ASK DR. BAUGHAN                                                         September 19, 1997

LET THE MANAGED CARE GAMES BEGIN!

This part of the country has been one of the last areas for managed care companies to sell a significant percentage of health care insurance.  But the percentage is growing, and one of the markers is how frequent we get phone calls from patients with the common misunderstandings or dissatisfactions of people unfamiliar with the concepts of managed care and how it differs from previous insurance.  Having practiced in Washington state, North Carolina and California before here, I have seen the same issues come up repeatedly.  The most common glitches surround the use of emergency services and visits to specialists, with ophthalmology (eye doctors), gynecology and orthopedics being the most frequent, followed closely by dermatology in communities with full time dermatologists.

It is becoming a bit of a ritual than the primary care doctors on call get paged between 5 and 7 p.m. by a patient who has gone to the emergency department and been told by the registration clerk that their visit requires approval by their primary care doctor.  This is a nuisance for both patient and doctor, so why do managed care companies require this?  The answer is simple: cost savings.  Emergency room care is more expensive than office care, often four times as expensive or more.  But the difficult question is, “How many visits in the evening could safely wait until the next day in the office?”  My rough impression recently has been, “About 25%.”  Some others are not true emergencies, but are reasonable requests to treat discomfort and suffering.  However, even if those 25% of visits are avoided by phone treatment or office treatment, that can help contain the cost of health care premiums.  So to avoid awkward situations and possible financial surprises, call your doctor (or the doctor on call) before going to an emergency room or urgent care center, whether in town or out of the area, for something that is not a true emergency.  If you are seriously bleeding, unable to breath, or having severe chest pain (or other clear emergencies), get help promptly and deal with the insurance issues later. 

Gynecology and ophthalmology visits can be confusing because many managed care companies offer plans that “allow” routine eye or gynecologic exams once a year without a referral.  It would then seem logical that if you had an eye or GYN problem, you would go back to that doctor.  It ain’t necessarily so.  Many eye or GYN problems can be well handled by primary care doctors, and most managed care plans require subsequent problems to have referrals beforehand.  There is a lively debate, and some much needed research being done, to determine if there are cost savings in primary care or specialists handling certain problems.  Expect to see many variations in plans trying to find the optimal balance between offering free choice versus cost savings.  Check out your plan and ask questions with specific scenarios.  If you get an answer, “You just need a referral from your primary care doctor,” do not interpret that to mean such a referral will be automatic.  Some managed care plans do not allow primary care doctors to approve referrals after they have already occurred (“I went to the urgent care center yesterday.  Will you send in the referral today?”)

It is an unsatisfying, but probably accurate, analogy to consider managed care plans like automobile warranties.  If your car is under warranty, you have considerable motivation to have your dealer (Oh my God, I’m comparing myself to a car dealer!  Not that I have anything against car dealers) fix your car.  If your dealer can’t fix it, they should refer you to someone who can.  You are always free to take your car (or body) elsewhere, but you will have to pay more.