ASK DR. BAUGHAN April 11, 1997
INSURANCE DILEMMAS
“What are the pros and cons of managed care versus traditional health insurance?”
Rural New England is one of the last places in the country to have to grapple with this question, but more frequently families and employers are doing just that. There are no easy answers, but I can offer some general guidelines from 20 years experience with different types of managed care programs. One wit has suggested the following approach: (1) Decide which diseases you are going to have (2) Find the best doctors for those diseases (3) Find the least expensive insurance that those doctors accept, and choose it. (4) If that doesn’t work, start over and pick new diseases. This may seem facetious, but there is a grain of truth in it.
Which people are most content with managed care programs? Those who know or can predict they will have certain expensive diseases. Such as? (1) Young couples anticipating pregnancy. Complications of pregnancy or intensive newborn care can be financially devastating even with the best of traditional (indemnity) insurance which might pay 80% of the cost. Twenty percent of several hundred thousand dollars can bankrupt young families. With managed care, there would be no additional cost. (2) Persons with chronic expensive diseases with doctors they like who accept their managed care insurance - diabetes, chronic lung disease, heart patients. (3) Healthy people who only need periodic preventive health visits.
Who are those most unhappy with managed care programs? (1) Those who want to see specialists initially for health problems rather than primary care doctors - this most commonly applies to dermatology, gynecology or orthopedics. (2) Those who want free choice of where they go for complicated care. If you want the ability to go to Houston to have Dr. DeBakey do your heart by-pass surgery, you won’t be happy with a managed care company. (3) Those who want impulsive or convenient care at emergency rooms or walk-in centers rather than establishing care with a primary doctor. (4) Those who want “everything done” for terminal care, even experimental procedures (these are the ones that create the headlines and lawsuits).
For what health problems is insurance the most problematic? Clearly, mental health and substance abuse. Managed care offers limited services and providers aimed at crisis management, not healing. They rather blatantly try NOT to care for chronic mental health outpatient problems. Unfortunately, traditional insurance is often not much better. The most recent insurance game is to split hairs over whether a problem is medical or psychological. If they can say a migraine is stress related, they claim “that’s mental health; we’re not responsible.” If it is not stress related, they are. Too often, insurors seek how NOT to provide a service rather than how to solve a health problem.
Locally, all the primary care providers accept the “major” managed care plans in the area, so access to the primary care provider of your choice is not limited by insurance, but by how busy the doctor is. A few new plans (or “products” of the older plans) might not have doctors signed up, so always check the list of doctors available. If you trust your primary doctor, ask him or her if the available specialists seem of good quality. If you care where you would go for specialty care - Portland, Dartmouth, Boston? - see if the plan would limit your choice. Beware of marketing ploys, such as, “We cover chiropractic care.” This may sound like routine care you may be used to; they may limit it to acute care with the referral of your primary provider.
The inevitable tension in any type of health insurance arises from our wish to have as much service as possible available for ourselves (because we really need it), and as little as possible for all those other people who didn’t take care of themselves anyway. Until we approach the problem from the perspective, “How can we make this work the best for the most people?,” it will continue to be frustrating and confusing.