Abuse under health coverage plans amid upcoming high court decision

This article was originally published by the Viễn Đông on May 21, 2012. It was written by Vanessa White.

http://www.viendongdaily.com/nhung-vu-lam-dung-ke-hoach-bao-hiem-y-te-gay-ton-kem-cho-tieu-SP2TkqN7.html

WESTMINSTER, California—A patient might be given a year’s worth refill on medication and sent away, told it is unnecessary to return for another visit in a month.

The doctor, then, might go on a vacation.

Or, a doctor might have a sicker patient visit monthly, receiving more money than if the patient were healthy and visited less.

It all depends on the plan, Garden Grove’s Tran Pharmacy Pharmacist Thư-Hằng Trần told the Viễn Đông in a 12 May 2012 phone interview explaining some of the differences between increasingly pushed managed care health coverage plans and fee-for-service health coverage plans. Aside from having a doctor as a close family member, Pharmacist Trần said that her knowledge on health coverage plans was gained from her own research and experiences.

After a “very bad” accident that put her in the hospital ten years ago, she said, she had to wait for approval from her health maintenance organization (HMO) each time she needed to see a specialist for follow-up treatment. An HMO provides or arranges managed care health coverage plans.

Fortunately, she added, her HMO quickly approved the requests and referrals that her family doctor wrote. Though, not all patients are so fortunate, she continued, adding that there are times when HMOs will take too long to approve a referral or request, upon which she advises the patients to demand approval.

“For some patients, if you don’t fight you don’t get the service,” she said.

ACA, Managed care vs. fee-for-service

Under the Patient Protection and Affordable Care Act (ACA), awaiting a June or July 2012 U.S. Supreme Court decision on its constitutionality, Medicaid will expand coverage to uninsured Americans who will be required to have health insurance by 2014. Medi-Cal is California’s version of Medicaid, which covers lower-income families with children, seniors, foster children, pregnant women, and people with specific diseases including breast cancer and HIV/AIDS.

The Viễn Đông has learned that the upcoming court decision could extend managed care plans to more patients, as more states are reportedly moving towards these types of plans. Such managed care plans are private, with the state paying the private HMO a fixed monthly payment.

When doctors actually receive payment for their services, they get about $120-130 monthly, even if their patients do not visit the doctors, Pharmacist Trần told the Viễn Đông.

Pharmacist Trần said that she generally likes the idea of managed care plans because they can save the state money if a patient’s care is adequately managed. Though, she has a problem when the health care system is abused.

For example, Pharmacist Trần said that HMOs can take advantage of the system by denying certain patient referrals and requests for services or choosing the route that costs less, regardless of the patient’s need. For example, if a patient feels in need of a wheelchair, an HMO might approve a $500 manual wheelchair for the patient instead of a $5,000 electric powered wheelchair.

Pharmacist Trần added that under managed care plans, doctors also will sometimes withhold services from patients who really need them because the doctors will have to spend more time and energy providing the services, while feeling like they are losing out on money they might have made from fee-for-service payments. With fee-for-service health coverage plans, doctors are paid per service.

Under Medicaid fee-for-service health coverage plans, Pharmacist Trần continued, patients can abuse the system by claiming to need an earlier mentioned $5,000 electric powered wheelchair or other treatment and medication that stay at the patient’s home, unused.

Or, she added, a patient might go to one doctor that prescribes a medication or treatment the patient does not want, so the patient will go to a different doctor. That doctor might prescribe another medication the patient does not want and the cycle continues, all the while costing the state money.

Both programs have their weaknesses and strengths, Pharmacist Trần suggested, with managed care plans being good for helping patients decide what care they need and fee-for-service plans allowing the patients a different level of flexibility in choosing services.

There are problems, she said, when the systems are abused.