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 BLUE BELL, Pa., Dec. 10 /PRNewswire/ -- This month, millions of

consumers will once again face the chore of examining health care benefit options to select a plan that best suits their needs and the needs of their families.
 The sluggish economy has made consumers even more determined to get the most value for their money, while not compromising their well-being.
 This is especially true when it comes to health care services, where a number of factors have combined to create a new breed of thrifty shopper. These people are no longer hapless patients who just want to get well without sacrificing their nest eggs for their health -- they are increasingly educated purchasers of health care services. And they want to know exactly what they are getting for their money.
 It wasn't always this way. Many people remember when employers paid for 100 percent of health benefits, and were less concerned with wringing every last drop of value from their health care dollar. Consumers paid deductibles, paid for preventive care services like check-ups -- which were not usually covered -- submitted their claim forms, and that was it.
 But skyrocketing health care costs have forced many employers to shift greater percentages of health insurance premiums to their employees. At the same time, many employers -- who recognize both the increasingly diverse needs of their employees, and the value placed on the benefits package by their employees -- are offering a greater range of benefits options.
 In response, employees, who are already fighting to make ends meet, are carefully evaluating their options to ensure that they get the coverage that gives them the most value.
 "Critical evaluation of health care benefits is crucial for today's consumer," said Marcy Abramson, vice president of U.S. Healthcare (NASDAQ: USHC), the nation's largest private practice health maintenance organization (HMO). "But to do that, you have to have at least a working knowledge of the health care industry -- which from a consumer's point-of-view often seems more complex than nuclear physics."
 The two options that most consumers are familiar with are indemnity coverage -- traditional health insurance -- and managed care programs, often referred to as HMOs. While many consumers initially resist giving up the freedom to select their own doctor and make independent health care decisions, Abramson is quick to point out that there are important questions that must be asked before choosing either option.
 "Many people will choose a doctor based on personality alone," she said, "but is a pleasant manner really the most important criteria?" She explained that managed care systems such as U.S. Healthcare often go to great lengths to ensure that their physicians are highly qualified to help consumers, both in providing quality medical care and, perhaps more importantly, in guiding consumers through the maze of health care treatment options.
 As medical technology becomes more sophisticated, family physicians play an increasingly important role in helping their patients to make decisions about the type and extent of care that is needed. Managed care systems were developed in part to assure that unnecessary medical expenses are not incurred.
 Abramson explained, "In a managed care system, if you have a headache, you start with your primary care physician, who can determine if single factors such as stress or excessive caffeine are causing the problem before recommending a specialist. This helps to improve the quality of care to members, while working to maintain lower costs for everyone in the system."
 "Consumers should ask how the physicians who work with a managed care plan are evaluated," she said. "Do medical directors go out to the offices and actually conduct audits, or do they simply review credentials? Are there ongoing annual evaluations, or just an initial check? How are physicians reimbursed?"
 Consumers who have traditional health coverage are finding that doctors are less and less likely to submit claim forms for medical care. This means that they must pay the doctor up front, submit a claim form, wait for reimbursement, and perhaps wade through levels of bureaucracy to have their claim settled fairly, if they aren't initially reimbursed in the way that they expected.
 For consumers who select a managed care option, physician reimbursement can take two forms. Staff model HMOs employ doctors and pay them salaries. Private practice HMOs, such as U.S. Healthcare, contract with independent physicians and other health care providers who agree to provide covered services for the HMO's members. This allows private practice model HMOs to offer a greater variety of physicians from which their members can select. In addition, they agree to accept the HMO's payment as payment in full and may not bill members for covered services.
 They also agree to abide by the HMO's quality assurance, utilization review, and grievance systems, which provide important consumer protections that are not available in traditional healthcare delivery systems.
 They should also be aware of the hidden costs of some coverage options. Many indemnity plans cover up to 80 percent of "usual and customary fees." This means that if the doctor has a higher fee than the average for the area, patients may have to pay more than 80 percent of his or her fee. In addition, there may be reimbursement caps, such as a day or dollar limit on hospitalization charges. It is also important to ask about benefit restrictions. For example, Abramson said, that while actually charging a co-payment for having a newborn in the hospital nursery, a health care insurer may claim to cover maternity in full.
 Along with hidden costs, consumers should look at what type of educational or preventive care programs are included in their health benefits. "Although most people would prefer not to get sick, they often only think of their health insurance as a resource in times of illness.
 "However, it is to the insurer's benefit, as well as the member's, to keep encouraging good health. So more and more health insurers are offering so-called 'wellness benefits' that consumers should not only be aware of, but take advantage of," Abramson said.
 Finally, there are claim forms. HMOs as a rule do not require members to fill them out, but traditional insurance plans do. While this option may seem to be a mere convenience, Abramson points out that time is at least as valuable as money to most people. "And not having to fill out complex claim forms is one way to save yourself a little time, and probably avoid some stress, as well," she explained.
 Knowing the right questions to ask is another way to avoid future hassles. By taking the time to learn all the options available in health care coverage today, consumers can ensure that they will be protected both now and in the future.
 U.S. Healthcare is one of the nation's leading operators of health maintenance organizations. Founded in 1976, the organization has more than 1.2 million members in six states including Pennsylvania, New Jersey, Delaware, New York, Connecticut and Massachusetts. U.S. Healthcare is dedicated to providing access to quality health services for its members while aggressively seeking solutions to the problem of spiraling costs.
 -0- 12/10/91
 /CONTACT: Dava Guerin of Weightman Public Relations, 215-561-6100, or evenings, 215-635-5985, for U.S. Healthcare/
 (USHC) CO: U.S. Healthcare ST: Pennsylvania IN: INS SU:

JS-MK -- PH009 -- 0982 12/10/91 11:32 EST
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Date:Dec 10, 1991

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