For many of us, making health care decisions in the 90s can seem as puzzling as mastering the Rubik’s Cube of the 80s. But putting the puzzle together step by step can take some of the frustration out of the process. These steps include selecting a health plan, choosing a primary care provider, and maximizing your time at office visits.
Women face a number of challenges and opportunities in the health insurance marketplace. On one hand, the increasing realization that women make tthe majority of health care choices for themselves and their families, as well as for some companies, has stimulated insurance organizations and health care providers to market special services and products to women, such as “well-woman visits”, enhanced obstetrical facilities, and women’s health centers. On the other hand, not all benefit plans are created equal or treat men and women equally. Cancer screening, family planning, or abortion services may not be covered by certain policies. Some insurance plans may impose a 9 month waiting period for prenatal care and maternity coverage. Shortened stays in hospitals after the delivery of a baby, known as “drive through deliveries”, have caused concern for women and their newborns and prompted recent legislative action . In 1995, 8 out of 16 insurance companies surveyed admitted that they denied coverage or increased the cost of premium to victims of domestic violence, the vast majority of which are women (recent legislation makes this practice illegal in California).
The key is looking past the label, whether it be HMO, PPO or fee-for service, and instead, inspecting the ingredients. For most women, obtaining optimal care depends on two factors: selecting an appropriate health plan that meets your current requirements and choosing a primary care physician who understands your unique health care needs. And even if these choices have already been made for you, once you get to the physician’s office, you can still maximize your care if you take some time to prepare.
SELECTING A HEALTH PLAN
All health plans are not alike, just as all women are not alike. Individiual medical history , health needs, and risk profile should be taken into consideration when reviewing benefits. For many women, their health needs may be grouped into the “Four M’s” : Maintenance and Preventive Services, Maternity and Reproductive Health Needs, Menopause and Chronic Conditions, and Mental Health. The following is a list of questions you might consider when reviewing an insurance plan. No plan can provide everything, so your decision will depend on what your current needs, future plans, and priorities are. And remember, once you’ve picked a plan, it’s just as important to know what’s not covered, as well as what is, so that you can make an informed choice and so you won’t be stuck with any unexpected charges.
Maintenance and Preventive Serices.
What types of preventive health services are offered? Are Pap smears, mammograms and “well-woman” exams, and immunizations fully covered? If so, how often? Does the plan allow for routine cholesterol and colon-cancer screenings? Are you entitled to a physical on a routine basis?
Maternity and Reproductive Health Services.
Does the plan cover, and to what extent, all forms of contraception, including oral or injectable contraceptives, tubal ligation, and devices such as diaphragms and IUDS? Is there a waiting period before maternity benefits can begin? Can you request a private room? Will the delivery be covered if it occurs outside of the provider’s area? How many days may the mother and baby remain hospitalized following delivery? How soon must you notify your provider about a newborn or adopted child? Is infertility treatment covered? To what extent? Does the plan pay for in vitro fertilization? Are abortions covered? Can you choose your own OB/GYN physician?
Menopause and Chronic Conditions.
To what extent are outpatient visits covered? If so, is there a co-payment? Is there a prescription plan? Are educational programs available? How do you access specialty care? Is there a referral process? How does that referral process work?
Does your insurance cover mental health care services? Is there a maximum number of outpatient visits allowed? If so, what’s your out-of-pocket expense for exceeding that limit? Can you continue seeing your own therapist? Does the plan have its own panel of therapiists? How are patients evaluated and referred? Does the plan cover treatment programs for substance abuse? If so, how often can you attend? Must you complete a chemical dependency program to receive full benefits?
In addition to meeting your health needs, aim for meeting your financial needs. If you have the freedom to select your own plan, would you prefer a higher annual deductible to lower monthly premiums? Do you want to be responsible for co-payments upon each visit? If you require medication on a regular basis, can you save money by requesting a generic prescription as opposed to a brand-name prescription?
It’s also important to know who to call. Get as much information from your benefits advisor, as well as printed materials. Find out from the insurance company who to call to clarifiy benefits, to handle disputes, or to answer general questions.. You may want to call theses numbers before signing up, just to “try out” the system.
THE PRIMARY CARE PROVIDER
Cost aside, many women feel they have limited choices when covered under their spouse’s or employer’s designated health care provider. Not so. Women can still play an active role in their care by carefully selecting a primary care physician (PCP), generally an internist or family practitioner. Most managed care plans require you to choose a PCP, but even if it’s not a requirement, a good primary care physician can provide continuity and comprehensive health care. Selecting a PCP who understands your specific needs is as important as selecting a comprehensive health care plan.
In today’s managed care environment, a trusted PCP can be an invaluable resource. Seen by some as the “gatekeepers” of the health care system who have the power to deny desired referrals and expensive testing, others choose to view them as individuals responsible for coordinating and managing patient care. Regardless, they are an integral piece in the managed-care puzzle. As a result, resist from opening the massive member directory book and dropping your finger on any physician’s name. Instead, consider the following questions before selecting your PCP:
Is the PCP board certified or board eligible? (Note: Most insurance companies contract with only these types of physicians). At what hospital(s) is the PCP affiliated? If he or she is affiliated with more than one, are you able to select the hospital of your choice? Is the PCP’s office conveniently located by your home and/or office? How does he or she handle after-hour calls or emergencies?
Unfortunately, most physicians can’t meet with every individual who is interested in becoming a new patient and most working women don’t have the extra time to schedule such meetings, either. However, you can probably obtain more information by scheduling a regular appointment and assessing the following: Is it difficult to schedule an appointment? How long must you wait before receiving an appointment? Did the reception and nursing staffs seem friendly and knowledgeable? Were the waiting and examination rooms clean? Were books and games available for your children if they accompanied you? Did you feel comfortable discussing personal issues and concerns with the PCP? Did he or she seem rushed during the appointment? Was the doctor familiar with your existing health problems and knowledgeable about the treatments currently available?
What do you do if your current physician does not participate in your new insurance plan? Replacing the physician who has treated your every ache and pain with an unknown physician simply because he or she is “in the book” can be difficult, however, many people are quick to assume that with new health care coverage comes new physicians, when in fact, that is not the case. Therefore, before hunting for a new PCP, check to see if your insurance plan will allow you to continue seeing your current physician. If so, you’re home free. If you do have to make a change, ask your original physician to supply your new PCP with your current medical records and a summary of your health history.
HOW TO MAKE THE MOST OF YOUR OFFICE VISIT
The reality for many physicians is that there are more patients to see in less time. Sometimes emergencies arise that have to take priority, or sick patients have to be squeezed in to an already busy schedule. But there are steps you can take to maximize the time you have with your physician.
Be on time. You may want to call ahead to see if your physician is running on time. If so, being on time maximizes your chances of having more time with your hysician..
Be prepared to present the PCP with a list of symptoms or concerns. Share the entire list at the beginning of your visit with the physician so that the list can be prioritized in case there isn’t enough time to address everything in one session. You may think the foot pain you’re experiencing should be the focal point of your visit, whereas the physician may feel your bouts with shortness of breath should get the attention first. You may not get to everything in a single seesion, , but by sharing your list at the beginning you will enable the physician to address the most pressing medical problems..
Make a additional appointments for consultation. If you find you’d like to have an in-depth discussion with about a certain aspect of your care, such as the pros and cons of hormone replacement therapy, you may want to consider scheduling an additional appointment to speak specifically about that issue. Ask if there are any educational materials or literature that you can read before the next visit. When you return, be prepared, having familiarized yourself with the subject and presenting a list of questions and concerns.
Often times, it can feel as if we have little or no control over such a significant aspect of our lives — our health care. Hopefully , you now can see that there are many steps you can take to optimize your care.
Mitzi R. Krockover, MD is Assisant Professor of Clinical Medicine, UCLA School of Medicine, and Medical Director of the Iris Cantor-UCLA Women’s Health Center, which integrates primary women’s health care with research and education.