Class 9 – PATIENT’S / CONSUMER’S PERSPECTIVE

Questions Patients Should Ask in Considering Joining HMO

HMOs Cost Containment policies, such as does HMO use any type of financial incentive to physicians to limit diagnostic tests or referrals to specialists -Also, about HMOs appeal policies such as how can the patient appeal a medical decision that both the patient and the patient’s physician think is wrong and how long will it take to get an answer

HMO’s choice of physicians – such as what if patient wants to see a doctor outside HMO then who pays or what if patient wants to switch doctors within HMO – Also, about emergency care, such as will patient be able to use closest medical facility in an emergency even if it is not contracted with HMO or part of the plan

About drugs – such as will patient be able to use medication that has worked for them in the past and may physician prescribe drugs for patient that are not on HMOs approved drug list

About access to specialists – such as how does HMO decide when patient gets to see specialist or how long will patient have to wait to be able to see specialist

The patient’s perspective towards managed care varies.  Some patients like the preventive side of medicine that managed care in theory proposes.  Others believe that managed care has not lived up to the promises.  There has been a lot of litigation involving patients suing MCO’s for various reasons.  Many times the lawsuits arise because the MCO did not render or make available quality and appropriate healthcare services in a timely manner resulting in the patient suffering substantial damages.

Questions You Should Ask Your HMO

If you are thinking of joining an HMO, call or write and ask the HMO to answer the following questions. If you don’t like the answers, discuss it with your employer benefits administrator and perhaps reconsider your decision to join.

1. Cost Containment

Do you provide any type of financial incentive to any physician to limit diagnostic tests or referrals to specialists?

2. Appeal

How can I appeal a medical decision my physician and I think is wrong? How long will it take to get an answer?

3. Choice of Physicians

What if I want to see a doctor outside your plan; who pays? What if I want to switch doctors within the plan?

4. Emergency Care

Would I be able to use the closest medical facility in an emergency even if it is not in the plan?

5. Drugs

Will I be able to use medication that have worked for me in the past? May my physician prescribe drugs for me that are not on your approved drug list?

6. Access to Specialists

How do you decide when I get to see a specialist? How long will I have to wait to get in?

    Patients have many concerns involving managed care, including:

  1. Choice – for both choice of provider and choice of health plan.  (a) Choice of provider involves which providers patients can go to, and this includes the choice to go to certain providers in the time-frame that the patient desires.  For example, patients may want to have the choice to go to a specialist for an elective procedure without first having to get authorization from the primary care physician.  With more choices of options such as to stay in-network or to go out-of-network, typically comes more costs. (b)  Choice of which health plan to select.  Studies are showing that more employers are going to make a defined contribution for healthcare costs and allow employees to pick their own health care plan, as compared to a monthly contribution to a designated health plan.  This means that employees will have to educate themselves and choose which healthcare plan they personally desire  as compared to having to use the company’s pre-determined and selected healthcare plan.
  2. Cost – what the out-of-pocket expenses are for the patient.  This includes monthly premium payments for healthcare insurance coverage, deductibles, copayments, and other out-of-pocket costs.  Health care market continues to shift the cost to the consumer or patient.
  3. Quality Care – Many patients expect quality to the point that quality is not an issue.  This means that the provider is competent in what they are doing and doing it in a legal, ethical, and caring manner for the patient.  Many studies are showing that certain patients are willing to pay the cost to go to certain providers that they believe render quality care that surpasses all other  providers rendering the same type of service.
  4. Education – Many patients are using the internet to study and educate themselves on whatever healthcare issue they may so desire.  Some patients share  information that they have discovered with their providers.
  5. Legal Concerns – Confidentiality issues with healthcare smart cards is a rising concern for certain patients.  For example, the sharing of certain medical conditions such as drug rehabilitation, alcohol abuse, etc. may be information that the patient, an employee of a company, may not want shared with their employer, and concerns that either:  (a) there really are not any safeguards to prevent the employer from accessing this type of information or that (b) there are not any real punitive damages involved if the employer or some other unauthorized third-party were to access this type of information.
  6. Other – there are many concerns of patients and this is just a broad overview of some such concerns.

    HMO market has remained flat at about 30% for the past two years while PPO market has jumped 43%.  If there is a choice, consumers are more likely to choose a PPO or point-of-service plan.

A.    SMART PATIENTS/ INTERNET EDUCATED

Patients can go on the Internet and acquire all kinds of information.  For example, patients can easily research various medical conditions or whatever type of information they desire to research.  According to industry sources, 33 to 45% of all Internet surfers are “healthcare retrievers”.

    Even people who do not have computers, can become Internet savvy.  For example consider how the National Library of Medicine and the National Institutes of Health (NIH) Office of the Director are ” installing a fully equipped computer laboratory with eight computers and high-speed Internet access in the American Indian Cultural Center in Waldorf, Maryland. The Federal commitment includes all hardware, software, Internet connectivity, and training.”  There are about 8,000 members of the Piscataway Indian Tribe that live in southern Maryland and most do not have home computers.  Health problems in this population include high blood pressure and diabetes.  The acting NIH deputy director states that “This facility is an important step in reducing health disparities and in improving the health status of an at-risk population by providing information“.

   Further, many patients know or are learning to ask questions about treatment options and about how their HMO works.  For example, according to one Internet site, ACHE Allied Citizens Healthcare Equity, a not-for-profit group out of Montana, there are questions patients should ask about their HMO.

B.    PATIENT RIGHTS

Many states have passed or considering passing legislation dealing with patient rights kind of issues.  For example, in Illinois, the state legislature passed the Managed Care Reform and Patient Rights Act (Public Act 91-0617).  Among other things this act defines medically appropriate health care protection, and works with issues including access to specialists, appeals, complaints, external independent reviews, etc.  For example some consider the following sections of the Act:

Section 35.  Medically appropriate health care protection – (b)  This is basically a section stating the Illinois public policy that health care providers are to be patient advocates.  This section states that it “is the public policy of the State of Illinois that a health care provider be encouraged to advocate for medically appropriate health care services for his or her patients.”  In this section look at Protest decisions, reasonable peer review, etc.

Section 40.  Access to specialists.  See re:  standing referral, etc.; provide regular updates to the enrollee’s primary care physician.

Section 45.    Health care services appeals, complaints, and external independent reviews.  See re:  (b) (ii)  “a treatment referral, service, procedure, or other health care service, the denial of which could significantly increase the risk to the enrollee’s health, the health care plan must allow for the filing of an appeal either orally or in writing.” Basically, then the health plan is to notify the party filing the appeal within 24 hours after the submission of the appeal  of all information the health plan requires to evaluate the appeal and the the health plan must render a decision on the appeal within 24 hours after receipt of the required information.

There are still many issues involving patient rights.  For example, a question may be how some of these patient rights type of laws are really going to be implemented.  Further, what the penalties are going to apply to the providers, Managed Care Organizations, and Employer Groups who fail to comply with such laws and regulations still remains open on many of these type of laws. It seems likely, that unless there is enough of a penalty involved to get the providers, Managed Care Organizations, and Employer Group’s attention, many of the laws may just look good on paper and not help the patient sufficiently.

C.    ALTERNATIVE CARE PROVIDERS

A survey by Consumer Reports states that an increasing number of doctors are suggesting alternative medicine to patients whose symptoms are not alleviated by conventional approaches.

A Journal of the American Medical Association survey found that 40% of patients told their doctors they were seeking alternative treatments in 1997, up from 28% in 1992.

Top rated alternative treatments include deep-tissue massage for back pain and fibromyalgia, chiropractic and acupressure.  Other alternative treatments most often used include megavitamins and nutritional supplements, and mind-body treatments such as meditation and relaxation therapy. Alternative medicine includes herbalists and massage therapists.

From the patient’s perspective, there may be concerns about lack of standards for treatments and services by alternative care providers.    There is work going on in the alternative care field on creating standards of care that are outcome-based.

Many patients may find that their health care plans do not cover or cover very little of alternative care.  For example, insurers may cover only 25% of some of the alternative medicine services.  Also, some alternative care providers may seek payment in cash form the patients prior to rendering service.