Have You Hugged Your HMO Provider Today?

God! I must look like a cynic to you, Swede. This is a breakdown on
how our HMOs operate. Do we need national health care or what?
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Gatekeeper

* Your physician is a gatekeeper. Isn’t a gate designed to keep something out? Whud up?
* Managed care changes the way physicians can care for you and limits the circumstances and level of care as well as the types of surgery and medicine you may receive. In fact, managed care pays gatekeeper/providers more for giving less care and penalizes gatekeeper/providers for giving the care you expect. Managed care mangles the doctor-patient relationship, which matters only when you need it most. Precisely because most managed care patients are healthy, you won’t miss your doctor-patient relationship until you need it, and when you are sick you may be too preoccupied to do anything about what has become a provider-client relationship.

Z score

* Managed care companies track prescriptions written, referrals made, procedures performed by each contracted provider/gatekeeper and create a report documenting provider/gatekeeper behavior and how it aligns with other provider/gatekeepers' behavior, the Z score. A copy is sent to each provider/gatekeeper. United Health Group plans to publish these reports. Provider/gatekeepers with statistics outside an established range are reprimanded and/or money is withheld until behavior is corrected, that is until patients are given fewer prescriptions, fewer referrals, fewer procedures. If you assume the prescriptions, referrals, procedures are unnecessary the result saves money. What if the prescriptions, referrals or procedures are necessary, and what if the patient is you? Ask your provvider/gatekeeper if your insurance company effectively restricts your care because other patients have needed prescriptions, referrals or procedures this month or this quarter and if your provider/gatekeeper must alter his behavior and your care. Managed care companies and your provider/gatekeeper promote alternative therapies, ostensibly responding to patient demand, but the truth is clear: non-medical therapies cost less than medical and surgical therapy, but effectiveness is not established.

Capitation (this is not even in the dictionary)

* This Conspiracy is a dirty little secret between your managed care company and your provider/gatekeeper. Your provider/gatekeeper is given a predetermined amount of money to spend on you for one year. If you need more care than the capitation payment covers, the money comes from the provider/gatekeeper 's pocket; if you need less care than the capitation payment covers, the excess money goes into the provider/gatekeeper's pocket. If your provider/gatekeeper is a saint, human nature may not affect the care you receive. Ask your provider/gatekeeper if you are capitated and if he/she is a saint.



Hospitalist

* Provider/gatekeepers no longer care for their hospitalized patients. Your care is turned over to a hospitalist (this isn’t in the dictionary either), another provider/gatekeeper, hired by your managed care company or the hospital, who works full time in the hospital. If you are hospitalized, this insurance company or hospital employee will direct your care and determine your length of stay. Ask your hospitalist what evaluations or treatments are excluded from your treatment plan. Ask your provider/gatekeeper if he/she will see you in the hospital and precisely what role he/she has in your care.



Decredential

* Provider/gatekeepers who resist managed care regulations and guidelines are expelled and their patients are sent to another provider/gatekeeper . This is called decredentialling. Your provider/gatekeeper is caught in a terrible, ethical bind between the medical imperative to care for you and the financial constraint imposed by your insurance company. Provider/gatekeeper autonomy in clinical decision-making has been commandeered by non-professionals. There are only two responses: cooperate or not. Ask your provider/gatekeeper about this.



Formulary

* Managed care companies block use of many new drugs and switch patients from trusted, reliable medications to cheaper drugs through their formulary. Formulary is a list of drugs approved by your insurance company; your provider/gatekeeper must select from that list. The list is different for every HMO. Some drugs are "preferred, " some are prohibited, and some will cost you a premium. Most are generics. The difference between a generic and name brand is greater than you might think. The FDA permits marketing of generic medications that work in the same way as a brand name. This does not mean the generic drug is the same as the brand name. It certainly does not mean a generic drug contains the same materials as the brand name. Ask to see your formulary, and then compare that list to the PDR (PHYSICIAN'S DESK REFERENCE)
* If you shift jobs or insurance coverage, you will shift your formulary. This alters your medications, and that can have dire consequences.
* Diabetic patients dependent and controlled by specific types of insulin are switched to cheaper, less-effective insulin, sometimes with devastating consequences.
* Heart patients are put on old-time remedies rather than new medications.
* Migraine sufferers can’t use new medications and suffer old-time treatments.
* Patients cannot benefit from recently released medications unless your HMO adds the newest drugs to your formulary.
* Patients have to pay full price for effective, but new medications that do not make it on the formulary.
* Provider/gatekeepers have to seek prior approval before prescribing some medications, and the hassle factor steers the medical decision-making about your health toward the hassle-free drugs on the formulary. Is that how you want your care determined? Just as a brand name drug is not biologically-equivalent to a generic brand, one generic brand is not biologically-equivalent to another generic brand of the same drug. Examine your medication each time you refill a prescription. If your drugs are switched and you experience an untoward reaction, report it to your provider/gatekeeper and MedWatch (1.800.FDA.1088)



Panels

* Managed care companies admit certain provider/gatekeepers to the panel, a list of contracted or owned provider/gatekeepers, and then direct patients to those provider/gatekeepers and to non-physician/provider/gatekeepers for cheaper service. Some HMOs publicize willingness to send you to “alternative” and “complementary” practitioners. Think about this, people.



Out of network

* Managed care companies or their provider/gatekeepers threaten patients with exclusion or imply consequences if you seek care from a primary care provider/gatekeeper or specialist not owned or contracted by your plan. Imagine if a provider/gatekeeper you have seen for years is not contracted with your HMO or if you develop a disorder and you learn of an expert who is not in your HMO network; if you seek care out of network, what repercussions will occur? Will your provider/gatekeeper view you as uncooperative, disrespectful? Will your managed care company limit your care? Your decision-making is colored by your natural inclination to cooperate with your managed care company and the provider/gatekeeper who oversees your health needs, so in a sense your choice is restricted without overt statements from your managed care company or provider/gatekeeper . This prompts some states to legislate freedom to seek out of network care.



Incentive payments

* Managed care companies pay “incentive payments” to provider/gatekeepers whose patients are not sent for specialist care or laboratory services. This translates into lower costs to the managed care company but delayed diagnosis and treatment of cancer and other disease. Ask your provider/gatekeeper if he/she accepts incentive payments from your managed care company.



National Practitioner Data Bank

* Contracted provider/gatekeepers who withdraw from managed care risk submission of their names to the National Practitioner Data Bank. (www.NPDB-HIPDB.com) The National Practitioner Data Bank was created to record names of physicians disciplined for hospital or medical infractions and malpractice. Presence of a physician’s name in the data bank complicates his or her ability to obtain malpractice insurance, hospital privileges and health insurance accreditation. Managed care companies report names of physicians who extract themselves from contracts as a clinical privilege report in retribution. As of December 31, 1998 Division of Quality Assurance operated by the Bureau of Health Professions of the Health Resources and Services Administration reports there were more than 200,000 reports in the data bank:

Reason Number
Malpractice payments

154,372
State licensing actions

29,372
Medicare exclusions

10,231
Professional society actions

358
Clinical privilege reports

7,680



PBM

* Pharmacy Benefit Managers (PBM) are the organizations that orchestrate your formulary, reducing competition for prices and alternatives for patients and driving neighborhood pharmacies out of business. PBMs are the managed care companies of the pharmacy world. They contract with pharmacies for specific drugs at specific prices and determine which drugs are sold and which pharmacies sell them. While some decisions are made through straightforward negotiations, rebates paid by drug companies to pharmacy benefits managers for preferred positions on formularies are common. Furthermore, the largest pharmacy benefit managers are owned by managed care companies or drug store chains, reducing competition and alternatives for you the patient and your doctor. Almost 70% of all prescriptions written in the US last year were handled by PBMs and HMOs.



Cherry-picking

* Medicare HMOs recruit patients at malls and restaurants, places frequented by healthy clients (you’re a client, expressed as “covered lives’” not a patient any more.) This avoids solicitations to seniors who are sick, disabled and not active. Since Medicare pays a fixed amount for each Medicare beneficiary enrolled in an HMO, the business people running the HMO want only the healthy. Selective enrollment by HMOs is called cherry-picking, and the practice is confirmed by many studies of Medicare HMOs yet tersely denied by the HMOs spokespeople. Despite this, Medicare HMOs will curtailed service and raised premiums in 2000, forced another 327,000 beneficiaries out of coverage, brought to 734,000 when added to the 407,000 dropped in 1999. One in ten Medicare HMO-enrolled beneficiaries have been dropped from managed care plans according to Karen Ignagni, president of American Association of Health Plans. The pattern was repeated in 2001, but the number of seniors dropped from HMOs as they pulled out of unprofitable markets exceeded 933,000. 65 HMOs did not renew contracts and 53 HMOs withdrew from coverage in specific counties with profits. Medicare pays an HMO $6,876 per year to cover one beneficiary in the top markets. Medicare payment is $6,492 per year in less-profitable markets.



Glide-paths

* Just as a pilot establishes an approach to the runway before landing, managed care companies authorize and limit levels of care for people of certain age with specific diagnoses, assuming that death will occur before severe complications from the diagnosis. These are called glide-paths. A pilot can be sure that the runway will not move and that nothing will happen to the runway before the plane lands, therefore the pilot can confidently commit to the landing. On the other hand, the managed care company has only statistical information on which to base life expectancy to determine the number of years you might endure your diagnosis. Limiting care because of life expectancy is a shameful abrogation of responsibility.

What if you outlive your life expectancy?

What if you get well?

What if you change insurance?

What if medical advances provided cures or more effective treatments?

Ask your provider/gatekeeper if you are on a glide-path.



Provider

* Provider is the managed care name for doctors, and everyone else who is supposed to care for your health. This is a not so subtle dig at your medical doctor. Think of your doctor who has dedicated four years of college, four years of medical school to earn the title doctor, four to six years or more of residency training before starting the practice of medicine finding himself in the same practitioner category as a physician’s assistant who has spent two years of training or a massage therapist who might have spent one year. Once you realize that medical decision-making actually is performed by the bureaucrats and clerks at your managed care company, you understand that your physician really is just a provider.



Gainsharing

* If you have Medicare, this term means you lose. Your provider/gatekeeper gets paid by your hospital when money-saving choices are made by your provider/gatekeeper. This is the deal. When you go to your hospital, Medicare pays the hospital a predetermined, set fee depending on your diagnosis, regardless of actual costs. If your provider/gatekeeper gets you out of the hospital fast, omits expensive tests, declines in-hospital treatment, the hospital gets paid the set amount, pocketing the difference between anticipated and actual costs. Part of the pocketed money is gainshared, slipped to your provider/gatekeeper. Ask about it.
* The story gets worse: While stating that gainsharing is illegal, the Inspector General wrote that "hospitals have a legitimate interest in enlisting physicians in their efforts to eliminate unnecessary costs," and therefore "hospitals and physicians may enter into arrangements based on a 'fixed fee' that is fair market value for services rendered, rather than a percentage of cost savings." If your gatekeeper/provider is paid off by the hospital as well as the managed care company, who looks out for the patient?



Pre-existing condition

* Insurance clerks use this term to "decline" coverage which ultimately costs you because the billing clerk in your gatekeeper/provider's office will bill you. Insurance companies get a claim for your visit. If the diagnosis permits, the insurance clerk might get your previous medical records and find that you have been previously diagnosed and treated for the disorder. If the diagnosis or treatment occurred prior to the effective date of current coverage or while you were covered by another carrier, pre-existing condition clauses take your insurance carrier off the hook. This is a real problem when your employer's Benefits Manager shops for your health insurance each year and gets a better price from a new carrier. A new carrier can give a better price because it will not be responsible for pre-existing conditions, you will. Sometimes your insurance company uses the pretense of pre-existing conditions to delay payment to your gatekeeper/provider while you prove that the disorder was not pre-existing, sort of a guilty until proved innocent ploy. This riles the billing clerk in your gatekeeper/provider's office, your gatekeeper/provider and you. It is all about money.



Co-Management

* This is when you surgeon turns you over to the provider that sent you for surgery sometimes sooner than you think you should be released. Sound like a kickback? The deal is this: Medicare pays a certain fee for each procedure and for follow-up care for a specified period of time, usually ninety days. As an incentive for the referral, the surgeon can orchestrate a kickback to the referral source by co-management; part of the surgery fee is paid to the referral source, ostensibly to cover follow-up care. This is outlawed by New York Medicare carriers unless the operating surgeon is unavailable and unless the provider is licensed to manage "all aspects of the postoperative care, including potential complications that would require a return to surgery." Tweet