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MANAGING THE HEALTH CARE MAZE

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MANAGING THE HEALTH CARE MAZE

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As we approach the next millennium, every facet of our lives-how we work, learn, play, and relax will change drastically due to constant technological advances. This rapid advancement is particularly evident in health care, as medical experts continue to develop new theories and treatments, Although change is certain, managed care-the system in which more than 100 million Americans receive health care -has become a permanent fixture in the lives of most Americans.

Since its evolution-resulting from the skyrocketing health costs of the late ’80s and early ’90s-managed care has been highly debated. Its vague, broad definition adds to the confusion and leaves its meaning open to different interpretations, The Managed Care Resource defines managed care as a system of health care delivery that influences utilization and cost of services and measures performance, thereby giving people access to quality, cost-effective health care. In simpler terms, managed care purchasers of health care-namely employers and insurance companies-negotiate with physicians, pharmacists, hospitals, and other health providers for discounted rates and fixed monthly fees. Managed care enrollees have access to these participating providers but often have to pay out-of-pocket when seeing a specialist outside of their network.

Supporters maintain that managed care reduces medical costs and ensures superior health care by eliminating financial barriers, allowing patients more access to care, promoting preventive medicine, and meticulously monitoring the quality of care. Detractors, on the other hand, contend that managed care is a threat because it sacrifices the patient’s well-being by withholding necessary treatments in favor of reducing costs.

These opposing points of view lead us to a vexing question: Is managed care a good thing? The reality is that managed care plans, if carefully chosen and utilized correctly, can provide us excellent health care.

KNOWING THE BASICS

Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) are the two dominant types of managed care. Both systems require a fixed monthly payment and provide preventive and primary care services at little or no additional cost. HMO enrollees, for a fixed low monthly cost, select a primary care physician from a fixed network, who determines if a specialist is necessary. If the patient uses a provider outside the network without HMO approval, she will have to pay the entire bill. Less stringent, yet more costly, is the PPO, in which enrollees can use any specialist in the network and will have to pay only part of the bill if a doctor outside the network is selected. Point-of-Service plans (POS) integrate the favorable aspects of HMOs and PPOs. Enrollees are assigned to a primary care doctor from within the network, yet they may go outside the network for care by paying a larger share of the cost.

Navigating the maze of available health plans can be an unnerving and time-consuming process. To combat the complexities, large companies are starting to see the value in using the Managed Care Store. As the only company of its kind in Dallas, the Managed Care Store provides a needed service by researching the most appropriate health plans for their clients’ specific needs Once a plan is chosen and implemented, their service continues as they teach consumers how to use their plan effectively and encourage employees to contact their account management staff to handle all aspects of their plan, including making appointments, referring clients to other doctors, and explaining bills. Recently, the Managed Care Store added a medical director to provide a doctor’s expertise when helping large companies implement and educate employees on managed care.

“Our vision is to see managed care back to its basic elements-prevention and wellness-and not just cost control,” says company president Katherine Stamper, who founded the Managed Care Store with her husband, Donny Lander-back, more than three years ago. “There’s no question that public perception of managed care is negative. We can teach people to utilize managed care in a manner that turns it into a true positive.”

Those who decide to shop for a health plan themselves should first gather pertinent information, such as a member handbook, an annual report, a copy of the enrollee contract, and the results of any member surveys. Before making a decision, certain questions should also be addressed. First, be sure that the plan includes doctors you like and hospitals you trust, Also, find out if treatments you foresee needing in the future, such as obstetrical services, special medications, and psychotherapy, are covered. Understand the pre-existing conditions of your plan. And most importantly, learn if the network’s doctors receive bonuses for miriimizing costs or if they are forbidden to discuss treatments not covered in their plan.



SELECTING A PROVIDER

For more than 20 years, United Health-Care has been recognized as a national leader in the health care industry. By anticipating consumers’ needs and concerns, United HealthCare has helped improve the quality and delivery of health care. The company has set industry standards by broadening access, allowing greater flexibility, controlling costs, and consistently developing new and innovative health services and products.

United HealthCare was the first company in Texas to respond to consumer demand for less restrictive managed care. “Our Choice health plan is considered an ’open access’ model because it allows enrollees direct access to network specialists,” says Richard Cook, CEO of the North Texas Division. The popularity of this product is evidenced by the fact that over 23.000 North Texans have enrolled in their Choice plans in the last nine months. “People are clearly more comfortable when they have more control over decisions affecting their health care,” adds Cook.

United HealthCare offers a large range of health services and products, including HMOs, PPOs, Medicare, workers’ compensation, and behavioral health services, Furthermore, it is distinguished from other companies by its ability to acquire data about treatments, outcomes, and costs, which it uses to plan models. This useful information is then provided to patients, employers, providers, and health care institutions nationwide.

As one of Texas’ largest and oldest managed care companies, Humana is able to offer a wide range of flexible and innovative benefit plans, including HMOs, PPOs, POS plans, and Medicare HMOs. Businesses of all sizes throughout the Dallas-Fort Worth area are covered through Humana Health Plan of North Texas. Humana is fully accredited by the National Committee for Quality Assurance (NCQA) as a result of meeting the rigorous standards in the following areas: quality improvement, physician credentialing, members’ rights and responsibilities, preventive health services, utilization management, and medical records.

Humana members enjoy affordable plans that are tailored to suit their needs. To accommodate the elderly, Humana Gold Plus Plan provides all the benefits of Medicare plus preventive services, coverage for routine doctor visits and hospital stays, worldwide emergency coverage, dental care, hearing tests, hearing aids, prescription drugs, eye exams, and eye wear with no deductibles.



GETTING THE BEST CARE

Doctors Hospital is a full-service, 268-bed, acute-care facility with three medical office buildings where patients in East Dallas and surrounding areas are provided advanced medical technology through in patient care and out-patient treatment. The more than 400 physicians practicing at the hospital specialize in cardiology, family practice, internal medicine, obstetrics and gynecology, oncology, ophthalmology, orthopedics, psychiatry surgery, among other things.

“Doctors Hospital offers the unique ness of being a full-service hospital with the latest technological advancements, yet our focus as a community hospital helps ensure that our patients receive personalized care in a convenient, customer-oriented manner,” says Steve Lagrone, director of business development at Doctors Hospital. The facility caters to the community by providing necessities such as a 24-hour emergency room, a home health care service, and a pain treatment clinic.

Columbia is one of the nations largest and fastest-growing health care organizations. The Columbia Healthcare Network of North Texas brings 17 different hospitals, eight out-patient surgery centers and the Columbia Homecare Group together with a common goal: to serve the medical needs of the 4.7 million Texans who live in the Dallas-Fort Worth area. The fully integrated system is comprised of more than 16,500 highly skilled physicians in 40-plus medical specialties, 17 state-of-the-art medical centers, eight out-patient centers, surgery centers, and three senior care centers. Colombia’s extensive network of outstanding primary and tertiary health centers assures convenient access to a range of services from routine office visits and diagnostic outpatient services to the most complex surgical procedures. One of their tertiary hospitals, Medical City Dallas Hospital, is rated one of the 100 Top Performing Hospitals in the country by the 1995 100 Top Hospitals “Benchmarks for Success” study conducted by HCIA and Mercer Consulting.

Services provided through Columbia Healthcare ] Network of North Texas include transfiants, women’s health, cardiology, oncolcgy, sports medicine, pediatrics, neurosurgery, and plastic surgery. Also available is the Columbia One Critical Care Team consisting of approximately 12 specially trained Critical Care paramedics and three pilots who handle the adult transports. Facilities of the Columbia Healthcare Network of North Texas include Medical City Dallas, Columbia Children’s Hospital at Medical City Dallas, Columbia Medical Plaza of Fort Worth, and medical centers in Lewisville, Las Colinas, Piano, Terrell, McKinney, Arlington, and Lancaster.

Columbia is helping refine today’s health care with OneSource, a division focused on the successful coordination and implementation of managed care plans. “OneSource strives to be the most comprehensive, cost-effective, quality-driven provider-sponsored health care network available,” says Tim Neil, Senior Vice President of OneSource Health Network-Central Group.

RHD Memorial Medical Center, which includes a 323-bed, medical/surgical hospital and three medical professional buildings in Farmers Branch, has the resources necessary to accommodate their primary focus: care for the entire family, With a medical staff of more than 450 affiliated physicians representing 35 specialties,

RHD has a wealth of advanced medical capabilities including open-heart surgery, new laser and minimally invasive surgery, trauma emergency care, and physical therapy, Their comprehensive cardiology program includes cardiac catheterization, angioplasty, open heart surgery, and cardiac rehabilitation. RHD patients also have access to obstetrics, medical and surgical intensive care, oncology, and orthopedics.

Other clinical specialties and services include imaging services such as Magnetic Resonance Imaging (MRI), Computerized Tomography by Cat Scan, Mammography, and Ultrasound. RHD’s Continent Ostomy Center reflects the medical center’s goal to be a leader in providing the latest in technology coupled with a community of concerned, dedicated professionals. “As long as the community continues to grow and change, we will strive to do the same. An example is with our new out-patient center opening in November,” said Shannon Fries, director of marketing for RHD.

Dallas is home to one of the nation’s top-ranked pediatric hospitals. A private, nonprofit organization, Children’s Med-ical Center is the only facility in Dallas that deals exclusively with the diseases and disorders that affect children from birth to age 18. The 322-bed facility provides a wide spectrum of pediatric care with a trauma unit, an advanced life support intensive care unit, diagnostic services such as radiology and nuclear medicine, and nearly 50 specialty clinics and programs. In addition, Children’s Medical Center offers extensive out-patient services to children suffering from asthma, cancer, cystic fibrosis, diabetes, epilepsy, hemophilia, and sleep disorders.

“It’s important for parents to examine their health plans to ensure that they include preventive and primary care coverage as well as coverage for catastrophic and chronic illnesses,” says Brian Alford, director of marketing and public relations for Children’s Medical Center. Caring for trauma victims – as many as 30 pet day – is just one example of extensive care available at Children’s.

Children’s Medical Center has proved its dedication to making life better for children by providing excellent care, regardless of families’ ability to pay. During the past five years, the hospital has provided children with approximately $200 million in uncompensated care.

Dallas/Fort Worth enjoys a stellar combination of medical experts, organizations, facilities, and providers. This wealth of options promises a future of better care for everyone and gives us every reason to embrace, rather than resist, managed care.