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Facing the Realities of Managed Care and HMOs

Bill, 55, was repairing his roof on a Saturday afternoon when he fell, sustaining a C4 spinal cord injury. He was rushed to the hospital and had surgery. Afterward, while he lay in the intensive care unit, a hospital representative informed him that his medical insurance would only cover 30 days of inpatient Rehabilitation, and would not cover rehabilitation in the hospital of his choice.

Bill found this difficult to believe. After all, he had paid high premiums for over 20 years to ensure that he and his family were covered by a large, reputable company. His doctors were recommending a rehabilitation stay of 8-12 weeks at a facility with special expertise in Cervical spinal cord injury.

Unfortunately, Bill’s options were limited. He could choose a different rehabilitation facility from the one dictated by his insurance and receive no insurance coverage at all for his rehabilitation; he could go to the designated facility and leave after 30 days, which would probably mean transferring to a skilled nursing facility; or he could remain hospitalized longer than 30 days at his own expense and wipe out his life savings. His wheelchair and other durable medical equipment choices were also limited because he had to use a vendor that had a contract with his managed care organization.

Situations like Bill’s are becoming more common as managed care systems enter the mainstream of American health care and dictate how persons with SCI are medically managed.

What is Managed Care?

Managed care is an organized system of health care coverage that includes a range of integrated services, facilities, and products. It developed out of a need for cost containment in health care. Health maintenance organizations (HMOs) are perhaps the best known examples of managed care systems.

In the not-so-distant past, insurance policies were purchased or received as a benefit from employment, and covered nearly all health care contingencies. Times have changed. With the soaring cost of health care, those all-inclusive policies with no limitations or caps are becoming a thing of the past. Many policies now exclude durable medical equipment and nursing home benefits, and inpatient rehabilitation benefits have been drastically cut or eliminated.

Managed-care plans and HMOs do lower costs, focus on preventive care, and encourage coordinated care through a primary care physician. But problems arise when these plans restrict persons with special conditions, such as SCI, from seeing specialists who have expertise in their condition. Shorter Acute rehabilitation stays, another managed-care trend, force persons with new injuries to try to cope with their physical Disability, learn how to manage their SCI, and come to terms with the related emotional issues in a much shorter time-a juggling act that is all but impossible. Often, patient stays are approved on a week-by-week basis, leaving both the patient and the rehabilitation staff uncertain about long-range treatment planning.

It is a given that our health care system is moving in the direction of managed care, due to the rising cost of medical care and the need for third-party payers to maximize profits. And it is a given that we will all be affected by it sooner or later.

Be a Good Consumer

A small but growing number of people with disabilities are enrolled in managed care plans. Washington state is already using this type of delivery system with Medicaid, and it is likely that Medicare will soon follow. Consumers should be aware that not all plans cover medical rehabilitation services.

If you are presently covered by a managed care plan, make it a priority to find out what your policy does and does not include. The National Health Council and the National Patient Empowerment Council suggest you ask the following questions before enrolling in a managed care plan or HMO:

  • Can I have as my primary care doctor a Physiatrist or other specialist knowledgeable about medical rehabilitation?
  • Can I see a doctor outside the plan? If so, is there a fee?
  • Do I have to pay extra if I want a second opinion?
  • What hospitals does the plan use?
  • Does the plan provide the full range of medically necessary services for people with SCI and other severe disabilities, including home-based rehabilitation?
  • Is durable medical equipment (e.g., wheelchairs, walkers, bathroom equipment) covered?
  • Does the plan cover post-hospitalization nursing home and home care?
  • Does the plan cover prescription medications?
  • Does the plan cover experimental treatments?
  • Is there a co-pay per doctor visit?
  • What is the deductible?
  • Is there a lifetime maximum coverage per person?

If your plan is deficient in one or more of these areas, you might consider purchasing an additional major medical policy with a high deductible amount (such as $1,000-$2,000). These offer relatively low-cost protection against financial devastation by an unexpected illness or injury.

One vital question that has not yet been answered is whether managed care organizations and HMOs can meet the unique and challenging needs of people with SCI without sacrificing quality of care in favor of cost containment and short hospital stays. Only time will tell us the answer. Meanwhile, it’s up to every consumer of SCI health care services to be informed about his/her health care coverage. Knowing the facts about your individual health care policy, managed care or not, will make you your own best advocate in navigating through the health care system.

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