Introduction

Reviews

Getting Good Care in an HMO—Part 3

Timothy B. McCall, M.D.

The secret of getting good care in an HMO is learning how to be an assertive and effective consumer. This week we will cover a few more things you can do to make sure you get the care you need, starting with emergency situations…

• In a true emergency get the medical care you need and worry about getting it approved later. If your plan requires pre-authorization before visiting an emergency room, try to get it but don’t delay needed services while you wait. If necessary, the staff in the E.R. can attempt to call for you. If the problem is life-threatening call 911 or go to the nearest hospital even if it’s not affiliated with your HMO.
• Do not be deflected on the telephone. HMOs may discourage “excessive” doctor’s 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. 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 you have your primary care doctor make an appointment with a specialist for you, you can be seen more quickly. For routine checkups or for non-urgent problems, you may simply have to wait a while to be seen, so make your appointment as soon as you think of it. If your HMO doesn’t have walk-in services and you’re truly sick don’t let them tell you that you can’t be seen that day. Instead, simply announce that you’re coming in and expect to be seen.
• Get smart about your medical problems. If you’re diagnosed with a medical condition the more you know about it, the better you’ll be able to ask intelligent questions, scrutinize what your doctor says and advocate for yourself. Good information is available in consumer health guides, from disease groups such as the National Headache Foundation and the American Diabetes Association, from the government and, increasingly, from the Internet and on-line services. If Linda Smith, the woman mentioned earlier, had read up on breast cancer, she might have learned that most experts recommend that a new lump be drained with a needle. If it doesn’t go away, it should be biopsied immediately. The information might have proved life-saving.
• Vote with your feet. If your HMO fails to meet your expectations because it’s poorly organized, isn’t responsive to your needs or doesn’t have quality doctors, switch plans when your period of obligation is up. If you get your health insurance through your employer, mention your problems to the benefits manager. Maybe they will have the good sense to choose a better plan next year. And write a letter to the administration telling them why you switched. If enough people do likewise, they’ll get the message.

Good luck!

Next: Avoiding Defensive Medicine

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