Managing your health plan - Surviving your health plan

You've no doubt already picked up on our bias that there's not much to choose from when it comes to picking health plans these days. When you're presented by your employer with a menu of plans, however, there are a few things you ought to take into account.

In choosing a health plan, you may be presented with managed care gobbledygook, such as MCO and PPO.  Try not to let this bother you.  Such terms have very little practical meaning. The big picture is what's important, and we've already told you about that.  However, for your convenience we provide you here with a quick and dirty glossary of managed care gobbledygook.

The most important consideration in choosing a health plan is this: is your doctor available under this plan?  Nurturing a good relationship with your primary care physician is so difficult today, and so vitally important to getting good health care, that this one consideration should dwarf all others - assuming, of course, that you've developed the kind of relationship with your doctor that we've outlined (see Managing your doctor.) 

Are you one of those patients who's willing to abandon such a relationship in order to avoid a moderately higher co-pay?  If so, then frankly we have very little to talk about. If you're willing to jeopardize your own health for a few bucks, then why shouldn't your HMO also jeopardize your health for even bigger bucks?  No reason we can think of.

If you have a particular bias toward specific hospitals in your area, or toward particular specialists, then try to choose a health plan that is serviced by these hospitals and/or specialists. The amount of out-of-pocket expense that might accrue to you under each plan is also important, but we again urge you to make this a secondary consideration - having a doctor who will advocate for you is by far the most important thing to consider.

The medical necessity scam

Getting what you need from your health plan can be tricky.  By far the best way of doing so, as we've stressed over and over, is to have a doctor who will do whatever is necessary to see that you are treated appropriately.  But given the duress doctors are working under, it's not realistic to expect them to always take up your cause, however dedicated they might be.  At least some of the time you will be on your own.

Most of the significant problems patients experience with health plans (other than, of course, the planned inconveniences and inefficiencies that discourage the use of certain services) fall into the category of "refusal of a requested service."  That is, the patient or the doctor requests a particular service, and the health plan denies the request, usually holding that the requested service is not "medically necessary."  This is a particularly good scheme for health plans, because medical necessity is so often a  subjective phenomenon. 

While some medical services are clearly necessary (e.g., penicillin for strep throat), and others are clearly not necessary (e.g., penicillin for a viral infection such as a cold), in many instances whether a medical service is necessary or not is much less clear cut.  There are many gray areas in medicine. A medical service may be wasted on one patient with a certain condition, and extremely useful for another patient with the same condition. Experts will often disagree on the usefulness of a particular service, either for all patients or for one particular patient.

Health plans traffic in these gray areas of medical necessity. They commonly will make a blanket statement about the usefulness of a service, often after ferreting out an "expert" whose opinion they admire, when such a blanket statement is clearly unjustified.    They'll deem any newer medical or surgical procedure to be "experimental" long after it has come into common clinical use, and without any defined criteria for declaring the procedure no longer experimental. They'll make a list of inappropriately simple rules, and give those rules to a functionary with little or no medical background to make determinations of medical necessity on a case-by-case basis. 

They'll persist in calling a particular service medically unnecessary long after they've been forced to reverse their decisions on that service many times.  Usually they'll get away with it, too, since their appeals process has been rendered so tedious that doctors, and often patients, are very reluctant to embark on it.

The basic problem, of course, is that the people who must cut the check (and who get to keep the money for themselves if they can avoid cutting the check) are the same people who get to determine medical necessity.  It's crazy, it's unfair, but it's the system we've chosen.

If your health plan has refused a medical service that you or your doctor have requested, you have a decision to make.  Unless the refused service falls into the "clear cut" category (where the majority of medical experts would agree with the health plan's decision,) then you potentially stand a good chance of ultimately having that refusal reversed - but only if you're willing to go through a very tedious appeals process first.

Appealing a health plan's decision

If appealing a health plan's decision were easy, then everybody would be doing it. While YourDoctorintheFamily.com can't prove it, and while the public relations director of any health plan would strenuously deny it, many plans behave as if the denial of medical services, coupled by a difficult appeals process, is simply a routine and effective cost-cutting measure.  Health plans know that the average subscriber will be daunted by the appeals process - indeed, they count on that fact. Indeed, because appealing these decisions is so odious, you'll want to do it only when it's really important.  You will want to choose your battles carefully.

You can think of the whole denial-appeal process as a game. Your move: you ask for a health care service.  Their move: they deny it. Your move: if you choose to go no further, they win.  If you choose to appeal, the game continues. The game may go back and forth through several more turns, until one of two things happens.  Either you give up, or they give in. 

The dynamics of this game are quite interesting.  You have a much better chance of winning if your doctor takes an active role in supporting your appeal.  If the medical reasons for providing you with the service are good enough, eventually your doctor will be permitted to talk to one of the health plan's actual medical officers, and the game is usually won at that point. 

(Of course, your doctor pays a price for giving you his assistance.  The time he loses in the process is a piece of it, since the appeals process is generally bogged down with time-consuming paperwork, and several telephone sessions. The larger price has to do with being labeled a troublemaker.  Doctors who appeal too often are duly noted by the health plans, and are eventually culled from the herd.)

You can even win without your doctor's direct assistance, if you're persistent enough. It will take some work, though.  You'll need to gather evidence that the medical service you're asking for is routinely used for conditions like yours, that medical experts recommend it, that other health plans pay for it, or even that your health plan has paid for it in other patients. You may need to hire an attorney.  You may even need to threaten to go public.

One suspects that health plans use typical risk management strategies to manage appeals.  They seem to stonewall to a certain point (knowing that most people drop out of the game after one or two "turns.") But they seem much more likely to give in if the subscriber persists beyond a certain point. This is especially true if the service being requested is not excessively expensive, and if granting it would not be particularly likely to open the floodgates to many similar requests. 

For this same reason, the threat of going public can occasionally be a good strategy, if less drastic means have failed.  But the patient must realize that actually going public can backfire severely.  Once the question enters the public arena, the health plan will have no choice but to fight to the bitter end - since if they grant the service now, they will have loudly and publicly set a new precedent, and will be expected to grant that same medical service to everybody else.

Rationing by omission

Patients ought to be aware that not all denial of medical services is out in the open. One of the more common means of withholding services is "rationing by omission."  That is, patients are simply not told all of the possible options for their medical condition.

Rationing by omission obviously requires the complicity of the patient's physician.  She has to agree not to spell out every alternative. Unfortunately, such complicity is much more common than most doctors like to think. In fact, the famous "gag clauses" that many HMOs have required their doctors to sign included language forbidding doctors to describe to their patients any treatments that are not offered by that HMO.  To do so, it is held, would undermine the patient's confidence in the HMO - an act explicitly forbidden by the gag clause. (See DrRich's discussion of gag clauses in the Grand Unification Theory.)

Avoiding rationing by omission is another reason it is vital for you to find a PCP who truly honors her primary commitment to the well-being of her patients. But to be sure you're not a victim of this sort of rationing, you'll need to arm yourself with as much knowledge of your medical condition as you possibly can.

Next: Managing your own health

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