If you are one of the millions of Americans who would sooner take out your own appendix than join a managed-care medical plan, prepare yourself for a surprise.
Supervised health care, the type provided by HMOs and other big medical networks, has provided high-quality care for millions of families during the past 20 years.
That fact may fly in the face of stories you have heard about patients getting first-degree hassles and second-class treatment in cost-conscious managed-care networks. But while many of those stories are well documented, they reflect the shortcomings of some networks.
On average, the doctors and hospitals working under the managed-care umbrella deserve good marks for their brand of health care, an assessment that is backed up by reams of medical data and scores of patient-satisfaction surveys.
Every industry, of course, has its lemons. The challenge for you will be to separate the quality providers from the rest.
The good news is that you can. With a telephone, a pad and pencil, and some smart questions, it is possible to do a head-to-toe checkup on any plan you may be asked to consider, perhaps by your employer or union.
And you’ll probably need to size up more than just one.
Roughly half of all employers offer two or more options, including HMOs, preferred-provider organizations and point-of-service plans.
How do you make sure you wind up in a plan that, if not among the 10 best, at least offers top-quality care? Start with your employee benefits department. In screening competing care providers, your employer may have gathered all or most of the information you’ll want.
If you can’t get the facts you want from your employer, phone the managed-care plan directly. Be aware that most plans don’t field many tough questions from consumers, so you may get the runaround at first.
Persist, however. A first-rate plan will try to give you all the information you seek. Here are the three areas to focus on:
To begin evaluating the quality of a plan’s medical staff, get the doctor directory for the plan you’re considering and see whether you or anyone you know can spot a physician you trust. Then, call that doctor and ask what he or she thinks of colleagues in the plan.
If the impression is favorable, you’ll hear about it instantly. If it isn’t, get ready for an indirect response-either a filibuster or a series of long pauses that can speak volumes. If you get either, look elsewhere for a health-care provider.
You’ll also want to find out the percentage of network doctors who are board certified. You can get that information in the physician directory or from the plan representative. A plan that falls short of the 70 percent network average for board certification is probably not setting high enough standards.
One caveat: There are more than 200 self-styled medical boards that offer membership with little or no testing requirements. Be sure the certification a doctor claims reflects membership in one of the 24 boards recognized by the American Board of Medical Specialties (as do the boards counted in the 70 percent average network certification rate cited above).
Other valuable bits of information can be gleaned from the forms doctors must fill out to join the plan, which plan sponsors should furnish to consumers without hesitation. Any reluctance to do so may signal that the network is less probing than it ought to be. Besides education and training, the form also should ask for the doctor’s malpractice insurer. Ask whether the application information is verified and how often it’s updated. The best plans check everything and update every two years, though it can cost a plan as much as $200 per investigation.
Will cost overshadow care?
While there’s no proof that the cost-consciousness of most medical networks cuts the quality of care, doctors, like most people, may find it difficult to keep money entirely out of their minds when doing their jobs. Managed-care plans employ several payment schemes for doctors, but all place some restraints on their income, and some may even penalize them for ordering up a lot of patient services. Each doctor responds to these influences differently. Thus, while it is impossible to make upfront observations about network quality based on how (and how much) it pays doctors, you should make a personal assessment after you join a plan. If the doctors seem unmotivated or uninterested, you can always vote with your feet.
One way managed-care plans cut costs is to restrict patients’ access to specialists or at least discourage it. To this end, most HMOs and POSs have “gatekeepers,” primary-care doctors who must authorize any consultations you have with specialists. Most PPOs place few or no restrictions on you. If it’s important to you to be able to see a specialist on your own initiative, pick a plan with no gatekeeper. Such plans are becoming less common, however.
Next, ask about preventive services. Whether a plan does all it can to keep you healthy is highly significant. Some plans leave it up to you to get preventive care or not, as you choose. Others mail general announcements and reminders, and still others keep individual records on patients and follow up with letters or phone messages if, say, a patient is overdue for a mammogram. Ask the plan you’re investigating how it makes sure patients get preventive services. While you may consider personal contacts a nuisance, they do indicate that a plan is serious about your health.
How happy will you be?
Naturally, top-quality medical care is the surest guarantor of patient satisfaction. But it’s not enough. A chaotic waiting room or a phone system operated by computers instead of people may drive you wild. If so, ask the plan’s representative about both. Find out how long you’ll have to wait for an appointment. The average for an urgent visit to an HMO physician, for example, is about two days (flat-out emergencies, of course, are handled immediately), while the wait for a routine visit averages four weeks.
Discover, too, how much time with the doctor is allotted per patient (average: about 15 minutes for all managed-care plans). You may also want to ask about demographics. Is your age group in the majority or the minority of the plan’s members? Being in the majority often means that more services and attention will be directed to your concerns.
One of the more traumatic things that can happen to you in a managed-care plan is to lose the doctor who has been treating you. Turnover rates in medical networks range from 5 percent to 15 percent a year, depending on the type of contracts doctors sign. Some plans will allow you to continue with a doctor who has left, at the plan’s expense, until treatment is completed. Others will require you to switch immediately. Be sure to ask about a plan’s policy.
Finally, ask how disputes between you and the plan over your care are resolved. A formal grievance procedure, with a panel of medical reviewers, is best. Worst is an ad hoc approach, with no systematic response to these problems. Also ask what percentage of disputes were resolved within one month. It should be 75 percent or more. Otherwise, the plan is either inefficient at resolving hassles or, worse, is generating serious problems.
