HMOverdose

THE BALTIMORE SUN

I didn't want to join a managed-care plan. I loved my Blue Cross-Blue Shield plan, but it didn't love my employer and dropped us like a hot potato one year when "not enough" employees had chosen it. So I got stuck in Tufts Associated Health Plan. It was the only one of the choices my employer offered that would let me stay with the two doctors I had seen for years.

I'm not sick, fortunately. I have routine and relatively trivial ailments, and one not-serious chronic problem for which I take a daily pill. I've gradually discovered what all those managed-care advocates mean when they say managed-care plans are more efficient and cut out unnecessary expenditures. They mean they shift their costs onto me and my doctors. They mean I get less care, but that's OK because the decrease doesn't show up in their accounting systems. On paper they look great.

For my chronic problem, I get checked out twice a year by a specialist to make sure that nothing's changed and that I'm still tolerating the medication without untoward side effects. But since I was forced into Tufts, neither my specialist nor I can decide whether and when I should have a checkup. Only my internist, the person Tufts calls my primary-care provider but who is also its gatekeeper, can authorize a visit to the specialist. If these are to be covered, I have to seek a "referral" from Dr. Gatekeeper. Three years ago that was a nuisance, but still relatively easy. Dr. Gatekeeper handed me a referral form, good for three visits with Dr. Specialist.

But things got more complicated. Tufts said a referral form was good only for three months. I don't need specialist visits often -- only every four or six months. So I started having to procure one of those forms for each visit to the specialist. At first, I could get a form with a phone call to Dr. Gatekeeper's office, but his staff got swamped with all this paperwork and asked me to send a written request with a stamped envelope addressed to the specialist, or I could come in and pick up the form. The little costs to me of Tufts' cost-saving strategies were starting to add up. I can't begin to calculate the costs to Dr. Gatekeeper as more of this and his staff's time went to referral paperwork.

Then there was the matter of my once-a-day pill. Last year I went abroad for two months and wanted a 60-day supply of pills to take along. But when my pharmacist tried to fill the prescription and bill it to Tufts, Tufts denied the request, saying it allows only a one-month supply, and will not pay for another refill until 28 days have elapsed. I contacted Tufts, explaining my situation. I got an unhelped response: Sorry, we can't bend our rules, but you can pay for your second-month stock now and file for reimbursement later. More time and money costs to me.

Once I learned of the one-month supply rule, I couldn't help but notice how it creates lots of waste, too. My pharmacist has to take the time to prepare 12 labels in a year, fill 12 bottles and file 12 claims, when she could just as well give me a year's supply, were it not for Tufts' cost-saving rule. She has to use 12 plastic bottles and caps, instead of one large one. I have to make 12 trips to the pharmacy. Does anybody think these costs are counted when the economists and health plans tote up all the savings from efficiency and good management in managed care?

Recently I hurt my knee and needed physical therapy. It was a specialist who examined me and prescribed physical therapy, but in order for my insurance to cover the treatment, I had to have a referral from Dr. Gatekeeper. Since I've rarely managed to procure a referral with fewer than two phone calls to the internist's office, I expected delays. So I went directly from my specialist to Dr. Gatekeeper's office, prescription for physical therapy in hand, to collect the precious referral. A clerk looked at the prescription (three times a week for three weeks, it said), filled out a form and told me she would have Dr. Gatekeeper sign it and would mail it to the physical therapist.

By the time of my third physical-therapy visit, the referral still hadn't arrived. I called Dr. Gatekeeper's office. The physical therapist's office called. Eventually a referral came, but it authorized only three visits. Meanwhile, the physical therapist, in self-defense born of experience, was having me sign an agreement before she treated me each time, saying I would be financially responsible for the services should my insurance not pay.

It turns out that the maximum number of visits Dr. Gatekeeper can authorize on one referral form is six. I'm way behind. I've already had seven visits, only three of which have been authorized, and I clearly need lots more.

So I called Dr. Gatekeeper's office once more to try to secure more referrals for more visits. This time, I was told that they now have a special telephone number for referral requests. I called the number, only to get a lengthy recording, reeling off at least 10 items of information I was supposed to leave if I wanted a prescription refill and then another 10 or so items of information if I wanted a referral.

I furiously scribbled notes, fished for my insurance card in my wallet and left the information. No referral has shown up at the physical therapist's office. I'm still liable for the payment. The bureaucratic snafus are getting deeper and deeper, and I can't talk to a real person in my internist's office anymore.

Meanwhile, Dr. Gatekeeper is paying the cost of an additional telephone line and perhaps an additional person to staff it. All his patients are paying the additional time cost of having to listen to a long recording and probably having to make a second phone call because they can't remember all the details they are supposed to provide. The physical therapist is out money because she can't get reimbursed until my referral forms show up. I may be out of money, if Dr. Gatekeeper's staff doesn't understand my recorded message or forgets to backdate the referral forms to cover the visits I've already had.

One day, while she was pushing and poking at my knee, the therapist explained to me how insurance has kept her payments so low that she has had to cut back each treatment session from an hour to 45 minutes In effect, while Tufts and other managed-care plans are bragging about how they are providing more care for less money, their members are getting less care for more money and more lost time.

What's happening is a massive substitution of paperwork for medical treatment and a massive shifting of the new costs of paperwork and monitoring onto patients and medical personnel. Since these are not highly visible cutbacks, like insurer refusals to pay for expensive cancer treatments or transplant operations, our politicians and policy makers aren't even noticing. While the managed-care plans and other insurers tell us how private enterprise and the competitive spirit are preserving the world's greatest health system and keeping us safe from bureaucracy, we patients are getting taken to the cleaners.

This article is reprinted from The New Republic.

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