. Healthcare, pay bonuses for low referral | | | | HMOs right now is the National Committee for |
| rates. Still others, such as Health Net, have | | | | Quality Assurance. This Washington, D.C., |
| so-called risk pools, whereby primary doctors get | | | | managed-care-industry watchdog collects various |
| a lump sum on top their capitation rate to pay for | | | | performance data on HMOs and provides it to |
| any patent test or specialist referrals. Anything | | | | employers. The group, which is just beginning to |
| left over is their bonus. "Capitation is the | | | | market its information to consumers, also runs a |
| strongest reason not to recommend a patient to | | | | reasonably helpful World Wide Web sire (http;// |
| specialist," contends Carolyn Clancy, director of | | | | where you can look up when your HMO was last |
| the Center for Primary Care Research at Agency | | | | audited and whether it has the NCQA seal of |
| for Health Care Policy and Research in Rockville, | | | | approval. But it pretty much ends there. Want to |
| Md. | | | | see your HMO's actual performance data? Sorry, |
| The pressure to avoid specialist can be | | | | that's not available to the public. Another negative: |
| considerable, says Dr. Lee fisher, a family | | | | Only about half of all HMOs have volunteered fro |
| physician in West Plan Beach, Fla. When he was | | | | an NCQA audit so far. "It's an evolving field, and |
| with CareFlorida, a regional HMO, it was withholding | | | | it's very young," concedes Barry Scholl, an NCQA |
| 20 percent of his pay every month, coughing up | | | | spokesman. "I mean, it's embryonic." |
| the money only if he kept referrals low or didn't | | | | 7. "We're loose with the facts." - You call your |
| order too many test or X-rays. Ultimately, Fischer | | | | HMO's toll-free number and get a |
| decided to drop out of HMOs altogether. "We | | | | cheerful-sounding representative who answers |
| were devoting more and more time to a small | | | | you claim question promptly and with authority. |
| pool of patients, and we weren't getting paid very | | | | But when you do what she suggests, the HMO |
| much for it, " he says. A spokesman says that | | | | denies your claim. |
| when CareFlorida merged with Foundation Health | | | | Sound familiar? It happens all the time. A recent |
| in 1994, it overhauled its capitation system. "It's | | | | study of HMOs by the New York City public |
| likely that he would not have this same issue if he | | | | advocate found that the companies; telephone |
| were contracting with CareFlorida today," the | | | | representatives often gave out badly misleading |
| spokesman claims. | | | | advice. Five of the 12 HMOs surveyed, for |
| 2. "Your primary-care doctor is your specialist." - | | | | instance, claimed that all of their physicians were |
| Everybody wants a doctor who's versatile, but | | | | board-certified, an exaggeration of up to 25 |
| sometimes, in their effort to rein in cost, HMOs | | | | percent. When a customer-service representative |
| really overdo it. How? By pushing their | | | | at one HMO was asked if she understood what |
| primary-care doctor to take on the additional | | | | board-certified meant, she replied, "It means they |
| duties of being a specialist. "Specialist immediately | | | | graduated from medical school." (In fact, it means |
| attack a problem with expensive procedures," | | | | the doctor has completed a period of post |
| says David Scroggins, a medical=industry | | | | medical-school training and passed an exam in his |
| management consultant with Clayton L. Scroggins | | | | or her specialty.) |
| Associates. "Consequently, HMOs put in the | | | | The study pointed out at number of other |
| primary care physician's contract a broader scope | | | | problems. Representatives gave inconsistent |
| of responsibilities." | | | | information about the number of allowable |
| Dr. David Himmelstein, a Boston-area primary care | | | | specialist visits for instance. And they gave out |
| physician, has seen these contracts time and time | | | | wrong advice about how soon you have to notify |
| again. "It's typically vague, | | | | the HMO after an emergency. |
| you're-responsible-for-everything type of | | | | Robert Krughoff, for one, wasn't terribly surprised |
| language, " he says. Some are even set up to | | | | by the study's findings. His group has done its |
| reduce a doctors monthly pay if he refers you | | | | own surveys and found, among other things, that |
| outside for work that was "reasonably available" in | | | | doctor turnover is often much higher than the |
| his own office, says Scoggins. | | | | numbers claimed by HMOs. "You should never |
| The result is that you'll have primary-care | | | | accept their statements at face value," he says. |
| physicians either doing procedures for which | | | | "Without auditing, HMO data is meaningless." |
| they're not adequately trained or, more | | | | 8. "We use second-rate parts." - "Top shelf" |
| commonly, just cutting corners. They'll do a | | | | doesn't quite describe the hip or knee |
| flexible sigmoidoscopy-in-serting a tube for a | | | | replacements you may get from an HMO. In fact, |
| colon-cancer check-instead of referring you to a | | | | "generic" may be more like it. "HMOs will often use |
| gastroenterologist. Or maybe they'll aggressively | | | | less-expensive versions of medical devices," |
| prescribe antibiotics for ear or sinus infections | | | | observes surgeon Malawer, who consults with |
| instead of sending you to an ear, nose and throat | | | | several medical-device companies. "In fact, there |
| specialist. What can you do? Speak up. If you | | | | are entire product lines developed for the HMO |
| don't pester your primary-care doctor for | | | | market." |
| specialist referrals, you may never get them. | | | | Although there's a constant stream of new |
| 3. "Your health is a numbers game to us." - | | | | devices coming into the marked, don't count on |
| Everybody knows HMOs have guidelines for the | | | | getting the latest rechnology, either. "There are |
| types of treatment they'll allow and the length of | | | | often better medical devices on the market than |
| care you're entitled to. That's how they keep their | | | | are being used, but HMOs are engaged in a policy |
| cost down. But did you ever wonder where most | | | | of silent rationing," argues Steve Speil, a |
| of them get those guidelines? Actuaries. | | | | spokesman for the Health industry Manufacturers |
| That's right: Number crunchers at actuarial firms | | | | Association. "They don't tell the patient about the |
| such as Milliman & Robertson collect historical | | | | alternatives because they would have to spend |
| care data and perform outcome studies on | | | | the extra money." |
| different procedures and lengths of stay. Then | | | | How can you tell if you're getting the real thing or |
| they provide the information to HMOs to be used | | | | a house brand? Ask how it's made. Most implants |
| industry standards. So never mind how you're | | | | are made by either a forging or a casting |
| feeling. If you've had a Caesarean section, | | | | process, says Dr. Charles Miller, professor of |
| according to Milliman, you should leave the hospital | | | | orthopedic surgery at the University of Virginia |
| within 48 hours. You've had a stroke? You're | | | | Health Sciences Center. "Forging is much, much |
| typically headed home within three days, even if | | | | stronger." For major work, such as hip |
| you can't walk out on your own. | | | | replacements, "these less expensive cast implants |
| It sound more than a little cold, well, that's | | | | are not appropriate," he adds. |
| because it is. "There's no scientific basis" for | | | | 9. "Send you to an expensive therapist? Are you |
| actuarial guidelines, says Carolyn Clancy. "Any | | | | Crazy?" - Treating mental health is one of the |
| guidelines are based on someone's 'expert opinion,' | | | | trickiest issues for any insurer, whether it's a |
| and that may come from a variety of | | | | fee-for-service plan or an HMO. How much |
| perspectives." | | | | therapy, after all is really enough? |
| And make no mistake: These guidelines are | | | | Unfortunately, some HMO critics say, |
| strictly enforced. Lee Wesner, an | | | | managed-care companies have an easy answer |
| electronics-manufacturing manager with Comsat, | | | | to that question: very little. Their response is |
| had a pinched nerve and needed back surgery. | | | | often to prescribe medication instead of therapy, |
| The condition was so bad that he was losing the | | | | because it's so much less expensive, says Russ |
| use of his foot and was actually dragging it. | | | | Newman, an executive director at the American |
| Delaying an operation could cause "serious | | | | Psychological Association. Medication is not an |
| damage" said his orthopedic specialist, Dr. Neil | | | | improper treatment," he adds. "It's just that [in |
| Kahanovitz, who asked Wesner's health plan, | | | | some cases] therapy is being completely |
| Jefferson Pilot, to approve the surgery. | | | | excluded." |
| Kahanovitz was told that the condition had only | | | | Dr. Edward Gordon, president of the New York |
| persisted for four weeks and that Wesner had to | | | | State Psychiatric Association, cites a recent case |
| wait the recommended six weeks. | | | | involving a severely dysfunctional family enrolled in |
| "The denial was based on a nontreating physician's | | | | the Physicians Health Services HMO. The father |
| interpretation of guidelines," Kahanovitz contends. | | | | had drug and alcohol problems and was |
| The other doctor "Failed to appreciate that the | | | | threatening his wife. Their child was suffering from |
| guidelines were designed to be used as exactly | | | | learning disabilities and chronic depression. Gordon |
| that, i.e., guidelines for proper, timely and | | | | would have recommended family counseling at |
| appropriate care." Kahanovitz later performed the | | | | least once a week. But the HMO- whose |
| operation and Wesner recovered. Still, the surgeon | | | | mental-health care was administered by a |
| says; "my patient needlessly suffered for two | | | | separate company, CMG health allowed only four |
| more weeks." A Jefferson-Pilot spokesman | | | | visits each for the mother and child during a |
| responds that the company looks at each case | | | | three-month period. Meanwhile, the two were put |
| individually and that it considers its guidelines | | | | on antidepressant drugs. "CMG has a reputation |
| appropriate. | | | | for being single-mindedly focused on reducing |
| 4. "Our exclusions could kill you." - Willing to try an | | | | services, " says Gordon. Responds Alan |
| experimental medical procedure? If you're in an | | | | Shusterman, chairman and CEO of CMG, "We are |
| HMO, good luck. Many not only frown on | | | | hard-nosed, but not about cost; [not are we] |
| experimental or non-FDA procedures, they strictly | | | | antipsychiatry. We're very aggressive about trying |
| forbid them. Take bone-marrow transplants. "In | | | | to get patient the most efficient and effective |
| general they're performed for leukemia patients," | | | | care possible." |
| says Dr. Martin Malawer, a Washington, D.C., | | | | 10. "Unhappy? Go ahead, just try to sue us." - |
| orthopedic oncology surgeon. "But for the last 10 | | | | Since doctors have long been a magnet fro mal |
| years they've also been proven to be effective | | | | practice suits, you might think that HMOs-which |
| treatment for breast cancer, although it's not an | | | | often dictate treatment- would now be taking |
| FDA-approved treatment." Because of this, many | | | | their share of litigation hits. But not so, for most |
| HMOs he deals with won't pay for it. Malawer | | | | HMOs have been cloaked with a protected status |
| thinks the logic is flawed. "Standards of care | | | | rivaling that of the spotted owl. |
| developed over time, and these HMOs are | | | | For many HMOs offered through large or midsize |
| impeding such developments." He says. By all | | | | employers, state law is superseded by the |
| means, you should spend a few minutes scanning | | | | Employee Retirement Income Security Act of |
| the fine print of your enrollee contract. That's | | | | 1974 (Erisa). Because Erisa was originally intended |
| where your HMO's rules about these procedures | | | | to regulate employee pension plans, there isn't |
| are spelled out. Chances are your contract will also | | | | much specific to health-plan regulation and, as a |
| explain that the policy covers only "medically | | | | result, the legislation makes lawsuits against a |
| necessary" treatments. | | | | health plan an uphill and unprofitable battle. |
| Unfortunately, that phase is wide open to | | | | For starters, any suit against your Erisa-governed |
| interpretation, notes Dr. Laura Sudarsky, a plastic | | | | HMO is properly a matter of federal law. "Being |
| surgeon practicing in New City, N.Y. She recently | | | | federal law, it's more-ambiguous legal terrain and |
| saw an asthmatic patient whose Oxford Health | | | | there are fewer [plaintiff's attorneys available," |
| Plans primary-care physician recommended | | | | says Mark Heiplerm a California civil litigator who |
| breast-reduction surgery. It's not uncommon for | | | | has successfully sued several California HMOs. |
| asthmatics to have breast reductions-it alleviates | | | | Worse, under Erisa you have no chance at any |
| some of the weight on the chest wall- but before | | | | punitive-damage award. "All the HMO has to do is |
| Sudarsky could operate, the HMO denied the | | | | pay for the disputed claim with no interest paid," |
| procedure. "Oxford said it did not meet their | | | | says Carol O'Brien, a senior attorney with the |
| criteria for reconstructive surgery, "Sudarsky | | | | America Medical Association. "There's only the |
| says. Tom Travers, vise president of health | | | | possibility of attorneys fees and cost (of |
| xcare delivery at Oxford, declines to comment on | | | | treatment) but no damages." |
| that case specifically. However, he adds, "There's | | | | Three exceptions: If you're a participant in a |
| no little black box into which we're putting health | | | | government plan or a plan sponsored by a |
| care and coming out with 20-30 percent savings. | | | | tax-exempt organization, or if you buy your |
| It's got to come from squeezing unnecessary | | | | health insurance n your own (not through an |
| services out of the health care dollar." | | | | employer), you plan is not covered by Erisa. |
| 5. You're not sick until we say you're sick." - Most | | | | Under these circumstances you have the potential |
| HMOs Demand Pre-approval for just about any | | | | to be awarded both bad-faith and punitive |
| care you get. For just about any care you get, | | | | damages, says Hiepler. Otherwise, you're out of |
| whether it's simple referral to see a specialist or | | | | luck. |
| an emergency. Why? "It's clear that the approval | | | | Health Insurance can be very tricky. Arm yourself |
| process is a hurdle to reduce procedures and | | | | by reading the policy exclusions and limitations |
| referrals," says David Himmelstein. "It's not the | | | | before you buy their plan. Most insurance |
| turndown that's the issue. It's the hassle it makes | | | | companies will reluctantly give you a sample policy |
| for the doctors." | | | | before you buy if you ask them. Always |
| Eric Jung, a Bellcore computer programmer, | | | | remember... they are in business to make money, |
| knows this firsthand. Last summer, he was on his | | | | anyway they can. |
| way back to New Jersey from Rhode Island | | | | This article would seem funny, except for the |
| when disaster struck. After stopping to eat, he | | | | fact that it is true. |
| was overcome with sudden and extreme | | | | I have written several other articles on related |
| diarrhea. " I realized I wasn't going to make it | | | | subjects for your information and caution. Shop |
| home," he says. "Then I realized I wasn't going to | | | | wisely. |