| e Marcus Welby days, people went to Dr. Welby, and | | | | regulating what specialists you can see. |
| he decided what tests and treatments were | | | | In reality, your primary can be your advocate and |
| necessary. Their health insurance companies, being | | | | help you negotiate the system. The problem is that |
| insurance companies and not trained physicians, paid | | | | your doctor may be "serving" many different plans, |
| most of the tab. | | | | with different sets of rules, and may need help to |
| Many people have the idea that managed healthcare, | | | | get you a good result. That's where you come in. |
| meaning a health maintenance organization (HMO), | | | | READ THE BOOK |
| preferred provider organization (PPO), or | | | | The first thing you need to do (really, don't wince) is |
| point-of-service plan (POS), is an affordable form of | | | | read your Evidence of Coverage booklet. This is your |
| the old fee-for-service system, but with more | | | | insurance policy: It tells you what your health plan will |
| paperwork and perhaps more insurance company | | | | cover and what it will not. You need to know what |
| "meddling." | | | | hospitals you can go or be taken to, what labs will do |
| People need to realize that this is a whole new | | | | your tests, when you can call an ambulance, what to |
| system, a binding legal contract, with strict limitations, | | | | do if you get sick on weekends, what home care will |
| says Paula Mikrut, MD, vice president of medical | | | | be allowed, what medical devices such as wheelchairs |
| affairs of Intergroup of Arizona, a medium-sized HMO | | | | are paid for, and dozens of other important things. |
| with 350,000 members. | | | | "It's only human to ignore conditions until they |
| When you sign up with an HMO, you are signing a | | | | become urgent," Dr. Mikrut says. "Many people don't |
| contract saying you will abide by the rules of the | | | | pick a primary until it's 3 in the morning and they're |
| road and will receive only covered benefits. Not all | | | | sick. But you have a diminished ability to deal with |
| tests, all treatments, all drugs, all doctors in town will | | | | your health plan under such conditions." |
| be covered. This is a fact of life under managed care. | | | | KEEP YOUR OWN MEDICAL RECORDS |
| MAKE THE SYSTEM WORK FOR YOU | | | | "File health insurance records just like you would keep |
| The first thing you can do to maximize what you get | | | | all the tax records for your house," advises Mikrut. "If |
| from your health plan is to choose a plan wisely. If | | | | you keep immunization records for child, keep a |
| your employer offers no choices, the following tips | | | | chronology of significant health events and doctors' |
| are even more important. If you do have a choice, it | | | | visits for everyone in your household -- adults too. |
| is up to you to check out the plans and see if they | | | | Know when you had your last tetanus shot, your last |
| meet your particular needs. | | | | mammogram." Although many plans will send you |
| The National Committee for Quality Assurance | | | | reminders of needed visits, ultimately it's your job to |
| (NCQA) in Washington rates plans by a number of | | | | make your own appointments. |
| criteria, including access to doctors, quality of | | | | Unless you have "open referral," your primary must |
| physicians, wellness and disease management | | | | recommend and approve a visit to a specialist. Most |
| programs in place (including how many people get | | | | plans allow such visits if medically reasonable, and |
| recommended tests), and how plans treat people | | | | almost all will allow a paid second opinion. |
| during and after an episode of injury or illness. Ratings | | | | As for pharmacy, as everyone knows by now, each |
| can be accessed on the Web site ( Employers use | | | | managed care company has a "formulary" of |
| this information to decide what plans to offer. You | | | | approved drugs. If you take a medicine "off the |
| should use it to decide which plan to choose. | | | | formulary" or a brand name, you will probably pay |
| You can choose a plan that includes your favorite | | | | more. Talk to your doctor, and ask about alternative |
| doctors, or you can choose a "primary care physician" | | | | medicines that are on the formulary. Some plans, |
| after you get in the plan. That doctor is your key to | | | | including Intergroup, issue a booklet to patients with |
| the system, although primaries are often called | | | | all the drugs on the formulary: Hand it to your doctor |
| "gatekeepers," which has a connotation of a closing | | | | and discuss selections. |
| gate, in some cases denying you treatment or | | | | |