Asking the right questions

Get the most from your managed care plan

June 21, 2000
Web posted at: 3:43 p.m. EDT (1943 GMT)

By Margaret Prinzavalli Sotham

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(womenconnect.com) -- You may have applauded with the rest of the audience when Helen Hunt's character in "As Good as it Gets" unleashed a stream of invective against her HMO for not taking care of her asthmatic child.

Frustration with managed care is well-documented and may sometimes be well-deserved. But as with any service you buy, it's important to be an informed consumer.

Under the old fee-for-service insurance system, you could see any doctor you wanted, take any drug that was prescribed, have any service your doctor ordered and pay a portion of the cost. Then, more than a decade of rising health costs led many employers to offer plans that trade restricted access to providers and services for lower costs.

About 85 percent of the American work force now is covered under this system known as managed care, and women make up the majority of the those enrolled. They're also more likely to make the health care decisions for their families -- such as kids and elderly parents -- and they use more health services than men.

So, how do you know you're getting the best quality of care from your managed care plan?

Dialing for data

First you need to know how well your health plan meets women's health needs. The National Partnership for Women and Families (www.nationalpartnership.org/) -- an advocacy group -- has compiled 17 "Principles for Quality Health Care," basic standards you might consider as a guide to quality.

These principles touch on a range of important issues for women including what types of services women can use and when they can use them; what role doctors play in medical decision-making; and how health plans should develop their treatment guidelines to improve women's health.

For instance, some women in managed care plans still have to get a referral before they can get an annual Pap test by an OB-GYN provider. This creates scheduling hassles and an extra step that might discourage important preventive care.

Plans also may not cover a visit to your OB-GYN provider between Pap tests, even if a problem occurs. It's important to find out up front what OB-GYN services are covered and whether you need a referral to use them.

Many patients also aren't aware that managed care plans establish a list of approved prescription drugs, called a formulary. Medications not on the formulary are generally not covered by the health plan, which means you get stuck paying full price or you accept a substitute that might not work as well for you.

While a prescription for a one-time illness can be tough on the pocketbook, imagine the financial toll for chronic conditions like high blood pressure or asthma.

More importantly, new research has shown that a drug's effectiveness can vary from women to men. Since most drugs have been tested only on men, you may be left without an effective treatment if the plan doesn't cover the specific drug your doctor prescribes.

Other important considerations: Who has the final say in health care decisions for you and your family? Can you challenge the health plan's decisions? The answers to these and other questions can have a dramatic impact on the quality of care you get from your health plan -- and ultimately, your health.

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