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Patients Are Not Alone in Worrying About Managed Care in Missouri

October 1, 1996
By: Ciprian Baltoiu
State Capital Bureau

Anchor introduction:

All HMO's want to be sure that people stay healthy. Those are the words that you will find every time you see an HMO plan. If the patients are concerned about what they get under that plan, some doctors worry more about how to managed between HMO's regulations and patients' needs.Ciprian Baltoiu has the story;

Ciprian Baltoiu
RunTime:
OutCue: SOC

HMO's are not new: they have been around since the early part of the 20th century, and evolved partly from European style.

But Europe is far away and here, year after year,there's a chorus of complains about HMO's.

So what's the best part of an HMO from the doctor's perspective?

H.J. Murrell is a radiation oncologist in Columbia and Jefferson City.

Actuality: Doctor Murrell
RunTime: 00:00:00-00:00:08
OutCue: "and customary rate"
Contents: There is an initial cost savings that then grows at the usual and customary rate.

Murrell says there are also problems with HMO's.

Doctors are assigned to a certain plan by a panel of other physicians...but sometimes those relationships don't work out.

Actuality:Doctor HJ Murrell
RunTime: 19
OutCue: "can happen too"
Contents: Murrell says that from time to time, the plans dismiss a doctor for a number of reasons. But he says that happens more often than a physician leaving because of frustration.

Murrell says the main problem when someone chooses an HMO plan is access to information.

Sometimes it's very hard to understand everything what is written in a contract.

Actuality: Doctor Murrell
RunTime: 00:00:00-00:00:10
OutCue: will not cover.
Contents: My principal criticism is that the contract offered by many managed care company's are difficult to interpret. I wish that the company's would use plain English and will explain clearly what they will cover and what they will not cover.

It's important to known what you're HMO plan covers when you sign the agreement.

You'll be surprised to find that your HMO may not pay to fix a broken leg or a broken arm unless you first go to your primary care physician.

This kind of thing causes patient complaints....which go to the Department of Insurance. The department has some regulatory authority over HMOs.

Randy McConnell is with Missouri's Department of Insurance:

Actuality:McConnell
RunTime:
OutCue: insured by HMO's.
Contents: Regard to doctors on HMO's is what we cold service capacity in terms that making sure there are enough primary care providers and specialists in order to serve the population which is insured by HMO's.

With such problems it's no surprise that some patients and even doctors decide to leave HMO's. But why does a doctor decide to leave an HMO plan and how often does it happen? C C Swarens executive vice-president of Missouri State Medical Association:

Actuality: CC Swarens
RunTime: 00:00:00-00:00:39
OutCue: can happen too.
Contents: One of the first problems that they encounter is that they're often second guessed on their treatment. In other words, if they would like a patient to spend another day in the hospital and feel that is very important. Some HMO's will just automatically deny and that sets up an appeal mechanism that the physician and the hospital must go through to try and get the care for this patient and you can imagine the time and expense that's involved in carrying out all of those chores."

Choosing health-care coverage has became an annual ritual for most Americans.An HMO need to have an adequate number of caring ,honest , and competent primary-care doctors.Also for doctors an HMO plan must offer them more flexibility to care for patients needs.

From The State Capitol I'm Ciprian Baltoiu