by Trish Ratto
As recently as five years ago, open enrollment time came and went pretty painlessly. Today, we must re-evaluate our health plan choices annually. Several factors may all contribute to the final choice: amount of the employee-paid contribution, amount of copayments and deductibles, accessibility of your doctor, anticipating your health needs in the coming year. As managed care is turning the art and science of healing into a commodity, the latest trends in health care are also important to factor into this year's open enrollment decisions.
Understanding Managed Care
The world of managed care employs a variety of techniques to keep costs down and profits up. Under the health maintenance organization's (HMO) "capitation" system, the physicians receive a fixed sum of money per patient. The doctors carry the risk of administering care within that sum of money. In some cases, if they spend too much on care, they lose money.
Physician Ann Weissman, a Health Net provider with the University Health Services, feels this is creating an atmosphere of insecurity.
"Patients fear they will be denied care. Doctors fear the quality of care may be compromised."
On the positive side, patients benefit from the convenience of receiving more care from their primary care physician directly before being sent to a specialist. This can also mean your doctor is managing your overall care better. On the flip side, physicians need to see more patients to make a living. This leads to shorter visits and more care delivered over the phone.
Medical Groups Downsizing
Another way some HMOs control costs is to limit the number of physicians in the medical group, says Weissman. "This is a significant change, as it means your doctor may be accessible through only one medical group."
Weissman recommends you speak directly with your primary care physician choice about which health insurance plan and medical group the physician plans to stay with and prefers to work with.
"Even though our UC health benefits package is standardized, the insurance company delegates much of the administration of the plan to the medical group. Some medical groups are more flexible than others."
Also, adds Weissman, medical groups maintain their own panel of specialists. If you anticipate referrals to specific specialists next year, explore their accessibility as well.
Health Plan Report Cards
The San Francisco Chronicle's Sept. 23 business section provided a comprehensive, up-to-date series of articles on today's health care system. Of particular note is one article covering another important trend -- making public the results of "report cards" on how well the plans are doing. "Many patients are satisfied with their physicians," says Weissman, "but these report cards often do not clearly distinguish between satisfaction with care from your doctor and satisfaction with the health plan administration."
The August and October 1996 issues of "Consumer Reports" also covered managed care. It may be no surprise that Consumer Reports, using their own criteria, found the highest rated plans were non-profit. They hypothesized that non-profits still cling to a sense of mission that goes beyond the bottom line.
What You Can Do
Do your homework. Select the type of health insurance -- HMO, fee-for-service or the combination plan -- that meets your anticipated needs. Within the limits of what out-of-pocket expenses you can reasonably afford, try to find the plan with the most flexibility. Establish a relationship with your primary care physician so the physician can go to bat for you, if needed. Learn to work within the system. Bone up on your medical needs to empower yourself to ask questions, work with your doctor and make informed decisions.
For More Help . . .
"Educational Materials: Health Insurance Decisions," a primer on identifying health and mental health needs, is available from Health* Matters at 643-4646, on the Internet at http://www.uhs.berkeley.edu and at the Open Enrollment Fair, Nov. 15, 9 a.m. to 3 p.m., Tan Oak Room, MLK Student Union.
Copies of the San Francisco Chronicle series and Consumer Reports articles are available for review in the Self-Care Resource Center, Tang Center, 11 a.m. to 4 p.m., Monday through Friday.
Trish Ratto, RD, is manager of Health*Matters and University Health Services editor of Health Beat.