Introduction

Reviews

Getting Good Care in an HMO—Part 1

Timothy B. McCall, M.D.

How successful you are in getting services in an HMO is often a function of how effective and how persistent you are in asking for them. Some basic HMO survival tactics include the following:

• Learn the system. HMOs have different rules and regulations, different services they will pay for, different services they deny. People who know the services they’re entitled to are more likely to get them. Study the brochures before you join, remembering that advertisements only stress a plan’s advantages. After you join, read the member handbook to get to know the ins and outs of your plan. Glance through the newsletters and other material they mail out for updates and changes in their policies. When you go for visits, ask the nurses and doctors or other members you bump into in the waiting room how to work the system to your benefit.
• Find out how the doctors are paid. HMOs pay some doctors a salary, some a monthly fee per patient and some by fee-for-service. Many use a combination of all three methods. Within the same HMO, for example, a primary care doctor may be paid a salary while a specialist gets a fee for every service. Most plans pay bonuses to primary care doctors who keep expenses down or penalize ones who spend too much on patient care but a few do not. Some bonus plans are tied to the use of expensive services like hospitalization and referrals to specialists. The different incentive systems affect how doctors order tests and allocate other services. It’s much easier to evaluate a doctor’s suggestions if you know where the incentives lie.
• Get a good primary care doctor. Since primary care doctors act as gatekeepers in HMOs, getting a good doctor is one key to success in a plan. Part of what defines a good doctor in an HMO is a willingness to go to bat for you when a test or treatment that is not usually covered is necessary. You may be able to learn through the grapevine who the good doctors are but since word-of-mouth is not completely reliable, ultimately you’ll have to depend on your experience. If after several visits you’re dissatisfied, consider switching to another doctor.

Remember, too, that choosing a good primary care doctor is only half the battle. Next, you need to be able to get an appointment. Often, the schedules of good primary care doctors fill up quickly and the HMO will attempt to shunt you to a nurse practitioner or to a physician assistant, which not coincidentally saves them money. For some problems seeing a non-physician may be fine with you. For others you may prefer to see your regular doctor.

There are sometimes tricks to getting appointments that you can learn from receptionists or from other members. Some plans, for example, will only book appointments for a given month starting on a particular day. If you can find out when that day is, you may have no problem getting an appointment with the doctor of your choice.

• Get a good primary care doctor. Since primary care doctors act as Learn the secrets of getting appointments. Choosing a good primary care doctor is only half the battle. You need to be able to get an appointment too. Often, the schedules of good primary care doctors fill up quickly. The HMO may offer you an earlier appointment with a nurse practitioner which--not coincidentally--saves them money.

For many routine problems, such as bladder infections or ankle sprains, a nurse practitioner is fine. They may handle some problems better than doctors, particularly when counseling or patient education is important. Due to their training as nurses, many practice a more personal brand of care and place more emphasis on prevention. Of interest, in patient satisfaction surveys nurse practitioners consistently score better than doctors. More complex medical problems, however, may require a doctor’s expertise.

HMOs may discourage “excessive” visits by making appointments, especially specialist appointments, difficult to obtain. When you call you may be told the first opening is months down the road. It may seem obvious but if the first appointment you’re offered seems too distant, ask if they haven’t got anything sooner. Could they call you if they get a cancellation? Sometimes if your primary care doctor make a specialist appointment for you, you can be seen more quickly. For routine checkups or for non-urgent problems, you may simply have to wait to be seen.

Sometimes you can learn other tricks about appointments from receptionists or from other members. Some plans, for example, will only book appointments for a given month starting on a particular day. If you can find out when that day is, you may have no problem getting an appointment with the doctor of your choice.

Next: Getting Good Care From an HMO, part 2

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