Changes in Health Care May Affect Your Choice of Plans
by Trish Ratto
"This evolutionary period of health care delivery is not without growing pains," stated the "Employee Benefits Review" newsletter recently sent to our homes by the Office of the President. Many of the health care providers at University Health Services agree. Managed care is reshaping the health care system with "growing pains" being felt by patients and doctors alike.
Below, as a means of assisting you in choosing a health insurance plan and medical group during the upcoming open enrollment period, Health Service staff offer insight into how some of these changes may be affecting your health care.
Prescriptions
Health plans are looking at prescription drugs as an area for cost savings. Formularies, which are lists of medications covered by the plans, are being created and enforced. This means fewer drugs--and fewer choices--may be covered. If access to a specific medication is a concern for you, try to look into a specific formulary by calling that health plan. Formularies are under continuous review, however, so this is no guarantee your drug choice will continue to be available.
Another trend is to fill long-term supplies of medications through a mail order system. While the mail order pharmacy offers the convenience of a low-cost, 90-day supply, you have to plan ahead carefully to get the most from this benefit. Otherwise, you may have to pay the co-payment for a 30-day supply obtained locally and a second co-pay when your 90-day supply arrives in the mail.
Access to Specialists
Medical groups are reducing and consolidating the number of physician specialists such as surgeons, OB/GYNs, or orthopedists available to members. Patients may be required to change specialists during the course of treatment. If you have been receiving care (or plan to) from a particular specialist, check into his or her accessibility in the coming year. Ask specialists directly what insurance plan, including which medical group, they belong to and plan to continue with.
Mental Health Benefits
Each medical group may have its own approach to implementing the generalized policies and guidelines for that health plan. This is particularly evident with the mental health benefits. If you anticipate using this benefit, explore your choice of therapists. Some groups may assign you to a therapist who will most likely be a psychiatrist; other groups may offer several choices in regard to the degree of the professional, therapists that reflect diversity, and a variety of services including group, couple or family counseling.
The coverage for crisis intervention is also subject to varying interpretations by medical groups, with some definitions being more constrained than others. Patients often receive authorization for a limited number of visits, requiring another approval to continue treatment. Depending on the problem, one medical group may approve more visits, another may not.
Physical Therapy
Physical therapy treatment is undergoing intense scrutiny for approval by medical groups and requests are sometimes denied. When your primary care physician recommends physical therapy and the medical group approves, it is often for a brief course of treatment for the acute phase of an injury. Because of this acute definition, most approvals average six visits. To make the most of your treatment with a physical therapist, make sure you are given self-care instructions to follow on your own.
Managed care means tight cost-controls that may influence your health care experiences. We encourage you, as a health care consumer, to go beyond the health insurance plan, talk with the medical group about the services and benefits you anticipate requiring and make your open enrollment decisions wisely with as much information as you can access.
Where To Go for More Help . . .
o Educational Materials: "A Primer for Selecting Your Health Insurance and Doctor" is available from Health*Matters at 643-4646. "Anticipating Your Mental HealthSubstance Abuse Treatment Needs When Choosing Your Health Insurance" is available from CARE Services at 643-7754. Both handouts will be available at the Open Enrollment Fair and online through Infocal (select "Health Services/Health Insurance Decisions)."
o Open Enrollment Fair: Nov.13, 9 a.m. to 3:30 p.m., Pauley Ballroom, MLK Student Union.
Trish Ratto is manager of Health*Matters, University Health Services.
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