August
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August
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HMOs and PPOs How does managed care manage mental health? |
Have
you read these? Essential information
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In the old days, your doctor made all the decisions about your medical care. Now it seems as though your insurance company is in charge. But, the insurance company's not entirely to blame What is managed care? HMOs typically provide
preventative care, have more restrictions on services and cost less. PPOs
give the consumer more control of health care decisions but cost more.
As of 2002, 164.3 million American's were enrolled in managed behavioral health programs, according to Susan Pisano, vice-president of communications for the trade association America's Health Insurance Plans. But managed care has come under fire for the quality of mental health services available to the estimated one in four American adults who suffer from a diagnosable mental disorder in a given year. Why is my coverage so limited? "Benefit limits are imposed by the benefits package an employer purchases," explains Pamela Greenberg, President and CO of the Association of Behavioral Health and Wellness. "Employers choose from a package that covers, for example, the number of visits, and the health plan administers the limits specified." The health plan companies say they attempt to keep costs down while providing the most appropriate care for the member. While your plan specifies, for example, the number of hospital days you cannot exceed, you may be allowed even fewer, if the health plan managers determine that it is not cost-effective and may not be in the best interest of the patient. "Sometimes participating in a day treatment program and being with a supportive family at night is a better choice," said Greenberg. HMO doctors are reimbursed at less than the standard rate for services, but as members of the plan's network, more patients are referred to them. Critics of managed care raise the concern that the system rewards doctors for delivering a minimum of care in favor of seeing a greater number of patients. Cigna Healthcare says "cost reductions can be achieved without affecting quality, simply by eliminating care that is unnecessary or of no proven value." Paying for individual services, they say, encourages overtreatment, which is not only expensive, but dangerous. While managed care makes drugs affordable to members, many plans use a formulary, a list of drugs covered by a member's benefit plan. The list results from the insurer comparing drugs' efficiency, side effects and cost.
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Plans say that because drug prices have risen three times faster than the rate of inflation over the last decade, cost-cutting measures are necessary. But formularies can mean that some patients can't get the drug their doctor thinks is best for them. How can mental health care coverage
be improved? Many states have passed more stringent laws against mental health care inequities. There is a loophole, however. "Self-funded" plans in which the employer assumes the financial risk of medical costs are exempt from these state laws. These employers usually contract with other companies to administer benefits. You may not be aware that your health-plan is self-funded because your membership card will carry the name of a well-known insurer. That company, however, is only the administrator of the plan. The employer sets all coverage restrictions. When Darla W., of Denver, questioned why her hospital stays were being limited to fewer days than mandated by Colorado state law, she learned her "self-insured" employer was exempt." And she's hardly alone. "They have complete discretion," says Michael Huotari of the Colorado Association of Health Plans, who estimated at least 60 percent of coverage in Colorado is self-funded and therefore exempt from state laws. The new federal parity bill (read about it) that would finally put some teeth in prohibitions against discrimination in mental health care coverage is supported by business and the managed care community, says Greenberg, who cites growing recognition of mental health disorders as illnesses. "There's been
a real sea change in employer's attitudes about mental health care,"
she says. "There's growing recognition that these disorders are illnesses."
Sources
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Comparison of HMOs
and PPOs HMOs and PPOs differ in primarily two ways: cost and type of access to services. HMO plans have restrictions on where and how you can receive care. PPO plans have fewer restrictions but can be more expensive. |
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Health Maintenance Organizations Members must choose a primary care physician (PCP) from among the plan's roster. All services: office visits, tests, hospitalizations, etc. are provided by contracted healthcare members. |
Preferred Provider Organizations PPO members are not required to choose a primary care physician. |
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| The PCP must refer patient to all other doctors or specialists, who are usually HMO contracted providers. | Either doctors or the members themselves can choose to see a specialist, even those outside the network. | ||||||||||
| The HMO usually chooses hospitals and specialists. | PPOs provide a list of pre-approved providers, but members may choose almost any doctor they choose, in or out of the network. | ||||||||||
| HMO's typically do not cover the services of doctors outside the network, except in cases of emergency. | Members typically pay for services as they are provided and are reimbursed by the PPO. If a member receives care from an out-of network provider, they will receive a lower rate of reimbursement. | ||||||||||
| HMO's typically do not have deductibles that must be met before coverage begins. HMO members usually pay a co-pay for services. | Members of PPOs may have to meet a deductible, which may reach hundreds of dollars, before coverage begins. And, co-payments are generally higher as are premiums. | ||||||||||
| Advantages: Generally HMO healthcare costs less than a PPO's and members are not responsible for billing procedures. |
Advantages: If you have a medical condition that frequently requires a specialist, because referral is not necessary. You may use alternative medicine services such as acupuncture.
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