Managed care plans like HMO's and PPO's have one common goal – to cut and control health care costs. If you're not already covered by a managed care plan, chances are that you will be soon. There are hundreds of managed care plans available, and each promises better health care at less cost.

As a physician, Dr. Gupta is concerned about the effect that the trend towards managed care will have on the quality of health care available to his patients. In this article, he points out ways in which the health care consumer can compare the quality of managed care plans.
Types of services affected

"When comparing managed care plans, you need to look at two types of services

– identical services and nonidentical services. Employers and insurance companies strive to control health care costs by controlling access in both categories. How companies cut costs in these two categories directly affects the quality of care that you receive," Dr. Gupta says.
Identical services

"Identical services are those in which the outcome for the patient does not depend upon who provides the services. The assumption is that you can get basically the same service form Place A, Place B, or Place


"A good example is prescription drugs. It makes sense to get a prescription from whoever can provide it for less money," Dr. Gupta says.
Non-identical services

Dr Gupta defines nonidentical services as those in which the outcome is directly influenced by who is providing the service.

"These services are often personal in nature, like the
services of  a  physician,
surgeon, nurse,Dr. Gupta says.  or  therapist,"

It is prudent to focus on cutting costs in the first category where services are pretty much alike from one provider to the next. To focus on reducing costs in the second category can directly and proportionately diminish the quality of care you receive," Dr. Gupta says. "Losses from reduced quality far outweigh the gains from reduced cost in this category."
When a discount is not a discount?

"Discounts are not always what they seem. For example, if you pay $100 for a service, and someone else can offer you an identical service for $80, then you've received a true discount of 20%.

On the other hand, let's say the service you receive costs $80, but it's only worth $20. You've actually paid 400% more – 4 times what the service is worth," Dr. Gupta says.

You and your physician

"Many individuals find that when they enroll in a managed care plan, they are forced to change doctors. The physician who knows your medical history and whom you've trusted for many years may not be a member of your new plan.

"Even if your doctor is on the plan, he or she may be faced with new restrictions. The plan may offer less freedom for your doctor to decide where and when to refer you for tests or to other physicians.

Your doctor now may be your health care gatekeeper. Managed care plans place severe limits on his judgement and discretion."

"You may not even be aware that the quality of care that your physician can provide has changed. Dr. Gupta suggests that is you've recently joined a managed care plan, you might want to ask if new restrictions have been placed on your doctor.
Beyond dollars

The efficiency of managed care is usually determined by the dollar savings to whoever pays the bills. "But there can be hidden costs to the consumer," Dr. Gupta notes.

He offers an example...

Suppose your physician decides that you need to have three diagnostic tests. Many

managed care plans will specify that each test has to be run separately. After results are evaluated, you go on to the next test, and so on. It would be simpler to have all tests to be run on the same day at the same place. Under some managed care, you may have to make three trips. You have to take time off from work on three different occasions. You may incur three times the travel expense. Your family has to arrange to drive you, or be with you on those three occasions.

The managed care company argues that it is saving money by possibly eliminating the need for a second or third test.

What have you saved? Nothing. What have you lost? You've lost additional time for yourself, your family and loved ones. You've experienced anxiety and stress from waiting extra days, or even weeks, for a definitive diagnosis.

The value of this time and anxiety isn't counted when cost comparisons are made. However, these hidden costs directly affect the patient and the family. Ironically, these hidden costs also affect the company that thinks it's saving money.

The employee experiences more stress and spends more time away from the job. The result is lost productivity for the employer.
Mortgaging the future

"Everyone wants to save money and control costs. Often the cheapest approach is not to use any health care at all, forego that extra test, or delay treatment. But in those situations, don't we run the risk of mortgaging our future health by saving a few pennies in the present?
What can the consumer do?

Dr. Gupta notes that how much choice you have in choosing a managed care plan will depend upon your individual situation. Does your employer offer a choice of health care insurance? What kinds of premiums can you afford? Do you purchase health insurance, or is it provided for you?

"Whether you select your plan or it is provided to you, you have the right to ask questions. If you are covered through your employer's managed care plan, ask your benefits administrator of human resources department the following:

What percentage of my premium goes toward the provider – physician, hospital, etc., and what percentage is retained for administrative costs and profit?

What restrictions are placed upon the gatekeepers – the primary care physicians? Can they refer to other doctors at their discretion? Can they order tests that they deem necessary? Are they free to exercise their own professional judgement?
The end result

"Managed care plans cut access to health care in order to save costs. After all the cuts have been made, the question remains – who does managed care benefit most? Is it the insurance company, the employer, or the patient? Ideally, managed care should benefit all.

"Healthcare is a complex matter. When we are healthy and feel fine, we don't appreciate the value of good health. When we are sick, we realize what we've lost. It would be wise to balance cost savings against the potential risk of not being able to regain lost health.

"As a physician and a healer, I feel that it's my duty to make patients aware of these issues. Hopefully, this will help them to evaluate the impact that managed care plans can have on their health," Dr. Gupta concludes.
The Hidden Costs of Some Managed Care Plans

    Takes longer to make an accurate diagnosis because of more restrictions on the physician.
    Added time away from work for the employee.
    More anxiety and stress for the patient and family.
    Lost productivity for the employer.


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