Breaking the HMO Woes: How to Become Your Own Advocate

| Jun 1, 1998

Bring up the subject of HMO medicine and you are bound to get a wide range of opinions. On the one hand there is the argument that HMOs have tamed the runaway costs of medical care and promise to "manage" health rather than cure illness. On the other hand, there is the view of the late Kenneth Facter, MD, JD, MBA. "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 who spend too much time and money," said Facter at a diabetes patient education conference in 1997.

No matter how you feel about HMOs, it appears that they will be around for some time. Currently 27 percent of insured Americans belong to an HMO, and it appears that this trend toward managed care is gaining even more momentum.

There are several different types of HMOs and several different types of plans within each system. All of these factors will affect the level of health care you receive for your diabetes and all deserve your close attention. However, most of those who belong to an HMO receive coverage as a work-related benefit and don't have a lot of control over which HMO they join.

This means knowing how to navigate the often confusing seas of HMO coverage is extremely important. You'll need to convince your HMO that good diabetes care is in the best interest of all parties involved, and you'll need the best strategies to get what you need when you encounter resistance. A healthy dose of patience and determination won't hurt either. The first step in the process is understanding exactly what you need.

Know Your Needs

As Kriss Halpern, an attorney who works with patients having disputes with HMOs and has type 1 diabetes himself, notes, "Knowing what you need is the first step to getting what you need." This requires that you understand the basics of proper diabetes care. (See page 23 for basic care guidelines.) But since there are few universals in diabetes, you must also be very familiar with all the special measures that managing your diabetes requires.

The Prevention Predicament

It seems that everywhere people with diabetes turn they are confronted with the same message: take steps now to control your disease and you can help prevent or delay a long list of potentially devastating complications in the future.

This may be difficult due to the nature of HMO medicine. HMOs collect yearly fees (and small copayments for doctor visits and prescriptions) and then provide members with their health care needs for the year. While more medical service once meant more revenue, HMOs increase profits by providing only what is absolutely necessary.

As Harvey Shapiro, MD, puts it in his book Managed Care Beware: 5 Steps You Need to Know to Survive HMOs and Get the Care You Deserve, "(HMOs') annual business reports refer to medical-loss ratio - the relationship between dollars accrued as premiums and money spent on medical care."

The challenge then is to convince HMOs that the higher short-term costs of better care can prevent the even higher costs of devastating diabetic complications in the future. See page 20 for an abridged list of quotes from respected medical journals showing the cost saving power of better diabetes care. These quotes can be used to pepper correspondence with your HMO when trying to get coverage for specific products and services necessary for your diabetes care.

The Power of the Purchaser

Many receive their HMO care as part of a group plan purchased by their employer. This has radically changed the nature of health care and the relationship between an insurance company and its individual members.

"Doctors who once called all the shots are now pawns on a corporate chessboard, and patients who considered themselves direct consumers of medical care now find themselves in a subgroup called 'covered-lives' while their employers enjoy the status of being the 'real' clients of HMOs," writes Shapiro.

The group plans purchased by employers and offered as a benefit to their employees are often cheaper and offer greater coverage than individual plans. However, you will only be covered for treatments and services included in the plan purchased by your employer.

Remember to check out all the plans that are available to you as part of that 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 your employer to make these available to you.

Since purchasers of group plans represent a far greater slice of revenue for the HMOs, they have more clout than any individual group member. Therefore, you might be better served by going to them first when trying to get better diabetes coverage in specific plans. If you can get your employer (or the purchaser of your group plan) to demand the services and products you need, you may have more success.

Get Your Doctor on Your Side

Your primary care physician is also an important resource in getting what you need from your HMO. All HMO members must see a primary care physician, or gatekeeper, who must approve any special care you may need - like going on the pump, using Humalog insulin or seeing a diabetes specialist, nutritionist or dietitian.

Obviously, if your primary care physician is sympathetic to your needs, you stand a far greater chance of having them met. If you feel that your physician is insensitive to your needs, unwilling to listen to your input, or hesitant to recommend you to a specialist when necessary, you should demand to see another provider. As Halpern points out, "If your doctor won't do that (understand your needs and support them) then you are already in trouble."

Once you find a physician who takes you seriously and is willing to listen to your concerns, your work is not over. You must also work to develop a good working relationship with your physician.

As one health insurance salesperson is quoted in Managed Care Beware, "The best thing you can do to get good care in an HMO is to build a relationship with your primary care doctor. If you need something the PCP (primary care physician) is the one who will clear the path."

Ann Albright, PhD, RD, director of the California Diabetes Control Program, agrees and offers some advice on how to craft this relationship to get the best results. "Present yourself as a patient who is motivated and looking for preventative measures," she advises. If your primary care physician is aware of your commitment to good preventative care and is on your side, he or she is far more likely to go to bat for you to get the care you need.

Having your doctor's support is also of great importance if you are ever required to take legal action against an HMO that refuses to provide payment for necessary services or equipment. According Facter, if you give up on trying to get what you need from your doctor, the current laws will claim that you did not exhaust all options open to you. This makes future legal action extremely difficult.

Still Can't Get What You Need?

If you have made use of all the resources mentioned above and your 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, and you must follow the rules to the letter.

"That appeal process is your trial," says Loring Spolter, a Fort Lauderdale, Fla., attorney who works with patients having disputes with HMOs. If you are forced to take your HMO to court to pursue a coverage problem, 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 appeal/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. See pages 18 and 20 for an example of a letter asking for additional services or equipment and an abridged list of helpful facts and statistics for such a letter.

You should keep copies of all such correspondence and send it all by certified mail, return receipt requested (especially during the appeals process).

Don't Give Up

Taking on the bureaucracy of an HMO can often be a daunting and frustrating process. Despite this, it is often necessary if you want to get the level of care necessary to keep you healthy. Knowing where to start and what to do will make things a lot easier.

You must be your own advocate, stay up-to-date with the newest developments in the treatment of diabetes, make use of all the resources available to you and, as Halpern puts it, "If all else fails - protest, demand, be heard."

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