The ABCs of HMOs

| Jun 1, 1997

How can I get the best diabetes care from an HMO? As health management organizations become more and more popular millions of people with diabetes find themselves asking this question every day. There are no easy answers, but there is one thing that all the experts agree upon - you must be your own tireless advocate.

What to Know Before Joining an HMO

When shopping for an HMO there are a few things you can do to make sure you get the plan that is best for you.

Knowing what your needs are is probably the most important thing you can do. Every specialist questioned for this article stressed the importance of having sound knowledge of the basics of optimal diabetes care and the treatments that work best for you.

The next step is to find out which HMO offers what you need. Unfortunately there is no quick and easy way to do this. You simply have to read as much as you can and get on the phone and start making calls.

Loring Spolter, a Fort Lauderdale, Fla. attorney who works with patients having disputes with HMOs, notes that it can be very hard for consumers to know which HMO is the best. He points out that the same HMO may be managed very differently in each state. So the HMO that your cousin raves about in Missouri might be a disaster in Michigan.

Spolter mentions that you can call your state's insurance commissioner to find out how many complaints have been filed against each HMO in your state. Even this can be misleading, however. One company with 1,000 complaints in the last year might look worse than one with 50; but the one with 50 complaints may only have 100 customers compared to 100,000 in the other.

It is best to look for a prevention-oriented plan, advises Nancy Clarke, the managed care coordinator for the Health Promotion and Chronic Disease Prevention arm of the Oregon Department of Health. Questions she recommends asking include: Does the HMO have specific guidelines for diabetes care? If so, ask to have them sent to you. Does it cover visits to a dietitian or a certified diabetes educator? If so, what do you have to do to see them? For a detailed list of questions see page 20.

Kenneth Facter, MD, JD, MBA, recommends choosing the plan with the most flexibility and feels that it is always worth paying a premium, if necessary, to see the doctor of your choice.

Kriss Halpern, an attorney from Los Angeles who has type I diabetes himself, suggests asking the HMO to send you its formularies to get an idea of its level of commitment to diabetes care. Formularies are detailed lists of procedures and medications that have been approved in advance.

Group Versus Individual Plans

Halpern notes that group plans are usually cheaper and better than individual plans. This is an advantage for those whose membership in an HMO is a work-related benefit. However, if you are part of a group plan your coverage won't necessarily reflect all of the HMO's diabetes care practices. Under a group plan, you will only be able to receive treatment and services that are included in the plan your employer purchased. Therefore it is equally important to discuss insurance issues with your employer. To avoid confusion find out what plan you will be (or are) covered by before speaking to the HMO.

Clarke points out that when dealing with both HMOs and the purchaser of your group plan it is important to point out to them that good preventative care is not only better for you, but cost effective as well.

HMOs Versus PPOs

The above is valuable advice for choosing the right HMO, but many experts feel that fighting to get proper diabetes care in an HMO is a losing battle.

At a recent "Taking Control of Your Diabetes '97" patient education conference Facter commented, "HMOs run on a sick system that rewards doctors for lesser care ... HMOs reward doctors who deal with you quickly and inexpensively and penalize doctors that spend too much time and money."

When asked to give advice on how to choose the best HMO, Spolter, who has type I diabetes himself, responded, "Don't join an HMO. People with diabetes are better served by a PPO (preferred provider organization)." Some employers offer a choice between PPO or HMO coverage - many do not.

These programs cost more than HMOs, but Spolter feels the difference is well worth the benefits they provide. A key benefit is that some PPOs do not have a "gatekeeper" - the primary care physician present in HMOs who must approve your seeing a specialist. If you have the choice of deciding between a PPO with a gatekeeper and one without, Spolter suggests going with the non-gatekeeper program.

If the program does have gatekeepers, patients can often choose who their primary care physicians, or gatekeepers, are. Spolter also suggests meeting with some of the available primary care physicians and selecting one who will approve your request to be treated by an endocrinologist.

Not everyone shares these views, however. Clarke believes that it would be a mistake to assume all HMOs are inferior, noting that outstanding comprehensive diabetes programs have been pioneered by several HMOs. She says that many HMOs use their computers and integrated delivery systems to remind doctors and patients what needs to be done, use care managers to keep treatment of multiple health problems coordinated, manage transitions from inpatient to outpatient settings and provide a range of education and support services for their providers and patients. Some HMOs even pay their doctors based on how well they meet diabetes prevention targets, she adds.

Before choosing an HMO, a PPO, or a particular plan in either type of organization, make sure there is no confusion. "If you have gone to the trouble to ask these questions, take down the names and addresses of people you have spoken with. Send them a letter thanking them and confirming all aspects of coverage that you discussed. As with all correspondence, keep a copy for your records," recommends Halpern.

So I'm In an HMO. Now What?

Once you have chosen, or been assigned to, an HMO your work is not over. You must continue to stay as up-to-date as possible on current treatment options and diabetes research.

"I am my own advocate. You must know what it means to have good care and you must know what you need so you can get it," says Ann Albright, PhD, RD, director of the California Diabetes Control Program.

Get Your Doctor on Your Side

You should not settle for a primary care physician that you are not completely comfortable with. If you feel that a doctor is insensitive to your needs, unwilling to listen to you, or hesitant to recommend you to a specialist when necessary, demand to see another provider. This can be a hassle, but far more than an inconvenience is at stake. "If your doctor won't do that (understand your needs and support them) then you are already in trouble," says Halpern.

Albright, who has had type I diabetes for 30 years, notes that after finding a doctor who takes you seriously and is willing to listen to your concerns it is important to develop a good working relationship. "Present yourself as a patient who is motivated and looking for preventative measures," she says.

A good relationship with your primary care physician is very important. He or she must be on your side and willing to go to bat for you to get the care you need. Having a doctor that is unwilling to fight for you will complicate necessary legal efforts should your health care provider refuse to approve payment for necessary services or equipment, notes Spolter.

As the laws read now, it is extremely important that you follow through with your doctor to the last step, Facter adds. If you give up on trying to get what you need from your doctor, the law will claim that you didn't exhaust all the options available to you, making legal action extremely difficult.

The Power of the Purchaser

If you are a member of a group plan, the purchaser of your plan can be an important resource. The care you receive is dependent on the plan(s) that the purchaser chose. Remember to check what plans are available to you as a member of the group.

If you are not receiving sufficient coverage for your diabetes management program, see if the HMO has any other plans that would better serve your needs. If better plans are offered, appeal to the owner of your plan to make these available to you. Again, when appealing for improved care remember to point out the long-term savings of better care, and, as always, keep copies of all correspondence.

Purchasers can also be a valuable ally when trying to get the HMO to offer better coverage. Christina Bethell, PhD, MPH, MBA, is the director of accountability measurement for the Foundation for Accountability. The foundation is working to develop a means by which purchasers of plans and consumers can access records of patient experiences and outcome measurements for managed care organizations.

Bethell explains that in the current system individual consumers have very little power to influence managed care policies. Purchasers of group plans have more clout as they represent a far greater slice of revenue for the HMOs. If you can get your employer or the purchaser of your group plan to demand the services you desire, you may have more success.

They Just Won't Give Me What I Need!

If you have made use of all the resources mentioned above and the HMO still refuses payment of necessary procedures and/or equipment, you will need to ask about the HMO's internal appeal process. This is a long and frustrating process, but you must follow the rules to the letter.

"That appeal process is your trial," says Spolter. If you are forced to pursue it as far as the court you must realize that "the court will not be a trial. They will only review information you placed in your HMO appellate file ... The HMO appeals process is your only shot at introducing evidence which may later be reviewed by a judge," he adds.

Once you enter the appeals/grievance process you are at the mercy of the HMO's regulations, and the system is not designed for your benefit. Filing deadlines are very short and must be met. Failure to meet any of the HMO's requirements will negate your appeal.

In an HMO appeal, your physician must carefully substantiate your need for the treatment that the HMO is resisting. Documentation must be detailed and comprehensive. Your physician or attorney should provide the HMO with articles from professional journals which verify that the desired treatment is effective and can save expenses by avoiding costly complications, says Spolter.

Facter, Spolter and Halpern all recommend that, in addition to keeping copies of all correspondence, you should send all letters by certified mail, return receipt requested (especially during the appeals process).

Taking Legal Action

If the appeal fails, legal action may be your only recourse. But remember that once a case goes to trial no new evidence will be accepted. It all depends on how you dealt with the HMO's appeals process.

As Spolter mentioned in the March 1997 issue of Diabetes Health, hiring a lawyer can encourage more prompt action. "When insurance companies receive correspondence on legal letterhead it's amazing how frequently denials turn into approvals," he says

If you can't afford an attorney, Halpern notes that many attorneys will speak with you on an initial consultation for free.

HMOs Are Just Like HbA1cs

Dealing with HMOs is anything but quick and easy. It can often feel like you are David up against a bureaucratic Goliath. But, like David, you can win too. Halpern, who has had to go through many of these same headaches to get proper coverage of his diabetes, lends a helpful reminder: "Don't get too frustrated and angry when it gets hard, because it will. Just like you can't give up on your HbA1cs you can't give up on getting proper care from your HMO."

Unfortunately the policy makers of most providers just don't understand the disease. If people with diabetes are to get sufficient coverage "we must push the fact that it is a life threatening disease. We don't like to talk about it, but that is what the public responds to," says Albright. "Once you have suffered a major complication - renal, cardiovascular, etc. - you become a "dialysis patient" or a "heart patient" (in the eyes of the HMO) with little recognition of the diabetes," she adds.

With One Voice

Several of the specialists contributing to this article expressed their belief that a unified voice for people with diabetes is very important if the necessary changes in diabetes coverage are to take place.

"We all need to work together. If more people insist on good diabetes care, and show that we are willing to give it (diabetes management) our best effort, we can overcome and get the care we need," says Albright.

"Don't forget, there are over 16 million people with diabetes in the United States. If we work together they will have to listen," says Halpern.

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