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It's open season on HMOs. Legislators, consumers and even physicians have joined the fray — and now you can, too. That's because it’s open enrollment season for health plans. You can fire yours and seek greener pastures, especially if you've been disappointed in the service or lack of same.
Shopping for health insurance in the managed care era requires consumers to know HMOs from PPOs and to create a customized health care plan that anticipates future needs. During open enrollment, providers (hospitals, doctors, etc.) and health plans (HealthNet, Blue Cross, etc.) offer consumers stacks of information thicker than an election pamphlet — but potentially more important.
Now that HMOs have established themselves as the gatekeepers to medical care, the focus is on physician groups and making sure you can keep your doctor through job and/or health plan changes and that your doctor can refer you to a stable of specialists. Put another way, the health plan manages the primary care physician and the primary care physician manages your access to the system of specialists and services.
 "Plans compete with each other on the basis of who has the most doctors," says Jeff Marold, director of practice management at Scripps Health. "You need to know what you are buying." Marold suggests reading the literature, but then going to the health plan's service department to find out how it’s going to work for you. A generic health plan may not matter to the young single, but marriage, children, chronic or pre-existing conditions require knowing in advance how the plan will serve the consumer. Marold sees the health care system as a number of doors (competing health plans) through which to access the doctor or doctors you need. "If you don’t have a primary care physician, you want a plan that allows you to see different doctors until you find one you like," he says. "Ask your friends and family. If you require specialty care, consider how far you'll have to go for treatment; an integrated system such as Scripps can communicate more effectively."
Health care experts agree; the day of the doctor who treats all ills is gone. "The primary physician is supposed to steer you through the maze of what is behind primary care. You'll rely on that doctor to coordinate your care," Marold adds.
The basics: You'll need a primary care physician you trust, who is accessible and who has access to specialists in a geographically desirable facility. In the world of managed care, there is an element of "you get what you pay for."
"Pressure on prices has leveled out and it’s a competitive market, so employers can get good proposals from a number of entities," says Marold. "But the question of whether the low cost provider is best is a complex one. There is a space between the monthly fee the employer pays and the exposure of the employee, like car insurance. The lower the premium, the more (exposure) is being pushed on the employee."
 If you have children or plan to, you'll need to ensure that the health plan not only provides pediatric care, but pediatric specialty care if needed. "People sometimes make the assumption that because you have a health plan, you can go to Children's," says Debbie Taheri, business outreach representative at Children's Hospital in Kearny Mesa. "But you cannot make that assumption." The key to receiving care at Children's, says Taheri, is to make sure your primary care physician's group has a relationship with Children's. "Certain pediatric care you can get anywhere," said Taheri. "But you might wind up with an adult doctor. We offer 100 percent pediatric specialty care." Before choosing a health care plan, Taheri suggests parents, or parents-to-be, ask questions:
- Is my child's physician and medical group associated with Children's Hospital, and do they routinely refer there?
- Are there restrictions on my doctor's ability to refer to pediatric specialists associated with Children's Hospital?
- Am I able to influence decisions regarding where my child receives specialty care or hospitalization?
- If surgery is required, will the plan and/or medical group cover the child's surgery at Children's Hospital?
- Are emergency room or urgent care visits at Children's covered by the plan?
- Does the plan include well-child, mental health and rehabilitation programs and coverage for catastrophic illness?
 Another specialty option is the UCSD Health Plan, which works only with Medicare and Medicaid. Recently, the federal government's Health Care Finance Administration notified Medicare patients that it will no longer be able to switch plans month-to-month or opt in and out of fee-for-service care. But, according to Nancy K. White, director of the UCSD Health Plan, there also are regulations stating that the treating physician has to approve any hand-off and be able to finish up any course of treatment already in progress.
As far as navigating the maze of specialists, facilities and treatments, White suggests letting your primary physician quarterback your care. "Talk to your doctor — they'll know about the specialists and the hospitals. Take the material (you receive from the health plan) with you. Often, the (doctor's) office staff can help you out," she says. "In San Diego, most of the time it doesn’t matter who your health plan is because if you can stay with the same primary throughout, you'll probably have access to the same specialists and hospitals. Make sure to stay with the same physician group." White offers one caveat: check the physician group's policy on referrals to specialists. "Some medical groups make their physicians get permission for every referral to a specialist. At UCSD, the primary care physician gets to make the call," says White.
That referral feature is a selling point and varies a great deal from group to group. The trend is to let physicians handle it, to progress from referral management to disease management. Sophisticated medical groups identify those members who might be in danger of deterioration in their health and provide services before they develop a serious condition.
When choosing coverage, White suggests doing some anonymous shopping to find out how long it takes to make an appointment. "It should be less than 30 days," she says. "Urgent care should be available in 24 to 48 hours; follow-up, two weeks. You need to determine whether they're too busy to see you." White offers additional tips:
- If you’re seeing a specialist and have to change health plans, find out if you'll be able to keep your specialist or what medical groups they work with.
- If you have a chronic condition, check the plan's specialty panel; "make sure the specialist is tied to the primary."
 Access to specialists can vary according to the medical group, says Jeff Lazenby, director of business development for Sharp Health Plan. Members serviced by the Rees-Stealy medical group can self-refer to specialists, without going through the primary care physician. Consumers can find out about particular specialist access and referral policies of medical groups at health fairs and in promotional literature.
Sharp focuses its employer marketing on San Diego’s small businesses impacted by managed care regulation. "Reform legislation is positive," says Lazenby, "but all of these things have cost benefit mandates."
Thus far, we’ve reviewed plans that network with doctors, hospitals, pharmacies and other providers. Kaiser Permanente is the region's most self-contained plan/provider, with its own medical group, administration, labs and pharmacies. But not even Kaiser is an island, says area marketing director Dennis Humberstone. "We use a number of specialists outside the Kaiser group," he says. "We use Scripps for cardiac care, Children's for pediatric intensive care, Palomar for non-surgical hospitalizations and OB/GYN normal deliveries. So we’re not strictly limited to Kaiser physicians."
 Humberstone is sensitive to suggestions that care at Kaiser is managed by administrators, rather than doctors, and that access is effectively limited by delay. "Kaiser is a group practice HMO," he says. "Our physicians are not employees, they are partners. At Kaiser, doctors are in charge of the care, and there are no constraints in or out of the system. If you haven't heard from the specialty department in three days, you can call and book it yourself."
Fifty percent of Kaiser's appointments are booked on the same day, said Humberstone, and the labs, X-ray, and pharmacies are in the same building as appointments for one-stop shopping.
Managed care has been a business success but a controversial one, in an industry once viewed with a religious sense of awe. Managed care plans and providers point to surveys that indicate the vast majority of members are satisfied with the service, but the vast majority of these are healthy people.
Reformers in Sacramento and Washington are succeeding by bringing to light what have become known as "HMO horror stories." Just before the House of Representatives approved legislation granting patients the right to sue health insurers for denying care, Rep. Greg Ganske, R-Iowa, told the story of a boy who lost his arms and legs to gangrene after his HMO ordered his parents to drive to a distant emergency room for treatment of a high fever.
The House bill also would guarantee access to "reasonable" emergency room care and give patients the right to see pediatricians and obstetricians without permission from primary care doctors.
But the fact that consumers have taken to the legislatures and courts for redress indicates the level of frustration with managed care. A survey released by the Harvard School of Public Health found that 39 percent of people who say managed care does a "bad job" base their opinion on direct personal experience. Almost 55 percent say their opinion is based on the media and word of mouth. On the floor of the House, Ganske pointed to the young gangrene victim, and said "He's not an anecdote."
And neither are you. Perhaps that’s the most important consideration in deciding which insurance company to trust with your health.
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