Issue date: Nov 7, 1999

Make managed care work for you
A new book, Outsmarting Managed Care, gives an insider's view of how to maneuver within the system to get the care you need.

By Kathy Balog

lose to 90% of Americans with health insurance are covered by HMOs and other managed-care plans. Arguments over benefits -- which doctors you may use, what procedures are covered -- pit patients' rights against cost management. That clash recently led Congress to pass two versions of a "patients' bill of rights," but any real relief is far off.

In the meantime, you can learn to circumvent the present system, Bruce Barron writes in his new book, Outsmarting Managed Care (Times Books, $15). Barron is an ob-gyn and associate professor at New York's Columbia-Presbyterian Medical Center who also did a stint as a medical director of one of the nation's biggest insurers.

Do the legwork before you get sick. "Know what your coverage is," Barron says. "The system is designed to frustrate you, so you must ask questions and find out what it will provide." Read the fine print in your plan options. That task can be daunting: Aetna U.S. Healthcare, the largest health insurer, receives 650,000 medical claims and 250,000 calls a day. But persistence in gathering information on your own can pay off.

Doctors.
Choose competence over personality. "You want somebody who knows how to take care of the problem." Check credentials by calling the supervising board certifier. Graduates of U.S. medical schools who work with university-based hospitals are preferred. "Doctors are not created equal. Don't just trust the booklet you get."

Care.
If coverage is denied, "climb the hierarchy," Barron says. Enlist your doctor's vocal support. "The more demanding you are, the greater the likelihood you'll get answers." Remember that the people making decisions usually aren't medical experts.

If you are hospitalized ...

Schedule operations early in the week; avoid Fridays, when hospitals normally cut back on staffing. "You can shoot a cannon on the weekend and not hit a doctor," Barron says.

Don't pick a hospital on the basis of how close it is to home. Look instead for a facility with a strong department in your area of concern (cardiac care, renal specialities, etc).

Record the name of everyone you speak to about billing disputes. Deal directly with the accounting department.

Know that hospitals use sliding-fee scales: Uninsured patients pay top dollar; insured patients are charged less, depending on their plan. So bargain, Barron says. "It's not like walking into a restaurant and offering $12.50 for a menu item that costs $15."