Navigating Managed Care with Patient Advocacy
by Lawrence N. Gelb, DMH, President, CareCounsel, LLC.
Jennifer Connors has been plagued by recurring ear infections, causing a
buzzing in her ears, a fever and a severe earache. To make a referral to a specialist, her doctor needed an authorization from her HMO. By the time she received the authorization, she was experiencing mild hearing
loss which her doctor said could be permanent. Jennifer finds herself squeezed between what her physician feels is the best care for her condition and her health plan which dictates the treatment it will cover.
In his book, Health Against Wealth, Wall Street Journal reporter George Anders calls managed care protocols for referrals to specialists “one of the most contentious issues for both patients and doctors.” HMOs argue, he says, “with some justification,” that primary care physicians would send too many patients directly to specialists if unmonitored. To compensate, health plans often build administrative barriers and create financial incentives for doctors not to make referrals.
Referrals are just one of the many problems health plan members may face as
managed care makes large inroads into today’s healthcare environment. It is also just one example of how managed care can affect physicians’ decision-making powers--preventing them from disclosing limits on coverage
or care, restricting their ability to perform specific tests and ordering certain procedures and tying their performance to the cost of care. In a recent Commonwealth Fund Survey of Physician Experiences with
Managed Care, more than 80 percent of physicians reported “serious” or “very serious” problems in referring patients to specialists, while one in 10 said they have a financial incentive not to make such referrals.
While critics contend that traditional fee-for-service generates run-away
health care costs, at least consumers get what they pay for--the physician of their choice, freedom to see specialists, ability to secure diagnostic tests and treatment and unlimited stays in the hospital. Managed
care, however, has turned all of that on its ear and brought a new healthcare system in its wake--one that appears complicated and often unresponsive to individual needs.
Although managed care organizations tout their ability to provide high-quality,
cost-effective care, disenchanted patients tell another story. They recount endless frustrations with physician access, treatment authorizations, emergency care and hospitalization and the inability to effectively
address these problems.
“Most managed care organizations have neglected to invest in customer service
or patient education because there is no fiscal return,” says Dard Hunter, a consultant in the Sacramento office of Johnson & Higgins. “An independent advocate, and that’s the key word, ‘advocate,’ could be a
breath of fresh air.”
An independent advocate’s primary role is to ensure that healthcare consumers
get their needs met by helping them gain more control over their interactions with the healthcare system. This sense of heightened mastery coupled with the ability to take a more assertive, proactive stance with the
health care system can lead to improved health status, according to respected researchers like Sherrie Kaplan, Ph.D, of the New England Medical Center’s Primary Care Outcomes Research Institute.
Serving as a confidential, reliable and objective source of healthcare
information, an independent advocate delivers real-time support by offering individualized health information to educate consumers; counseling about how to be a more active health care consumer; access to
independent medical experts for second opinions; tools so consumers can make informed and appropriate decisions about their own health care; and assistance in cutting through any red tape blocking the quality of
care to which they are entitled.
In addition, an advocate can relieve a large employer’s busy human resources
department by paving the transition to managed care and cost effectively assisting employees with problems presented by their health plans. The data collected by the advocacy organization, which categorizes
employees’ complaints by type, health plan and geographical location, can be a valuable resource in monitoring healthcare vendors’ performance.
Managed Care Demands New Skills
Although managed care is quickly
taking hold--an estimated 58 million Americans belong to HMOs--consumers are still getting their feet wet, learning how to work within the system to ensure the best possible care.
Choosing a health plan. Selecting health plans for a diverse population of people with a variety of needs can become a difficult process. An independent advocacy program can bring together the latest “report card” information and provide tools to make health insurance selection less intimidating. Consumers can feel confident that the support they receive is unbiased and not a marketing pitch.
Selecting a primary care physician. A patient advocate can help plan members choose the most appropriate primary care physician, the person who coordinates the entire delivery of care. Paying attention to access issues--waiting time, availability of appointments and time set aside for the doctor visit--competency, geographic location, access to medical records, ability to communicate and customer service are integral to developing a partnership with a physician. On the other hand, if a doctor doesn’t adequately fulfill a member’s need, an objective advocate may offer the impetus to find a new provider.
Referrals to specialists. Getting a prompt referral to a specialist is one of the most threatening situations facing a managed care member. An independent advocate can coach patients about how to push harder when the system doesn’t work for them. Once an authorization is granted, patients may still find long delays in scheduling an appointment, an unnecessary wait in a doctor’s office, poor customer service and specialists who are miles away.
Patient advocates argue that while the gatekeeper structure may work well for
healthy people, it may not be the ideal for seniors and those with chronic illnesses, presenting an obstacle for someone who needs to see a specialist regularly. An October 1996 article in the Journal of
the American Medical Association reported that elderly and chronically ill poor people tend to have worse physical health outcomes when treated in HMOs compared to fee-for-service systems.
Authorizations. The HMO authorization can be a critical barrier standing between patients and treatment. What used to be the physicians’ domain--determining what treatment is appropriate and necessary--has fallen under the providence of utilization review committees, often composed of non-clinicians. A patient advocate can counsel consumers about what steps to take for approval of or payment for care, if it is met with a denial by their managed care plan.
Pharmacy-related issues. Managed care organizations have developed formularies, which limit what medications doctors may prescribe. Managed care plans may reward physicians for recommending a generic over a brand name or deny physicians’ requests for a non-formulary drug they feel has more efficacy then a competitive drug on the formulary. HMOs also restrict which pharmacies members may access, sometimes forcing them to use inconveniently located ones.
Hospitalization. According to a 1997 Louis Harris and Associates poll, 70 percent of physicians practicing under managed care reported “very serious” or “serious” problems with limits on hospital lengths of stay. Fifty-seven percent said they had trouble at times getting their patients admitted. Again, members may find themselves squeezed between a physician who feels they should remain an extra day and the plan which won’t cover a longer stay. Members also may face coping with early discharge when they are not prepared to care for themselves. An independent advocate has more freedom than a managed care physician to push for an extra day in the hospital. In addition, an advocate can provide referrals to reputable home care services.
Second opinions. Getting a second opinion may seem insignificant to healthy members who access their doctors on a limited basis. But to a member who has suddenly been diagnosed with cancer, the second opinion may be the difference between life and death. Another opinion from a nationally recognized expert with no financial or administrative ties to the risk-bearing health plan can play a key role in raising the patient’s confidence level. The recommendation can result in a more extensive, life-saving treatment or prevent unnecessary excessive services.
Complaints. Families USA, a national healthcare consumer organization, has outlined eight protections needed for managed care consumers including the right to timely grievances and appeals when a service is denied or terminated. With the help of an advocate, managed care enrollees can prepare and track written appeals and file grievances related to denied claims, poor customer service and denied or delayed access to specialty or emergency care.
Using Health Information
If more informed patients have better health
outcomes, why not make it easy for health consumers to access the latest medical information? The best advocacy programs do just that, conducting customized searches of on-line medical databases to supply people
with the articles on everything from acupuncture to depression to rheumatoid arthritis. Teaching a kind of
“medical assertiveness training,” an advocacy program can coach patients on how to make the most of their office visits. And this is more important than ever, since 40 percent of doctors say they are spending less time with their patients than three years ago, according to the Louis Harris physician poll.
Patient Empowerment: A Reality
Patient empowerment is on the lips of
every managed care organization, but in reality, health plans have a financial incentive to limit a member’s ability to make decisions. If Families USA had its way, everyone would have somewhere to turn when they
are trying to choose a health plan or if they run into problems as a plan member. The organization recommends funding a network of ombudspersons or consumer advocates who can offer expert independent advice to
current and prospective managed care enrollees.
“There are so many inconsistencies in the rules of managed care, rules that
constantly change, making it difficult to understand how the system works,” says Scott Stone, practice administrator of the San Francisco Peninsula Cardiovascular Medical Group. “Explanations in simple, basic
language and warnings to pay attention to the small print would help consumers in their purchase of health care.”
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