Health Care Systems

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Health Care Systems

The issue of health care and health care reform is a topic of growing debate in the United States. Health care touches everyone. There are families who worry about their children and aging relatives; employers who must provide health insurance to their employees and the employees who need the benefits. In addition, there are the government officials and politicians who are concerned about the rising cost of health care; and, of course, the hospitals and doctors who are responsible for delivering health care.

Having adequate health care is extremely important to people. Even successful medical treatment can involve pain, anxiety, risk, and, inevitably, lots of money. The last thing a patient in a hospital wants to think about is "how am I going to pay for all of this?" Ideally, instead of worrying about money, a patient should be concentrating on getting well. However, the whole subject of health insurance can be mystifying. Very often people do not fully understand their health insurance plans, and many people have run into problems because of their lack of understanding.

This chapter is a starting point for becoming an informed health care consumer by providing valuable information to be used in making health care decisions. When confronted with choices about doctors, specialists, health care plans, and hospitals, a consumer needs to be empowered with the information to make affordable and effective decisions.

This chapter will cover the basics of health care, including information about the health care system in America and in other countries; the different kinds of health insurance; Medicare and Medicaid; and how to navigate the world of health insurance under many different conditions, in sickness and in health.


The United States health care system encompasses everyone and everything from the individual who is sick and in need of care, the clinic doctor who sees homeless people and families with no health insurance, to the hospital surgeon who performs state-of-the-art surgeries for thousands of dollars. It also includes executives and other business people who make decisions about health care that influence millions of people, and government officials who are desperate to reform (improve) health care. Health care is as small as the most personal and intimate choices people make about their own health and as big as multi-million-dollar business decisions and local, state, and federal policy-making. The U.S. health care system includes everyone who needs health care and everyone who delivers health care, which means that everyone is affected by health care.

Health Care Systems: Words to Know

A person who supports or defends a cause or a proposal.
To take a court's decision and have another higher court review it to either uphold or overturn the first decision.
An agreement between doctor and managed care organization wherein the doctor is paid per person.
Carve out:
Medical services, such as substance abuse treatment, that are separated from the rest of the services within a health care plan.
Chronic condition:
A condition that lasts a long time or occurs over and over again. Chronic conditions can be treated but not cured.
Clinical trial:
An investigation into new treatment methods for a specific disease or condition.
A fixed amount of money that patients pay for each doctor's visit and for each prescription.
Proof that a person is qualified to do a job.
The amount of money a patient must pay for services covered by the insurance company before the plan will pay for any medical bills.
A process in which doctors use medication to reduce or eliminate drugs or alcohol from a person's body.
The unexpected onset of a serious medical condition or life-threatening injury that requires immediate attention.
When a doctor or hospital is paid for each service performed.
A list of prescription drugs preferred by the health plan for its members.
Generic drug:
Drugs that are approved by the Food and Drug Administration but do not go by specific brand names and therefore are less expensive than brand name drugs.
Indemnity plan:
A plan in which the insurance company sets a standard amount that it will pay for specific medical services.
The joint state-federal health care program for low-income people.
The federal health insurance program for senior citizens.
Private insurance that helps pay for some of the costs involved in Medicare.
National health care system:
A system in which the government provides medical care to all its citizens.
Off-label drug:
A drug that is not formally approved by the Food and Drug Administration but is approved for legal use in some medical treatments.
Point of service:
A health plan in which members can see the doctor of their choosing at the time they need to see a doctor.
Preferred provider organization:
A health plan in which members have their health care paid for only when they choose from a network of doctors and hospitals.
Consideration paid for a contract of insurance.
Preventative care:
Medical care that helps to maintain one's health, such as regular checkups.
Primary care physician:
The doctor who is responsible for the total care of a patient and has the ability to refer patients to other doctors or specialists.
The process of limiting certain products or services because of a shortage.
Permission from the primary care physician to see another doctor.
Reimbursement plan:
A plan where a patient must pay for medical services up front and then get paid back from the insurance company.
Social Security:
A government program that provides economic security to people.
A doctor who concentrates on only one area of medicine, such as a dermatologist (skin specialist).

The United States has the most advanced medical care in the world. Most Americans receive health care that is adequate, or even excellent, under the current system. However, there are many problems with the health care system in the United States. For those Americans who are insured because they can afford private health insurance or they receive health insurance through their employers, the current health care system usually works. However, more than thirty-seven million Americans do not have health insurance. Some of the uninsured people work for companies that do not provide health insurance, and some are denied medical insurance because they suffer from previous medical conditions. Others are unemployed or cannot afford private insurance, but they may not be poor enough to qualify for government assistance.

Most people without health insurance cannot afford preventative caresuch as regular physicals or immunizationswhich helps maintain one's health. As a result, small health problems can develop into big health problems, and many of the uninsured are left with no choice but to seek treatment in hospital emergency rooms, which is extremely costly for hospitals. If patients cannot pay for their care, the hospitals must either absorb the loss or pass the cost on to paying patients as costs rise for everything from doctors' services to aspirin. Sometimes hospitals turn away uninsured patients to avoid the expense of treating them. (When there is a medical emergency, however, it is illegal for hospitals to turn away uninsured patients.)


In recent years, health insurance has become big business and competition between health care providers is fierce. As a result, the price of health insurance has gone up, even while the coverage of services and treatments has become more limited and restricted. The costs for health care in America are the highest in the world. Most Americans agree that health care costs must be controlled, but few agree on how to control the costs. Many reforms have been proposed, from minor improvements to broad sweeping changes. Health insurance and health care are at the center of a nationwide debate: how can America make health care more widely available to everyone and also control costs?


A common misconception surrounding the health care debate in the United States is that many other countries have already figured out the answers, and that all America has to do is replicate a foreign health care system and the problems will be solved. There are accounts of how everyone in Canada gets top quality medical care at reasonable costs. Germany and Britain are held up as examples of countries with effective health care systems. How is it that America spends more on health care than every other country and still does not manage to provide coverage for all its citizens?

There is no question that the United States can learn from the experiences of other countries, but there are no easy answers. Building a national health policy is tied closely to the values and priorities of the nation.

Canada, for example, has a national health system called Medicare, which covers all of its citizens. The Canadian government finances Medicare by raising people's taxes. All medical bills go to the government for reimbursement, so much of the paperwork is eliminated. Canada's health system is the second most expensive in the world, after the United States. Canadians pay about ten percent of their income for this universal insurance. People can choose their own doctors and see any specialists needed. The range of services is broad and fair because every personrich or pooris treated the same.

Canada makes this system work by imposing price controls on doctors and hospitals and keeping to a strict budget. The Canadian system is fair, but is it working? Business leaders say that the high tax rates are negatively affecting economic growth and employment rates in Canada. The tight budget also means that patients often have a lengthy wait for the care they need. Minor procedures and operations are often not available until the problem has become serious or even life threatening. As a result of these problems, benefits are starting to be reduced, and doctors are spending less time with patients (thirty percent less than American doctors). Even as American politicians are arguing that we should reform the U.S. health care system to be more like Canada's, Canadian politicians are urging the adoption of some of America's health care policies.

There are characteristics about foreign health systems to admire: universal coverage, lower costs, and free medical education. Every benefit, however, is balanced by a compromise, such as the limiting of choice and the rationing of services. Higher taxes, for example, help to pay for health care in countries like Germany.

Other countries have also pointed out that one reason for their lower health care costs is that the United States must treat different social problems that can become medical problems. For example, Americans pay for the high rates of teenage pregnancy, drug abuse, and violence. America also has a greater elderly population than many other countries. Both of these factors serve to increase costs for health care in the United States. It is hoped that the national debate over health care will help Americans decide what is right for the people.


Modern managed health care grew out of a desire to reform the traditional health care system, or the fee-for-service method of charging for health care.


Under the fee-for-service method, doctors and hospitals got paid for each service they performed. There were no limits on their treatment decisions; doctors or hospitals could order as many tests as they felt necessary, for example. Doctors and hospitals made a lot of money under this system because they decided the prices charged for every visit. However, patients did not always benefit because their insurance companies would often only pay a percentage of the fees being charged. For example, if a doctor charged $100 for a checkup, but the insurance company felt that $80 was a fair price, the patient would have to pay the extra $20, until a certain deductible was met. (A deductible is the amount of money, as determined by the health care plan, a patient must pay for services before the health care plan will pay for any medical bills.)

The different types of fee-for-service include indemnity plans and reimbursement plans. In an indemnity plan, the insurer sets an amount that it will pay for a specific medical service. In a reimbursement plan, the patient must pay all fees up front and then file claims to be reimbursed by the insurer. Fee-for-service health care is no longer widely in use. Most people today have some kind of managed care insurance.


Sometimes doctors reach an agreement with a managed care organization called capitation, wherein the doctor is paid per person. Under this agreement, doctors accept members of the plan for a certain set price per member, no matter how often the member sees the doctor. For example, the doctor may be paid $20.00 per member every month and that amount doesn't change if the member comes in for five appointments that month or none.

Managed Care

There are many kinds of managed care organizations, but there are some common characteristics among them. All managed care organizations supervise the financing of medical care delivered to members. They all are concerned with cost-effectiveness, or saving money. By buying services in bulk, for many members at a time, managed care organizations can get lower prices with doctors and hospitals. Managed care organizations also reduce costs by limiting choice, which means providing members with a list of doctors from which to choose and lists of labs where tests can be performed. Even doctors are provided with lists of medicines from which to choose. Different plans have different restrictions on choice. Many people feel that limited choices are the downside of managed care. Generally, a member can expand the possible choices if he or she is willing to pay more.

At the same time, managed care organizations take care of the delivery system for their members. For example, they manage who provides the health care, where it is provided, and the different kinds of doctors in their particular system. Nurses, doctors, therapists, pharmacists, and hospitals are all a part of the delivery system.


Managed care organizations make the primary care physician the core of health care delivery. Choosing a primary care physician is one of the most important choices in any managed care plan. The primary care physician is responsible for the total care of a member and may also act as a gatekeeper to additional medical services, which means the primary care physician is responsible for referring the patient to other doctors, or specialists. A specialist is a doctor who concentrates on only one area of medicine, such as a dermatologist (skin specialist) or cardiologist (heart specialist).

The first step in choosing a primary care physician is to look at the plan's list of approved physicians. Choosing just any doctor won't do; it is important to find a doctor whose style and approach to health care matches that of the patient. It's recommended that a person ask family and friends about doctors they have seen in the past and would recommend. They may be able to provide important information about how long it takes to get an appointment with a specific doctor or whether the doctor is understanding and easy to talk to. It is also appropriate to ask the insurance plan about the doctor's credentials and whether the plan has received any feedback on the doctor from patient surveys.

In making the final decision there are some other questions to consider:

  • Is the location of the doctor's office convenient?
  • What are the office hours? Does the office open early? Does the doctor make appointments after 5 p.m.? Does the doctor have Saturday hours?
  • Is the office clean and orderly? Is the office staff friendly and polite?
  • How do patients communicate with the doctor? Does the doctor have an answering service or voice mail where a patient can leave a message? Will a nurse return calls? Will someone return the call within twenty-four hours?

Making an interview appointment is one way to question the doctor. A phone interview can be sufficient if there is not time to make an appointment. If a patient has a chronic (frequently recurring) condition or special health care concerns, it is even more important to find a doctor with a similar approach to treatment and with experience in treating the specific condition.

Choosing a primary care physician is not a permanent choice. Patients can consult their plan handbook for instructions about how to change doctors. Some plans will limit the number of times one can change doctors within a year. Make sure to alert both the insurance plan and the doctor's office (so that patient records can be transferred) if changing doctors.

The Referral Process

Understanding the referral process is critical to navigating the managed care organization. Managed care organizations require patients to get a referral from the primary care physician (the doctor responsible for a patient's total health care) in order to see a specialist. A referral is like a permission slip from the primary care physician. It allows patients to seek treatment from a specialist when the primary care physician is unable to treat the patient's problem. This is one way to keep insurance costs down. Without a referral, the patient may be charged full price for any medical care received by a specialist. Plans deal with referrals in different ways. Certain regular health visits may not require a referral. For example, women can often see a gynecologist (doctors who specialize in treating the female reproductive system) without getting a referral from the primary care physician. The complexities of the referral process may be a factor in the choice of an insurance plan.

Types of Managed Health Care Plans

Managed health care is an alphabet soup of confusing abbreviations: HMOs, PPOs, POS. What do they all mean? Surprisingly, many people do not know.

HEALTH MAINTENANCE ORGANIZATIONS (HMO). HMOs were designed to provide one-stop-shopping for patients: everything a patient might need with no hidden costs. An individual or an employer pays for health coverage in advance by paying the health coverage premium (the amount paid for an insurance policy). Provided a patient stays within the plan, there will not be any additional costs except for copayments, if applicable.

Health maintenance organizations are called such because HMOs generally cover preventative care, such as yearly checkups and immunizations. HMOs have a self-interest in keeping people healthy because healthy people don't spend a lot of money on health care. HMOs want to promote preventive health care so problems are caught or stopped before they can start. HMOs also control the quality of health care for members. The majority of services must be pre-approved by the primary care physician. The referral process allows all service to be reviewed by the HMO for necessity, appropriateness, and cost.

Of course, there are good parts and bad parts of this system. Good HMOs use referrals to screen out bad or inappropriate medical practices. However, bad HMOs can use referrals to limit care that is really necessary for the health of the patient. One criticism of HMOs is that decisions about the necessity or appropriateness of care are made not by doctors but by business people who may care more about cost than quality of care.

There are several different kinds of HMOs. The two most common are staff model HMOs and independent practice associations (IPAs). The staff model HMO is the best example of the one-stop-shopping approach. The doctors, medical records, labs, and pharmacy are all housed within one location. Sometimes services may be off-site from the central location. Patients may have to go to another location to see a specialist, but the specialist must still work for the same HMO system.

IPAs are made up of doctors, both primary care physicians and specialists, who see plan members in their own offices, instead of under one roof. Doctors may participate in several different IPAs. One advantage to IPAs is that there may be a larger selection of doctors and specialists from which to choose than in a staff model HMO. It's necessary to weigh these advantages

against the convenience of the staff model HMO to make the best choice for oneself. Some people will have more choices than others. They will either ask their insurance company what kind of HMOs are available for them depending on what they can afford, or they will have to pick whatever their employers offer them.

There are several more types of HMOs, but the major difference among the types is in the details of the agreement made between the managed care organization and the doctors, such as patient access to doctors, referrals, and payment arrangements.

PREFERRED PROVIDER ORGANIZATION (PPO). A preferred provider organization is another kind of health plan in which members have their health care paid for only when they choose from a network of doctors and hospitals. The network is a group of health care providers who have contracts with the PPO. The health care providers agree to offer a discount rate to PPO members. The PPO coordinates referrals and reviews treatment recommendations from participating doctors. A PPO can offer more choice and flexibility in choosing a doctor than an HMO. However, if a member sees a doctor outside of the network, the member will be required to pay part, or all, of the fee.

POINT OF SERVICE (POS). A point of service plan offers the most choice to the individual by combining HMOs, PPOs, and more traditional health care plans. The member can choose at the time of each visit, or what's referred to as "the point of service," which doctor to see. For example, while a patient may choose to use a primary care physician from an HMO for a regular checkup, he or she may later decide to go out of network for another service, such as to a cardiologist, or heart specialist. Therefore, the patient chooses, each time there is a need for a doctor, who he or she is going to see. A POS plan has different levels of cost to the member. For example, a member can see a doctor in the HMO for no extra cost, a doctor in the PPO network for some out-of-pocket cost, or even go to a doctor outside of the HMO or PPO for a higher outof-pocket cost. The PPO may still require referrals from a primary care physician. Since plans vary, members should fully understand the costs and restrictions before visiting a doctor.


Carve outs are medical services that are separated from the rest of the services within a health care plan. These services are contracted for separately from all other medical services. Carve outs often include mental health and substance abuse treatment, dental and vision care, and pharmacy benefits. Some plans offer these services as a piece of their regular coverage while other plans "carve out" the services, and members choose whether or not the coverage is desired, for an additional premium cost. Specialty HMOs can be set up for one set of medical services, such as dental services. Specialty HMOs operate just like regular HMOs but may have different rules about referrals, so it's important to check out the requirements for making use of these benefits. Check out the fees for seeing specialty providers and the process for getting referrals. There may also be separate lists for participating physicians in specialty areas like counselors, therapists, and dentists.

MANAGED INDEMNITY. The managed indemnity is the final option for patients choosing fee-for-service plans. A member of a managed indemnity plan can choose to see any doctor. However, members must get prior approval for outpatient procedures and hospitalizations. Managed indemnity plans do not always cover preventative health care visits, and members sometimes have to file claim forms for certain services.

There are many kinds of managed health care organizations. Every managed care plan has rules for using its services, especially for referrals. These rules can be complicated but are important for an individual to understand when choosing a health care plan. The trick is to assess one's needs for health care and match those needs with the most accommodating managed care plan. A little homework early on can make for a productive relationship with the managed care organization.


Medicare is the federal health insurance program for senior citizens and for some younger individuals who are disabled. Nearly all Americans age sixty-five or older are covered under Medicare. Medicare is a component of the Social Security program, and anyone who is eligible for Social Security benefits will be automatically enrolled. (Social Security is a government program that provides financial assistance to senior citizens, the unemployed, or the disabled. Money is funneled into the program by a tax on employers and employees.)

This is not to say that health care choices become simpler for senior citizens. While Medicare has a great deal to offer, it does not cover all the medical care an individual will generally need.

Medicare has two parts. Medicare Part A is hospital insurance and applies to hospital costs, nursing facilities, psychiatric hospitals, and hospice care (care for the terminally ill). If an individual qualifies for Medicare, Part A is free of cost. If an individual does not automatically qualify for Medicare, Part A can be purchased for a monthly fee.


Medicare offers two programs for low-income people over age sixty-five and for the disabled. Under the Qualified Medicare Beneficiaries Program (QMB), people with incomes at or below the federal poverty level do not have to pay the standard Medicare copayments and deductibles. The poverty level varies by the size of the household and is updated every year. Savings and assets cannot exceed four thousand dollars for one person and six thousand dollars for a couple. The state picks up the Medicare costs for those individuals who qualify for QMB.

The Specified Low Income Medicare Beneficiary (SLMB) Program assists people with incomes at or near the poverty level. The SLMB program covers the costs for Medicare Part B.

For more information on these programs, contact the local Department of Social Services or Area Agency on Aging or call the Medicare Hotline at 1-800-683-6833.

Medicare Part B is medical insurance that covers certain doctors' fees, lab tests, X rays, many outpatient services, home health care, and in-home use of medical equipment. Individuals who qualify for Medicare are automatically enrolled in Part B unless it is declined. Part B has a monthly cost that will be deducted from a person's Social Security check.

Medicare pays for many health care expenses but not all of them. In particular, Medicare does not cover most nursing home care, long-term care in the home, routine foot care, most dental care or dentures, most immunization shots (except flu shots), most routine checkups and related tests, or prescription drugs outside the hospital. Many senior citizens will require services that Medicare does not cover. Medicare also requires copayments and deductibles for covered services, and these costs can add up over time.

To limit the risk of having to pay for medical services, a person should first always ask doctors if they accept Medicare. It's also important to ask if the doctors accept Medicare assignment. Medicare assignment is the amount of money that Medicare has designated for certain services. If the doctor does not agree with the amount of the Medicare assignment, then the doctor will bill the patients, who must then make up the difference with their own money. Finally, patients should ask their doctors if Medicare covers the services planned for their visits.


Medigap is private insurance that people buy to supplement Medicare. Medigap literally fills in the gap when Medicare doesn't pay for something, such as prescription drugs not used in a hospital. It also helps to pay for some of the extra costs that Medicare requires, such as copayments. Medigap should be seriously considered if the individual can afford the cost. In most states, there are ten Medigap programs from which to choose, labeled A through J. All insurers offering Medigap insurance are minimally required to offer plan A and can offer other plans at their discretion.


The ten Medigap plans vary significantly in their coverage of services and in their costs. As with all insurance, individuals should choose the plan that most fits their health care needs. In selecting a Medigap plan, one must remember that Medicare pays only for services determined to be medically necessary and only the amount determined to be reasonable. If Medicare won't pay for a specific service, chances are that Medigap won't either. As explained above, Medigap helps pay for outpatient prescription drugs or the copayments that go along with Medicare. It may not cover services that are not covered by Medicare, but it will help lessen the total costs of health care. The Medigap premium will depend either on an age-entry rating or an attainedage rating. Using an age-entry rating, the premium will be higher the older one is upon entering the plan, but does not change as one ages. Using an attained-age rating, the premium will increase every year.

Medicare and HMOs

Medicare normally operates on a fee-for-service basis. Patients are billed for each visit to a health care provider. In a growing number of places, though, HMOs are available to Medicare enrollees as well.

HMO coverage can be more comprehensive, and thus preferable, to a fee-for-service plan. However, HMOs require that members see only providers within the HMO network. A member who sees a doctor outside of the network is likely to pay more money.

HMOs provide many benefits to complement Medicare coverage: costs are low, there is no paperwork, and primary care physicians coordinate the care. On the downside, HMOs may limit services due to cost, members must get a referral in order to see a specialist, members must see doctors from a plan-approved list, and the health care is confined to a specific location. Senior citizens who spend the winter months away from home, for example, might find an HMO unsuitable because the plan does not cover their health care costs during that time.



While the health care system in the United States is considered among the best in the world, the number of people who do not have health care is still a major problem facing the country. One in every six people under the age of sixty-five, including many children, is uninsured. Medicaid is the joint state-federal health care program for low-income people. Medicaid also covers people who are chronically sick or disabled. Over thirty-six million people rely on Medicaid for health care.

Many states are adopting managed care, instead of fee-for-service, for Medicaid recipients. Roughly one in three people on Medicaid are in a managed care program. Medicaid is different in every state and the District of Columbia. The federal government dictates the rules by which states must run their Medicaid programs.


Sometimes the rules for a managed care plan are difficult for people receiving Medicaid. For example, one plan required all appointments to be made by phone. This would be a problem if a person didn't have a phone, or if a person spoke a different language and could not communicate over the phone. If people have problems with Medicaid or the managed care plan, they can and should make the complaints known to both the plan's members services department and the local or state social services department. Unless people speak up, those who are making the decisions may not even be aware that there's a problem.

Some states are now extending Medicaid benefits to low-income people who work and are not eligible for welfare. Many of these efforts are aimed at insuring children whose parents work but still cannot afford private insurance. Medicaid managed care is an option being offered to families around the country.

Having health care coverage under Medicaid does not automatically mean easy access to health care. Many low-income Medicaid recipients have had difficulty in finding local providers, because low-income neighborhoods are often underserved by the medical community. Because Medicaid also limits the amount it will pay for services and often pays below market rates, many doctors won't accept Medicaid patients. Medicaid patients traditionally are forced to rely on emergency rooms for primary care treatment.

Managed care can correct some of these problems for Medicaid beneficiaries. Once a person is enrolled in a managed care program through Medicaid, the act of searching for a provider is unnecessary. The managed care plan will provide a list of approved providers. Access to preventive care is increased through the use of a primary care physician. Managed care has also improved the range of benefits for Medicaid recipients in some states. Despite these benefits, Medicaid managed care is not without problems. Sometimes people get very little time to choose a managed care plan, and/or sometimes the state does not send out a list of providers when it is time to pick a managed care plan. If a person does not choose right away, he or she will be automatically enrolled in a plan. As a result, the providers could be far away and not accessible by public transportation. Also, if a person already has a relationship with a doctor, and the doctor is not a part of the managed care plan network, the continuity of care is interrupted. The transition to managed care for many Medicaid recipients has been less than smooth.


The key to handling emergencies smoothly is advance preparation. Whether a person has a raging fever in the middle of the night or falls and breaks an arm, some knowledge in advance will help ease a stressful situation.

It doesn't matter which health insurance plan a person chooses, reading the materials and familiarizing oneself with emergency procedures is a smart idea. Emergency care is often listed in a separate section in the member's handbook and will explain what to do in case of an emergency. Emergency situations often call for quick action. The more a person has done in advance, the more quickly decisions can be made.

Emergency Preparation

The following checklist includes some things to do to prepare for emergencies:

  • Leave a set of clear and simple instructions for emergencies and important telephone numbers near the phone for babysitters and family members.
  • Program the telephone speed dial with 911 and the health plan's advice line and urgent care line numbers.
  • Check out the health plan's policies for out of town or out of service area emergency care
  • Check into how to notify the health care plan in the event of hospitalization.
  • Keep the health care plan ID card close by, in a wallet or purse.

Emergency Care or Urgent Care?

A big part of the health insurance reform that led to managed care was the need to keep people from using the emergency room for everything except true emergency care. Treatment in the emergency room at a hospital is extremely costly. Managed care does not want members to use emergency rooms for non-emergency situations, such as the flu or an earache.

An emergency is defined as the unexpected onset of a serious condition or life-threatening injury that requires immediate medical treatment. An urgent condition needs treatment within twenty-four hours, in contrast with the immediacy of an emergency. An urgent condition can be treated by a primary care physician or at an urgent care clinic, if available. It is not always clear, however, whether a health problem is an emergency or an urgent care situation. Some managed care plans will cover only emergency care, if it turns out to have truly been an emergency. Whether or not the patient believed it was an emergency does not matter. Other managed care plans use the prudent lay person standard: the decision to seek emergency care will be covered if it is one that an average person with average medical knowledge would

make at the time. The decision of whether a condition is an emergency, urgent, or can wait for a regular appointment rests solely on the individual. Common sense is a good guide when all else fails.

If it's obviously an emergency, the person should call 911 (or other emergency numbers). If it is less clear and there is time, the person should call the plan's advice line, or urgent care line. When calling 911, the person should be prepared to describe:

  • ABCs: airways, breathing, and circulation. If any airways are obstructed, if breathing is abnormal or there is no breathing, and if a body part has gone numb or the person is turning blue.
  • Symptoms: where it hurts, how often, and if the person's temperature is abnormally high or low.
  • Chronology: when the symptoms started or when the accident occurred.
  • Vital extras: age of the patient, any medications being taken or allergies, chronic illnesses, and any special circumstances (such as what the person ate).

Generally, managed care plans will pay for treatment of emergencies at the nearest hospital. If a person does not have time to notify the plan in advance of hospitalization, it is important to call the plan on the following day or within twenty-four to forty-eight hours, depending on the plan.

If a person seeks emergency treatment and the plan denies coverage, the person can appeal that decision. In that case, the person should gather copies of documents and medical records from the hospital. If there were any other people present at the onset of the illness or when the accident occurred, the person appealing should get statements from these people.


Most people consider themselves healthy. However, the federal government has data to show that the average American has 1.7 conditions. This may sound surprising, but chronic conditions include hay fever, migraine headaches, and astigmatism that requires eyeglasses. Most people only consider more serious conditions to be chronic, like asthma, diabetes, arthritis, and heart problems. A chronic condition is any health problem that lasts a long time or recurs frequently. A chronic condition can be treated but cannot be completely cured.

The first step to ensuring excellent health care is to fully understand the chronic condition: When do attacks occur? How long do they last? What are minor symptoms vs. intense symptoms? What are successful treatments for the condition? Are there preventative measures that can be effective?



If a person is confronted with bad health news, it is imperative to get a second opinion on both the diagnosis of the health problem and the suggested course of treatment. Most conditions can wait for a patient to get a second, or even a third, opinion. The patient should choose an expert for the second opinion and should not be afraid to consider alternative options, especially when surgery is recommended as a part of the treatment. In fact, some health plans will require a second opinion before approving surgery. Plans may cover the expense of a second opinion if the patient uses another doctor within the same network. If the person feels strongly about seeing a doctor outside of the network, the expense may be worth it for one's peace of mind and well-being.

The second step is to find a health care plan that provides all the options and services to successfully treat the condition. Under managed care, a primary care physician and a specialist will care for a person with a chronic condition. The primary care physician will coordinate the overall treatment and is responsible for giving the patient the needed referrals to see the specialists. It is important to pick a primary care physician who is knowledgeable about the chronic condition and is easy to talk to.

Treating a chronic condition successfully, and quickly, can depend on the managed care organization's rules for seeing a specialist. Sometimes the rules and restrictions for seeing a specialist can be complicated, time-consuming, and frustrating. It is important to follow these rules, however, to ensure the highest amount of coverage from the health plan.

People need to ask some hard questions of their health care plan about their own specific chronic conditions. For example, fill in the blank with the name of the chronic condition:

  • Does the plan contract with doctors, hospitals, and community-based health care providers with a track record of serving patients?
  • Can a physician with experience in be the primary care physician?
  • Does the plan have a drug formulary (a list of drugs and classes of drugs preferred by the health care plan for use by its members)?
  • If so, are off-label drugs and new drugs for included in the formulary?

Other questions to ask when dealing with a chronic condition include (adapted from AIDS Action Foundation, Medicaid Reform and Managed Care, undated):

  • How and how often is the formulary revised to include new and more effective drugs as they become available?
  • What information does the plan have on the health outcomes of chronically ill people, including those with ?
  • What are the plan's policies on specialist referrals?
  • What are the plan's policies on new drugs, new treatment rules, and participation in clinical trials?
  • Many plans have consumer boards or advisory committees. If the plan has one, are people with and providers with expertise included?


An off-label drug is one that has not been formally approved by the Food and Drug Administration. The drugs have been approved for legal use but have not been approved to treat specific conditions. Off-label use is common in cancer treatment, for example. Off-label is not to be confused with generic drugs. Generic drugs are approved by the Food and Drug Administration for specific conditions, but do not go by specific brand names, which makes them less expensive for the consumer.

Referrals with Chronic Conditions

Referrals are the most complicated factor in dealing with chronic conditions and managed care. The process and rules for referrals vary from plan to plan. Some questions to ask the health care plan are:

  • How does one get a referral, and for how long can it be used?
  • How often can the referral be used before having to get another one? Is it one referral per specialist visit or does one referral cover a series of visits?

Referrals cover not only specialist visits but laboratory tests. Unless a patient has a condition that is life-threatening, the tests may not be performed on the same day as the doctor visit.

Prescription Drugs and Chronic Conditions

Some chronic conditions require no medication while other conditions require medication only during flare-ups, or when the condition is actively bothering the patient. Still other conditions require the long-term use of a prescribed medication. All health care consumers should understand the terms formularies, generic substitution, and therapeutic substitution.

FORMULARIES. Formularies are lists of prescription drugs preferred by the HMO for its members and are common in managed care. Plans develop the formularies on the basis of drug safety, effectiveness, cost, and cost-effectiveness. Formularies can be restrictive and can potentially impact the care a person receives. Managed care has been criticized for taking improper savings on drug use at the expense of consumers' health, even to the extent that illnesses and deaths could have been prevented.

People with chronic conditions need to pay special attention to their health plan's formularies. A doctor's knowledge of formularies is not dependable because a doctor may deal with numerous health care plans. In an open formulary, a patient should be able to get any drug, with some drugs requiring an additional co-payment. In a closed formulary, a patient who wants a specific drug may have to wait for the doctor to seek prior authorization, or approval, if the drug is not on the approved formulary list. If authorization for the nonformulary drug is not granted, the patient can file an appeal or even explore legal action.

GENERIC SUBSTITUTION. Generic substitution is the substitution of one medication with another drug that contains the same active ingredients in the same amount and dosage, but sold by a different company. Generic drugs are common because they cost much less than brand-name drugs. In changing from a brand-name drug to a generic drug, or vice versa, a patient may experience some side effects.

THERAPEUTIC SUBSTITUTION. Therapeutic substitution is the replacement of a prescribed drug with an entirely different drug in the same pharmacological or therapeutic class. These substitutions can pose more danger to the patient than generic substitutions. Different drugs, even those in the same class, can have significantly different effects on people. Pharmacists or hospitals should inform the doctor of any therapeutic substitutions, but they do not always do so. Consumers should check any differences between what was prescribed and what was received.

Emergencies and Chronic Conditions

Sometimes chronic conditions can be so severe that hospitalization is required. It is the patient's responsibility to learn about the chronic condition, including how to know when an episode is mild or serious and what to do about it. The primary care physician or the specialist can provide a list of symptoms, including recommendations for when a patient will need to go to the emergency room.

Disease Management

Some health care plans have disease management programs for people who suffer from chronic conditions like asthma, diabetes, or arthritis. A call to the plan's advice line or member services department will provide information about what is available. These programs focus on care for the whole patient, not just the symptoms or conditions associated with the disease. The disease management program may include patient education or behavior modification (a change in habits and lifestyle) classes, long-term monitored drug use, or the assignment to a case manager, who can recommend treatments and services that might not normally be covered under the plan. The case manager will coordinate the overall care of the patient.



Chiropractors, massage therapists, naturopaths and acupuncturists used to be considered alternative health care providers. Today these services are no longer thought of as alternatives to mainstream medicine. Instead they are considered complementary services. These services can be used alone or in conjunction with conventional treatments. As alternative medicine is more widely accepted, more health care plans are covering the alternative services for their patients. [See also Chapter 7: Health Care Careers and Chapter 10: Alternative Medicine for more information on alternative medicine.]

Some alternative clinicians are licensed by states and recognized as providers by health care plans. However, alternative treatments are often covered only for specific conditions. For example, a health care plan may cover acupuncture treatment for chronic pain management for one patient. Another patient who wants to use acupuncture for a knee injury may be denied coverage by the same health plan. If a consumer is interested in alternative care, it is important to find out what kinds of treatments are covered and for what conditions.

There remains a lack of mainstream research about alternative medicine and its effectiveness. As a result, managed care organizations will only cover treatments with clear outcomes and evidence. Some alternative practices may not meet these strict guidelines.

Once again, communication with the primary care physician is critical. A patient who decides to pursue alternative treatment should inform and consult with the primary care physician to ensure coordination of all health services. At the same time, a patient should always inform the alternative provider of treatments and medications prescribed by the physician. A patient will get the most effective care when all providers are working with the same information and for the same purposes.


Chiropractic is the oldest alternative clinical practice in the United States and the most widely licensed. All fifty states and the District of Columbia license chiropractors.

Chiropractors, or doctors of chiropractic, regularly treat lower back pain, headaches, and problems with the neck, the upper back, and the nervous system through spinal manipulation.

Managed care plans vary in their coverage of chiropractic treatment. Some HMOs have chiropractors as part of the network of providers. If patients think chiropractic treatments would be beneficial, they should review the health plan's materials and call member services for more information.


Acupuncture is an ancient Asian medical practice that involves using very thin needles to pierce different parts of the body to treat certain conditions or relieve pain. Acupuncturists are licensed in twenty-four states and the District of Columbia.

Managed care plans vary widely in their coverage for acupuncture therapy. Some plans do not cover acupuncture at all. Other plans will cover acupuncture for use as an anesthesia (pain blocker) during surgery. If patients think acupuncture treatments would be beneficial, they should review the health plan's materials and call member services for more information. The patient should be prepared to offer evidence that the acupuncture treatment is medically necessary.


Doctors of naturopathy, or naturopaths, believe in treating illnesses without the use of medications or surgeries, relying instead on natural elements for healing. Some states license naturopaths, but many naturopaths practice without a license in a physician's office or independently. If the naturopath practices in conjunction with a physician, and the doctor prescribes the treatments, the chances of getting health care reimbursement or coverage are greater.

Managed care plans want to do whatever it takes to keep members healthy. Not only is the practice of alternative medicine spreading, health care plans have started to offer complimentary extras to members that focus on member wellness. For example, most health plans have newsletters that contain information about healthy habits and preventive care, self-care and self-help practices, and member services such as exercise classes, yoga, meditation, nutrition education, help to stop smoking, and weight management. There may also be support groups or classes for people suffering from serious illnesses.


Coverage of mental health and substance abuse problems varies widely from plan to plan. Just because the information booklet of a health care plan lists mental health and substance abuse care as covered expenses does not mean a consumer won't encounter difficulty. Some plans are more restrictive in reality than they are on paper and may involve a lot of outof-pocket costs.

Mental health and substance abuse are often carve outs (see page 147) from the rest of the health plan. The care may actually come from a different company with a whole other set of phone numbers and addresses, and another set of rules to learn. These plans decide which kind of medical professional will treat the patient, what medicine or testing is required and approved, whether the treatment will be inpatient or outpatient, and how many sessions are needed and allowed.


Experimental treatment is different from alternative treatment. Experimental or investigational treatments may very well be effective but are not yet considered standard treatment in the medical community. A practice could be termed experimental because

  • there is inadequate scientific evidence to support the treatment's effectiveness;
  • the treatment has not been found to be as safe or effective as the standard treatment; or
  • in the case of a prescription drug, the Food and Drug Administration has not yet approved the product.

If a patient has not succeeded with standard treatment, or no standard treatment is available, it could be worthwhile to investigate participating in a clinical trial. A clinical trial is an investigation into new treatment methods, materials, or procedures for a specific disease or condition. Clinical trials can give a patient access to state-of-the-art care before it is widely available. The treatment may not always be effective, but many patients who are suffering from serious conditions are willing to experiment.

Most health plans do not cover experimental treatments. The primary care physician or specialist supervising the treatment can help by submitting documentation to support the need for the experimental treatment. If the plan still denies coverage, the patient can submit a formal appeal.

Managed care organizations require that all mental health or substance abuse treatments, like all medical treatments, meet the test of medical necessity. There is the very real possibility that, in order to control costs, the managed care plan will first approve treatment that may not be sufficient for the patient. Health care consumers must be their own advocates. However, in cases of mental health or substance abuse problems, the instability caused by the condition may make this more difficult. If individuals cannot advocate for themselves, a family member may need to step in to ensure that the individual gets the care needed for recovery.

Sometimes consumers do not meet the requirements for medical necessity of mental health or substance abuse treatment. This means that the problems of some patients may not be viewed as worthy of treatment by their health care providers. For example, a person who is experiencing stress or grief may wish to seek counseling, but the health care plan may only provide for a few sessions. Other times, the consumer has to wait to be referred for services. Both can be frustrating scenarios when a person is in need. The smartest way to avoid these situations is to evaluate a health plan for mental health and substance abuse treatment coverage before it is needed.

Some questions to keep in mind when evaluating a health care plan for coverage of mental health issues:

  • Who are the mental health providers, and what are their qualifications?
  • How does one get information on mental health providers?
  • How many visits are covered by the plan? How many initial visits are allowed before the mental health provider must make the case that further treatment is medically necessary?
  • How does one schedule an appointment? Is a referral needed in advance? If so, who gives the referral, the primary care physician or someone else?
  • Does the plan offer rehabilitation coverage? What about substance abuse detoxification?
  • Does the plan have enough mental health providers so that waiting for an appointment is not an issue?
  • How much are the copayments and deductibles?

Mental health care is no different from the rest of managed care. There are many complex rules for getting care, and many of the rules center around the referral process. Not understanding the referral process in advance can add even more stress to a stressful situation. The referral will allow a certain number of visits or a certain length of time during which the referral is valid. If the referral runs out, a patient may have to work with the mental health provider and primary care physician to request extended treatment.

Choosing a mental health provider is as serious as choosing a primary care physician. A patient may be choosing from psychiatrists, psychologists, marriage and family therapists, clinical social workers, psychiatric nurses, and licensed professional counselors. The mental health provider devises a treatment plan and submits it to the managed care organization for approval. This is when it will be determined if mental health treatment is medically necessary.

Outpatient Care

Most mental health and substance abuse treatment will be delivered through outpatient care. Outpatient means that a patient will receive treatment during the day but will not live at the treatment center. As stated earlier, once a provider has been chosen, a treatment plan will be developed. A patient will be authorized for a certain number of visits in a specific length of time.

If therapists think patients need more time or more visits, they will complete the Patient Evaluation and Treatment plan before the authorized time runs out. Another decision will then be made by the managed care organization about whether to extend the treatment for more time or more visits.

Inpatient Care

Inpatient care, or hospitalization, is a difficult subject in managed care. Therapists may see that because the patient lives at the treatment center, inpatient care provides the best opportunity for treatment. The patient and family members may also believe that the hospital provides the safest environment for the patient. However, managed care organizations will generally push for outpatient care because it is less expensive. If inpatient care is approved, it will be approved for only a short amount of time in most cases.

If a patient and therapist feel strongly about having inpatient care, the therapist will have to fight for the patient to receive inpatient care, especially inpatient care beyond the initially approved time period. The outpatient therapist may be a different person from the inpatient therapist, but either can push the limits of the health plan to get the best treatment for the patient.

Common complaints about mental health treatment are:

  • denial of care;
  • excessive demands for personal patient information from the managed care organization;
  • untrained employees following rigid rules in denying treatment;
  • interruption of treatment; and
  • unclear, or even deceptive, statements about mental health benefits by the managed care organization.


It's not uncommon to disagree with a decision made by a health care plan. The complexities and restrictions of managed care call for people to learn how to advocate (support) for themselves. A person can challenge any bill or service problem. Problems can occur even when the rules and procedures are followed exactly. The first step is to file a grievance, or complaint. Grievance proceedings can be slow and long. A member's handbook will give information on how to file a grievance. The most important thing is for people to know their rights when it comes to their personal health care.

Some plans have very limited mental health benefits. When changing plans, continuity of care can become a problem. A patient may have been seeing a therapist for a period of time but, under a new plan, the therapist is not a part of the approved provider list. Sometimes the patient can continue with the therapist for a higher out-of-pocket cost. Sometimes the patient will be forced to change therapists.



Castro, Janice. The American Way of Health. New York: Little, Brown and Company, 1994.

Horowitz, David and Dana Shilling. The Fight Back Guide to Health Insurance. New York: Dell Publishing, 1993.

Kerczyk, Sophie M. and Hazel A. Witte. The Complete Idiot's Guide to Managed Health Care. New York: Alpha Books, 1998.

Miller, Marc S., ed. Health Care Choices for Today's Consumers. Washington, DC: Living Planet Press, 1995.

Wekesser, Carol, ed. Health Care in America, Opposing Viewpoints. San Diego, Calif.: Greenhaven Press, Inc, 1994.

Web sites

Agency for Health Care Policy and Research. [Online] (Accessed September 27, 1999).

American Association of Health Plans. [Online] (Accessed September 26, 1999).

Families USA. [Online] (Accessed September 27, 1999).

Health Care Financing Administration. [Online] (Accessed September 27, 1999).

Health Pages. [Online] (Accessed September 26, 1999).

Healthfinders. [Online] (Accessed September 27, 1999).

National Association of Insurance Commissioners. [Online] (Accessed September 27, 1999).

National Committee on Quality Assurance. [Online] (Accessed September 27, 1999).

National Conference of State Legislatures. [Online] (Accessed September 26, 1999).

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