Private Insurance

Frequently Asked Questions

1. Q. Will managed care save money?
   
   A. Under some circumstances, yes. Since there is such fierce competition for an enrolled population, managed care plans try to offer insurance plans that employers can afford. However, keeping costs down in one sector may increase costs in another
2. Q. Does managed care affect consumer choice of provider?
   
   A. Very much so. Managed care requires the enrolled member to select a primary physician from a panel of physicians associated with the plan. Some newer Point-of-service options allow more consumer choice outside of that panel-- but this costs more out of the pocket of the member.
3. Q. How are primary care providers used in managed care plans?
   
   A. Primary care providers are called the "gatekeepers," the coordinators of care, and, so far, they are doing fairly well under managed care. Primary care providers may be physicians in the specialties of family medicine, internal medicine, pediatrics. Some times those in obstetrics/gynecology are included in the definition of primary care and many managed care plans allow women to chose such a provider as their gatekeeper. Primary care providers may also be nonphysicians. In many managed care plans, members can chose nurse practitioners as their primary care provider. Physician assistants are also used to work along side physicians in many settings.
4. Q. What happens to specialists in managed care plans?
   
   A. A major goal of managed care plans is to hold down costs. Since specialists are the most expensive physicians, it follows that limiting access to specialists would play a part in holding down those costs. Most managed care plans have panels of physicians that are 50% specialist physicians.
5. Q. What happens to hospitals with managed care?
   
   A. All managed care plans need hospital beds for their sickest patients. One hospital may contract with several managed care plans to provide those beds. In many cases, hospitals are positioning themselves to be leaders of managed care networks.
6. Q. How does prevention fit into managed care?
   
   A. When originally conceived, "Health Maintenance Organizations" described well the organization, lots of prevention, health education, and general health maintenance went on. Prevention logically should be an integral part of managed care, and there is a great opportunity to include it.
7. Q. How does managed care affect the quality of care?
   
   A. It can improve it or make it worse, depending on the managed care plan. Most consider the greatest strength of managed care to be its focus on the coordination of care. If the system does a good job of managing patient care, and not solely costs, it can be a high quality system. When done well, costs are controlled while providing patient care appropriate for patient needs.
8. Q. What is the concern about big corporations entering the managed care field?
   
   A. There is concern that as health care becomes more of a commodity for insurance companies, employers, and entrepreneurs, people's health will be given less importance than costs and profits.
9. Q. What kind of record do the large HMO's have when it comes to administrative costs, profits, and spending on patient care?
   
   A. There’s an incredible variation. Usually the not-for-profit HMO's spend more on patient care.
10. Q. What can managed care do to cover people who are uninsured or who can’t afford insurance?
    
    A. What managed care could do and what it usually does are two different things. Attempts are being made in some states, for example Oregon, to use managed care to extend coverage to the uninsured. Otherwise, most managed care plans, especially those which are "for-profit," do nothing to address this issue. Ignoring the needs of the uninsured is also basic to our current fee for-service system.
11. Q. What role do communities have in managed care?
    
    A. Communities, if they are informed and motivated, can take an active role and use managed care positively. When buy-outs of local hospitals are involved with the entrance of managed care into the communities, as is the case in many rural communities, often times approval and input from community residents is part of the development plan of the managed care organization. After all, that plan will be competing for your insurance dollars and they want to settle in a community where the climate is favorable to their success.
12. Q. What are the risks to our rural areas?
    
    A. Urban-based enterprises could draw provides and patients away from their rural areas, or leave only the sicker and poorer patients to be cared for by rural providers.
13. Q. Is managed care socialism?
    
    A. In its present application, it¹s just the opposite. It¹s being used as a tool for "free enterprise" and fierce competition. A socialist health plan would guarantee access for all Americans. There is nothing required of managed care that would lead to universal access.
14. Q. Is fee-for-service medicine dead?
    
    A. Not yet, but some predict it will be in a few years. The "point-of-service" where you can pay a bit extra to chose a physician not included in the plan¹s panel may modify what evolves.
15. Q. Has health care become a commodity?
    
    A. Very definitely. First patients became consumers of health care. Now they are "covered lives," an insurance term which further depersonalizes the patient.