How To Choose a Managed Care Organization if you use a Wheelchair
Managed care organizations are necessary in today's health care environment. They keep costs down. But they don't always offer what you might need for your medical benefits. So, the more you know about MCOs, the easier it will be for you know what medical insurance benefits you really have and what you should ask for if they are not covered.
By Mark Schmeler, MS, OTR/L, ATP
Good or bad, managed care has brought on new ways in which health care services are delivered to the public. What's important for you is to understand where it came from and what it is, so that you can make an informed decision when choosing a managed care plan -- especially as it relates to rehabilitation services.
Managed care is the offspring of industry stakeholders -- the insurance companies that felt they needed to control skyrocketing medical costs, the public and employers who could no longer afford health insurance premiums, and health care providers who needed to reassess cost-effectiveness. As with any offspring, managed care is going through various stages of development depending on the organization and geographic location.
In 1999, DaimlerChrysler stated that 7 percent of the cost of every new vehicle it manufacturers is spent on health care services for its 122,000 employees, retirees, and dependents living in the United States. It added that it pays its health care suppliers more money than any other vendor.
The reality is, close to 14 percent of our nations gross domestic product is spent on health care today compared to less than 9 percent in 1980. This constitutes more than one trillion dollars in annual spending. Health care spending per capita has almost quadrupled in the same period. Projections remain that the Medicare Trust fund is expected to go bankrupt in the next 10 years. Given these facts, something drastic needed to happen.
Health care is no different than any other business. Attempts were made by the Clinton Administration in 1993 to initiate socialized medicine to control costs and improve access. The proposal was never accepted by our society, which values a free and open enterprise. Instead, health care industry reform was left in the hands of a market driven system.
On the surface, managed care is often portrayed as managed cost with little concern for the overall well being of the individual. In many instances, this was and still is the case. The problem is that a battle developed between physicians and insurance payers. In many locations, payers started to restrict and dominate control of health care and how it was delivered. Physicians especially felt the squeeze, as they were no longer working in the best interest of their patients but rather for the insurance company or payer. Providers either gave into these restrictions or exited the business.
The Growth of Health Networks
We are starting to see another stage of development in the evolution of managed care. To trim overhead costs, to gain some market control, and to be competitive in negotiating managed care contracts, health care organizations (hospitals, physician practices, clinics, etc.) are consolidating into large networks and health systems. Consolidation makes the new network or system more comprehensive and diverse in the scope of services provided.
Having diverse services also allows for cost shifting, if necessary, between services that might not otherwise survive financially. An unprofitable service can remain available because it is being carried by a profitable service offered by the same network.
A health network is similar to a large one-stop shop department store with a wide range of products. One component (or product) of a health system is rehabilitation services. Rehab services are also diverse in and of themselves. They should include everything from in-patient rehab, to outpatient services, to home care, to rehab equipment. The quality of these services is sometimes hard to judge.
How to Choose What's Right For You
As a consumer of the health industry, you need to be aware of what is available in your market and how to measure quality.
QUESTIONS TO ASK ABOUT A MANAGED CARE PLAN
- Is your current Primary Care Physician or specialists provider in the plan?
- What specialists are providers in the plan and are they conveniently located in your geographic region?
- Do you need a referral from your Primary Care Physician or prior authorization from the plans administration to see a specialist?
- Which primary care hospitals participate in the plan and are they conveniently located in your geographic location?
- Which specialty hospitals participate in the plan and are they conveniently located in your geographic location?
- Is there an academic (University) affiliation with any of the participating hospitals or providers?
- Are the participating hospitals accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO)?
- What are the procedures for obtaining Emergency Care?
- What are the procedures for obtaining medical care when you are traveling outside your geographic location?
- Likewise, is there a specified distance you need to be away from home to receive medical care from another provider outside the network?
- Does the plan cover in-patient, out-patient, and home based rehabilitation services and if so, how much or for how many days?
- Does the plan cover Durable Medical Equipment (DME) and if so, up to how much?
- Specifically, does the plan cover all types of wheelchairs including ultra-lightweight manual wheelchairs and power wheelchairs?
- Does your current DME Supplier participate in the plan?
- Does the plan have a contract with a DME Supplier that is capable of providing and servicing Rehabilitation Technology or other specialized Assistive Technology Devices?
- Does this DME Supplier have Certified Assistive Technology Suppliers (ATS) or Certified Rehabilitation Technology Suppliers (CRTS) on staff?
- Is the Rehab Technology Supplier able to provide 24 hour emergency service?
- Does the Rehab Technology Supplier work closely with knowledgeable clinicians to identify the best equipment to meet an individuals needs?
- If a request for service is denied by the plan, what is the appeals process?
- Is an appeal reviewed by an unbiased external reviewer or someone who works for the plan?
- Sooner or later, everyone is going to be asked to choose a managed care provider or be assigned one. State Medicaid programs in some areas are already mandating managed care and Medicare is looking to implement a similar program.
You can indirectly choose your fate by choosing your health insurance and in turn your health care providers. There are comprehensive health systems that are fully equipped to provide the full spectrum of health services. In rehabilitation, this works well when appropriate clinical pathways (the progress from one area to another that you take in rehab) are instituted within a well-organized health system. There also needs to be full cooperation among all parties involved, especially you, the consumer, and your funding source.
Choosing a health plan and, in turn, a health network can be tricky and will involve some homework. The first and utmost important factor is to determine whether or not the plan covers rehabilitation and durable medical equipment (DME) and, if so, how much. Some lower cost plans seem intriguing as they claim to cover all doctors visits, prescriptions and hospitalizations. However, the fine print clearly states rehabilitation and DME are not covered or are very restricted.
Crucial to you and any person with a disability is to ensure that your primary care physician participates (is a provider for) the MCO under consideration. The MCO will give you a list of such providers. You then need to know what specialty services you have access to, such as medical specialists, hospitals, pharmacies and equipment suppliers. Access to these services is important to the special health needs of people with disabilities. Again, check the MCO's list.
Coverage for and access to rehabilitation services is also a gray area when looking at managed care plans. Policies state they cover rehab but do not always specify where, for how much or for how long. Your rehab needs vary depending on your type of disability, but there may be a one size fits all allowable written in the policy. If you require in-patient rehabilitation, you want to make sure it is provided at a reputable rehabilitation hospital or center with experienced professionals, specialty services, and state of the art facilities. Some insurers have contracts with skilled nursing facilities that claim to provide rehab at a lower cost. The same goes for outpatient rehab; you want access to good services.
DME is the umbrella term used in the insurance industry to describe all equipment, including assistive and rehabilitation technology. Generally, insurers are reluctant to pay for equipment, especially if it is expensive and cheaper alternatives are perceived as being just as beneficial. Some policies have a capped allowable for DME which may be as low as $500. This will not even cover the cost of a standard wheelchair, let alone a cushion to sit on. Managed care organizations (MCOs) also tend to have a contract with a single supplier of DME. That supplier usually represents a whole continuum of home medical equipment, such as walkers, hospital beds, standard wheelchairs, etc., but may not have any expertise in sophisticated rehabilitation technology to meet a persons specialized needs.
Check to see whether you can still see your primary care physician, even if he is not part of the MCO plan, and still receive reimbursement. If you choose to go to a provider not listed with the MCO, check to see what you need to do to receive reimbursement. There should be some appeals process.
Lastly, look at the MCOs overall reputation, as well as the reputation of the health systems it contracts to. Also keep in mind that a large, well-known hospital with a good reputation for saving lives and curing sickness may not always have the same capabilities for providing rehabilitation services.
Not everyone has a choice of health plans especially if they work for themselves or a very small company. If an MCO does not provide the services you need, you need to firstly attempt to convince them that the services are needed and reasonable. This is best done by having a qualified clinician such as your primary care physician or a specialist write a letter of medical necessity that also explains the cost benefit of the intervention. If the service is still denied, take it through the appeals process. If you are unable to do this yourself, seek the assistance of an organization such as the Center for Independent Living or Disability Law Project. It is also important to advise your employer as to the problems. They may have some clout especially if the company is self-insured (i.e. they pay the MCO to manage their own healthcare dollars). The company may also take these problems into consideration when it is time to renegotiate the contract and looking at other health plans. Health plans can only exist if they maintain a certain number of subscribers and therefore need to be competitive related to cost and quality. The last thing they ant is unhappy customers who may take their business elsewhere.
In many cases, managed care works well and it has shown to reduce costs. The key is to identify a good MCO and understand how it operates. Every organization has procedures and people usually get what they need when they follow the procedures. You can learn a lot about a MCO through its marketing material. In many states, health insurers are required to publish in common, understandable language how they operate, who they operate with, and exactly what they do not cover. But more so, you can learn a lot by experience and the experience of others.
Mark Schmeler is an occupational therapist and an assistive technology practitioner. He is director of clinical services for the Center for Assistive Technology, University of Pittsburgh Medical Center in Pittsburgh < http://www.rst.upmc.edu/cat > . He is a member of the American Occupational Therapy Association and the Rehabilitation Engineering and Assistive Technology Society of America. You can e-mail Mark at: Mark Schmeler
Last Updated: 3-2-2006