Medical Mayhem.

As doctors, employers, and insurance providers battle over healthcare issues, patients get caught in the crossfire 

IT'S POSSIBLY EVERY WOMAN'S GREATEST FEAR. DURING A REGULAR CHECKUP, J.C. GRAHAM'S doctor told her that she'd found lumps in both of her breasts. "She told me not to panic," Graham (not her real name) recalls, "but of course I panicked." Immediately, Graham leaped up and dialed the number of her girlfriend to voice her concern. By the time Graham returned to the waiting area, she was in tears. Although Graham and the receptionist hadn't exchanged words, "she could read the expression on my face and started hugging me," Graham sighs.

The 36-year-old's visit to her gynecologist during her lunch break was supposed to be routine, but it was far from ordinary. Graham's next steps were under the direction of her managed healthcare provider, Oxford Health Plans Inc., based in Trumbull, Connecticut. It dictated that she schedule an appointment with her primary care physician (PCP) to see if she'd confirm the initial findings and, in turn, direct her to another specialist. "To me, this just added to the delay," Graham says." Although I was able to see my primary care provider in a few days, it took three weeks for me to get an appointment for a mammogram and another couple of days for me to see the specialist."

On October 17, 2000, more than a month after the initial diagnosis, Graham was scheduled for a biopsy at New York's Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx so that doctors could determine whether or not the lumps were malignant. Graham went to her appointment as scheduled only to find confusion surrounding her case. "The problem arose with the referrals," Graham explains. Apparently one of her practitioners had provided the wrong paperwork. "So I called my primary care physician and told her that I needed to get a referral for the needle biopsy and was told the breast specialist should have given me one. The breast specialist told me to get the form from my primary. Then I had to run to my primary to get the referral, only to hear that the breast specialist should have given me one. The two offices were in conflict."

Finally, the primary care office provided the referral and Graham proceeded to the hospital to make her appointment. But then she was informed that the original procedure needed to be changed and the need for another referral surfaced. "By this time I was livid because I was getting caught in a web of paperwork. Something that should have taken a half hour to 45 minutes took the entire morning because I was [getting] the runaround."

Fortunately, Graham's procedure was finally performed and the results showed that the lumps were benign. Still, she wonders whether the means taken to get to the end could have been simplified and a lot more sensitive and says, "I wonder, if [the condition] was malignant, would my experience have been any different."

Like most Americans, Graham is a member of an employer-sponsored managed healthcare program. Under this plan, insurance providers pay physicians a predetermined amount for each patient under their care, whether the patient is treated or not. Then, specific services are paid for at a set rate. In addition, doctors are given clear guidelines on how medical conditions should be treated as well as what tests should be performed. This enables the insurance provider to predict treatment costs. Participating employees are required to choose a physician within the insurance provider's network or pick up the tab (or some portion of it) themselves. The benefits of this type of system are twofold: (1) physicians are guaranteed payment as well as a stream of patients from the plan's enrollees and (2) healthcare costs--which increased by double digits through the early '90s--are contained.

And for a long time managed care delivered on the promise. During the mid-1990s, increases in the nation's healthcare costs were at a minimum. Practitioners were drawn in by the steady flow of patients and payments. In addition, the advent of managed care enabled employers to offer competitive health plans at an affordable price. It was working fine, or so it seemed.

But now the cap is coming off of healthcare costs. Government spending on healthcare is expected to double by 2007. Plus, employers predict premium increases of 8% to 20% next year. And cost increases in the pharmaceutical industry are adding more pressure.

Also, the benefits of managed care aren't as apparent to physicians or their patients. Doctors don't like insurance companies sticking their noses into medical decisions and the "guaranteed" payments don't always cover the additional administrative costs doctors have to incur, considering the additional paperwork requirements of managed-care organizations. As for their patients, they want to handpick doctors and have a say in treatment options--period.

So what's the solution? We've talked to doctors, employers, insurance providers, and other industry experts to gain insight on how you can successfully maneuver through the medical madness to get the treatment you deserve. Here's their take on the current medical industry and suggestions on how you can make the system work for you.

STRAIGHT FROM THE DOCTOR'S MOUTH

Managed healthcare breeds inefficiency. Patients are often required to take time off from work to see their general practitioner and later a specialist if it's deemed necessary. And that's assuming they're able to get an appointment, explains Dr. Stephen Cohen, founder and executive vice president of Physicians Who Care, a nonprofit organization in San Antonio, Texas, that advocates patient treatment without outside interference from insurance providers. "A patient will call in with a problem and the appointment is so many weeks out that the problem has resolved itself," he says. And in some cases the situation becomes substantially worse.

Black doctors, in particular, have their own issues with the managed-care system, according to Wilhelmina A. Leigh, senior research associate at the Joint Center for Political and Economic Studies, a Washington, D.C.-based research organization that hosts roundtable discussions on healthcare and other issues. "Black doctors say they [are invited to] contract into managed-care plans only so the plans can steal their patients. After the contract is fulfilled, they're kicked out of the plan. When patients call managed-care providers to make an appointment, they're told their doctor is no longer a part of their plan and [patients] are referred to another doctor," she says. "I've also heard that the advent of managed care has forced a change in the way offices operate. [In the past], one doctor could manage an office and see patients throughout his or her working career, but managed care has made it so that doctors have to work in groups to lower their overhead [costs] so that they can live off what they earn from managed-care plans. In addition, they [deal with] a range of medical plans, so the office has to hire a full-time person to fill out forms and get reimbursements to make sure the office stays solvent."

Despite these issues, some physicians do admit that managed care has done some good. "Now we have clinical pathways that allow us to provide the same quality care but at decreased costs," points out Dr. Miguel West, the associate director at Howard University Hospital's Transplant Center in Washington, D.C. "Basically, the patient has a certain [treatment] pathway that they must follow; we know the test the patient needs, on which days, and the medications he or she requires. Unless we run into a problem that we didn't anticipate, we're now able to better predict the length of a hospital stay, which largely affects costs."

But do doctors think managed care benefits their patients? "From the patients' point of view, another level of bureaucracy is added because they need a referral from their primary doctor to see specialists," West explains. "I also don't find that the savings trickle down to the consumer. Instead, the dollars are going to the administrators of the insurance companies."

IT'S YOUR OWN FAULT, SAY INSURANCE PROVIDERS

"It was because of the desire of employers to keep healthcare costs affordable that managed care came about," insists Richard Coorsh, spokesperson for the Health Insurance Association of America (HIAA), an advocate organization for insurance providers based in Washington, D.C. But he says managed healthcare has provided a host of benefits for almost everyone. Employers were able to offer competitive healthcare at an affordable price. Plus, "managed care enabled consumers to get high quality healthcare at affordable premiums and elevated the quality of care delivered by doctors, hospitals, and other healthcare providers."

According to Coorsh, the majority of employees are very satisfied with their managed-care programs and he cites several studies to support his claim. The Harris Poll, conducted by the Rochester, New York-based market research firm Harris Interactive, reported that 69% of health plan members gave their plan the highest rating in 1999. In addition, an article in The Wall Street Journal (February 21, 2001) reported that as far as HMOs are concerned, "consumers never had it so good." According to the article, 21% of HMOs in 1999 didn't require their members to get approval from their primary physician before seeing a specialist--that was a 13% increase from two years before. In addition, a wider variety of services--such as chiropractic, alternative medicine, acupuncture, infertility treatments, and preventive-care management--are now covered by some employer-sponsored plans. "The insurance industry is constantly evolving to meet the demands of consumers, and you're seeing more flexibility in terms of people being able to see more doctors. There are also more services being reimbursed and new grievance procedures put in place," adds Coorsh. "The quality of care received by patients under managed care is as good as the quality of care under fee-for-service coverage and, in many cases, it's even better."

Other negative perceptions about managed care may be based on confusion rather than experience. "Managed care is a term that is often misused or misunderstood," explains Coorsh. He says most consumers don't know that managed care encompasses a wide range of different types of coverage. Although most people are familiar with the HMO option under managed healthcare, the particulars of each plan vary widely. Another managed-care plan option, called a preferred provider organization (PPO), has its own nuances. "Many people who have PPO coverage do not differentiate between PPO coverage and old style fee-for-service coverage because on the surface they look very similar," states Coorsh.

A Washington, D.C.-based group, the Center for Studying Health System Change, reported that 24% of the respondents incorrectly indicated that they were in an HMO. And these people, who mistakenly associated themselves with an HMO plan, expressed their dissatisfaction at a higher rate than those who knew they were members of an HMO plan. After adjustments for mistakes were made, satisfaction levels were about equal for HMO and other plan members. According to the study, consumer concerns may be more driven by negative hype than actual experience.

BUT HOW DO AFRICAN AMERICAN CONSUMERS FARE?

Managed healthcare may be bad news for African American consumers, according to Vernellia Randall, a law professor at the University of Dayton. Since doctors are provided with incentives for reducing the amount of services that they provide patients (only receiving a set amount of money from insurance providers), managed healthcare has the potential to be discriminatory. "If you have a quota to meet, you meet it with the people who are going to give you the least trouble," she explains. According to Randall, African Americans are less healthy than their white counterparts because they receive less healthcare and have less access to health services. Thus, "the perception is that treating minorities is more costly and there is no way to hold managed care accountable," says Randall.

Randall also believes that we'll see a reduction in the number of health services in minority communities as a result of the growing popularity of managed healthcare plans. "[Managed healthcare providers] make money by consolidating. Providers in the minority community cost more because taking care of minority patients costs more. So [doctors will be phased out] of minority neighborhoods [if they join managed-care providers], and [then they'll have to] consolidate somewhere else."

While the current pay-for-service system also has components of discrimination, Randall believes the managed-care system is far worse because "it forces doctors to ration services and use their existing biases and stereotypes to make decisions, unless some kind of oversight exists."

As a short-term solution, she suggests the government collect race-based data from all medical providers to ensure that minority patients are treated fairly. She also calls for antidiscrimination laws that are specifically designed for the healthcare industry. In the long term, Randall and other experts say universal healthcare, where services will be rationed more equally, is the only fair solution for all.

Still, there are specific things you can do to maneuver your way through the medical mayhem:

* Study your health plan's guidelines. "To get good care, you need to understand the system," asserts Cohen. He says the current medical system puts significant barriers in place to prevent people from receiving medical care. After all, the managed healthcare system encourages doctors to provide as little service as possible. The more familiar you become with your plan, the better able you are to find rules that work in your favor.

* Invite your physician to participate. If you have a doctor you like that's not covered under your current healthcare plan, call the program's customer service department to find out how you can get your doctor to become a participating provider. Then pass the information along to your doctor.

* Bring written questions to your appointments. Managed healthcare requires that physicians reduce the time they spend with each patient. So prepare a written list of questions and concerns in advance of your appointment.

* Take on a challenge. If your treatment option isn't covered under your plan, you can protest by filing a complaint with your provider. If that doesn't work, you still have the right to make an external appeal as stipulated by the Patient Protection Act (www.house.gov/myrick/ppalink.htm). Just contact your local commissioner's office or insurance plan for your state guidelines.

* Understand that healthcare is a team effort. You can only rely on your doctor for quality care if you provide him or her with honest information about your symptoms. Once you're treated, take your medication as prescribed and follow your doctor's advice. You should also remember that doctors can't work miracles. It's up to you to seek medical advice earlier rather than later, get regular checkups, eat right, exercise, and make whatever lifestyle changes you and your doctor deem necessary.

RELATED ARTICLE: EMPLOYER-SPONSORED HEALTHCARE OPTIONS

Indemnity insurance or fee for service. This is what everyone grew up on. You go to the doctor, pay out of your pocket, send in your claim, and your insurance company reimburses you for a certain predetermined percentage.

Preferred Provider Organization (PPO). This is the most liberal form of managed care. It's subject to a deductible and coinsurance. Employees can either use a health provider from the insurer's network or go out of network for a reduced benefit. Most people fall under this option.

Point of Service Program (POS). This is similar to a PPO with one exception, when you do use the network of providers, you have to go through the primary "gatekeeper" physician who will refer you to the hospitals or specialists as they see fit. Should you use a network provider, you get 100% coverage after a nominal copayment. However, if you don't use your primary gatekeeper, you can expect to receive a reduced reimbursement that is subject to a deductible and coinsurance.

Health Maintenance Organization (HMO). This plan requires that you only use physicians and hospitals that are within the insurer's network. If you do not go through your primary care physician, you are liable for 100% of the payment. The HMO is the least expensive from the employer's perspective.