How to stay healthy under managed care

Dear WW: My employer just switched to an HMO. I don’t like giving up my old doctor, and I’m afraid I won’t get as good treatment. WHAT’S UP, DOC?

Dear What’s,

A buddy of mine once bought a way-cool car. There was only one problem. He was always hitching rides in my old beater because between the breakdowns and the “hi-test” gas, his car was too rich for the road.

It was kind of like our health care system in the 80’s: a hot rod of a system that became too expensive to run. So here we are in the 90’s, leaping-or being pushed-into some form of managed care. This means insurance companies have gone from being passive bill payers to calling the shots on many aspects of health care. From now on, you’ll need to be more aggressive if you want to get the highest quality care.

For starters, read your contract (not to make my writing look snappy in comparison, but to help you understand the rules your new health provider is following). If you can decode the fine print (which the folks in HR should be happy to help you with) you’ll find out what limits the company has placed on your care, and perhaps even some ways to challenge their decisions. Next, swallow any intimidation those white coats give you and ask your doctor the following questions.

Are there limits on what I can be told about treatment options? These are commonly known as “gag orders” and they’re much more serious than when your doctor takes the tongue depressor and makes you say “ahh.” Under a gag order, medical staff are prohibited from telling you about treatments that aren’t covered by your health plan. Most docs aren’t covered by gag orders, but you want to know if yours is.

Does your doc make money from any of the treatment he’s recommending? X-rays, lab tests, prescriptions, even referrals to other doctors can earn your doc a kickback. You want to know if something other than your health is influencing his opinion.

Is your doctor compensated under a “capitated” plan? Under “capitation” (couldn’t they have picked a better word?) the insurance company pays your doc a set fee for you each month, regardless of what happens. Obviously, the less treatment you receive, the more money he gets. Proponents of capitation argue that providers don’t under-treat their patients because limiting care creates more serious (read expensive) illness later on. But capitation’s critics point out that insurance companies are more concerned about today’s expenses than tomorrow’s (can you say “quarterly earnings”), and therefore do have an incentive to restrict treatment. In any event, the doctors I talked to in preparing this column felt that too many doctors these days are cutting too many corners.

B.M.C. (before managed care) you probably paid too much money for too many medical services. Now the challenge is making sure you get what you need. Most studies suggest that patients do-but that the burden falls on you to learn the rules, ask the tough questions, and work the system. Don’t let your new doctor substitute the hypocritic oath for the Hippocratic.

Bob Rosner is a best-selling author, speaker and internationally syndicated columnist. Sherrie Campbell is a relationship and business professional, having applied her counseling background in a variety of challenging organizational settings. They’d love to hear your thoughts on this topic, especially if you have better ideas than they do. Also check out their complete column archive at workmash.org, “The Boss’s Survival Guide” and “Gray Matters: The workplace survival guide.” Send your questions or comments to bob@workmash.org.