Constant changes in health care may make it more difficult for you to know how to make the best choices for you and your family. Many Americans feel that health care is a rightÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Âa right that should not be taken away because they are sick or have a pre-existing condition.
Managed care plans are designed to provide health care to all members at a relatively low cost. One basic component of managed care plans is the notion that your primary care provider (PCP) can effectively treat almost all of your medical needs. However, studies have shown that patients with asthma or allergies experience a better outcome when their care is directed by an allergist/immunologist. The best medical care for many people with asthma and allergy involves a team approach by a PCP and an allergist/immunologist.
Potential challenges of a managed care plan may include :
- being restricted to physicians who are chosen by the plan;
- being denied certain medical devices or medications;
- having a PCP limit your access to the allergist/immunologist or other specialists;
- being penalized for pre-existing health conditions.
- Types of managed care
Risk Contracted Individual Practice Association (IPA) ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Â Physicians are prepaid a monthly capitation, which is a fixed amount per enrolled member. The physician receives the same rate whether members see the doctor that month or not. A co-payment from patients may be required in some cases.
Group Model Health Maintenance Organization ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Â An HMO contracts with a group of physicians to provide health care services. Physicians continue to practice in their own offices but pool and distribute income based on an agreed-upon plan.
Network Model Health Maintenance Organization ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Â An HMO contracts with several physician groups. Physicians that may share in savings but also may provide care to other patients who are non-HMO members.
Staff Model Health Maintenance Organization ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Â A form of an HMO in which physicians are employees of the HMO.
Preferred Provider Organization (PPO) ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Â An HMO or other managed care organization contracts with a selected group of physicians who agree to abide by a certain reimbursement and payment structure. Patients may be able to see a physician outside of the PPO structure, but usually must pay higher co-payments or deductibles in order to receive that care.
Point of Service Option ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Â Patients seeking treatment from a non-participating health care provider may be allowed to do so on approval if they are willing to pay a fee for the service in addition to the usual premium.
In many plans, patients must first be seen by a PCP who acts as a gatekeeper, deciding whether or not the patient can see a specialist.
What you should know
So, what does managed care mean to you and your family? Your freedom to choose an allergy/immunology specialist may be curtailed or denied, or you may have difficulty obtaining such medical aids as a peak flow meter, home nebulizer, skin tests, or allergy shots. Additionally, you may have difficulty getting a particular medication that works best for your condition, such as a prescribed bronchodilator, anti-inflammatory medications, self-administered adrenaline, antihistamines or gamma globulin.
When choosing a health care plan, make sure to ask the appropriate questions. Ask your employer to provide materials that can help you make this important decision. Identify coverages, effective dates, co-payments, deductibles, pre-existing condition limitations, point-of-service optionsÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Âincluding the additional amount you will be expected to pay, limitations on devices or drugs, and access to an allergist/immunologist or other specialists.
Take time to study the plan, and do not sign up for a plan until you are satisfied that it is the best one for you and your family. Try to plan for and consider unforeseen medical needsÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬Âthe least expensive plan may end up costing you and your family more in the long run.
You should be able to review a list of participating physicians, covered services, formulary lists (medicines), and other rules before you sign up for a plan. This includes information about your right to contest the gatekeeper’s denial of referral to a specialist if you feel the decision is not in the best health interests of you or your family. Request information about the point-of-service option, which will allow you to see the allergist/immunologist or other specialist of your choice, who may not be a part of your health care plan.
- Taking action
What can you do if you cannot see the physician who can best treat your condition, or receive a prescription for the specific drug that works best? Managed health care plans are driven by customer satisfaction as well as costs. To remain competitive, the insurance company must achieve the reputation of taking good care of its members. If you have difficulty seeing the physician of your choice or if you are dissatisfied with any part of your health care, you should contact the customer service department for the plan at the company’s main office.
However, the employee benefits manager at your workplace will be your strongest ally. Managed care organizations listen to employers, as they compete to be health plan carriers for businesses. If your problem is still not resolved to your satisfaction, you may contact the Insurance Commissioner’s office in your state capital. Sufficient demands from health care consumers can increase accessibility to appropriate care without raising premiums.
Allergist/immunologistÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂA physician who has completed specialty training in pediatrics or internal medicine, and has elected at least two additional years of training in the diagnosis and treatment of allergic and immunologic diseases.
CapitationÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂMethod of reimbursement in which a physician is paid a fixed amount of money per each member enrolled in a health care plan.
Co-paymentÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂA fixed amount paid by the patient at the time services are rendered. Typical co-payments are for office visits, prescriptions or hospitalizations.
DeductibleÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂThe portion of health care which must be paid by the patient before insurance coverage applies.
Direct accessÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂPatients may consult the specialists of their choice for a specific medical problem without being required to obtain prior approval of the gatekeeper.
Fee-for-serviceÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂTraditional health care payment system under which providers receive a fee for each service rendered.
FormularyÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂPrescription medications that have been approved by a particular health care plan for its enrollees.
GatekeeperÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂThe primary care physician or other provider whom a patient must see for all initial medical visits. For referrals to all specialists or diagnostic, therapeutic or hospital services, the patient must see the gatekeeper first.
Health care payersÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂInsurance companies, hospitals, some physician groups, and employers who are responsible for paying the cost of health care for enrollees.
Managed careÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂA health care insurance plan designed to provide high quality care at low cost. This care includes a detailed plan with a set of rules to be followed by the patient.
Point of serviceÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂAllows patients to see their personal doctors who may not be a part of the insurance network. The doctor may be compensated at a lower rate and the patient may be charged a portion of the cost.
Pre-existing conditionÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂAn illness, disease or condition that an individual has at the time of enrollment in a health care plan.
Primary care provider (PCP)ÃƒÂ¢Ã¢â€šÂ¬Ã¢â‚¬ÂA generalist physician such as a pediatrician, internist or family physician.