The ABC’s of health insurance
HMO, PCP, PPO, POS — feel like you’re wading through alphabet soup? Read on for translations of common terms.
• Health maintenance organizations (HMO) require you to choose a primary care physician (PCP), who coordinates all of your care, including visits to specialists.
• Preferred provider organizations (PPO) let you make your own choices from a network of preferred providers (in some plans, you can pay a higher fee for out-of-network care) and may not require you to have a primary care physician.
• Point-of-service plans (POS) let you choose between receiving care from participating providers (you’ll be reimbursed more for this), or non-participating providers(you’ll be reimbursed less for this).
Some plans offer lower premiums (monthly payments) in exchange for a higher yearly deductible (the amount you must pay personally before insurance provides any coverage). Some plans require co-pays, a set fee you pay for health care visits or medications. Others ask you to pay co-insurance, which means you’re responsible for a portion (20 percent, for example) of eligible expenses charged by a provider or the amount the insurer agrees to pay for specific services.
Many plans require preauthorization or precertification for certain services, such as surgery or visits to a specialist. Some pick up the tab on preventive care services, such as flu shots, cholesterol tests, or colonoscopy. Most have formularies that list pre-approved, commonly prescribed drugs.
Team approach results in better care
Donna Matthews (right), discusses her log of blood glucose levels with Dr. Mark Drews (left), a primary care physician at Whittier Street Health Center. (Photo by Tony Irving)
By all accounts, Donna Matthews is a “good” patient.
As a diabetic, she checks her blood sugar level four to five times a day – and more if she does not feel well. She writes the numbers down in a log that she dutifully presents at each doctor’s appointment.
Talk about patient empowerment. “I think I’m a little OCD (obsessive-compulsive disorder) now,” she admits.
But that “OCD” serves her well. She can name each of her medications and the dosage. She asks questions; she writes things down. To say the least, Matthews is prepared — and clear on specific problems.
The reason for her obsessiveness is also clear. “I don’t want to get any worse,” she said.
The notion of patient empowerment — that patients take an active role in their care — is a growing concept. It’s not that patients are taking over; they’re just taking part. They weigh treatment options, learn about their illnesses and make decisions about their care.
Research has shown that patients who interact with and have a good relationship with their providers not only receive better care but are happier with that care.
If only all of Dr. Mark Drews’ patients were as good as Matthews. As an internist at Whittier Street Health Center, he averages about 70 patients a week, and maybe he has twenty minutes with each of one of them.
But a lot has to happen in those 20 minutes.
Especially considering that primary care physicians (PCPs) are increasingly being asked to do more with less time – and with fewer doctors. PCPs are becoming such a rare commodity that in 2009 the Massachusetts Medical Society concluded that the shortage of doctors of internal medicine is “severe,” and that of family medicine is “critical.”
Complicating the problem is that only 60 percent of family practitioners and a scant 44 percent of internists are accepting new patients, according to the society’s Physician Workforce Study.
What’s worse, on average, patients in this area have to wait 44 days for an appointment.
Although a 2009 report in the Archives of Internal Medicine found that visits with PCPs increased from an average of 18 minutes to almost 21 minutes, one thing remains clear: there’s not much time behind those closed doors.
Time constraints pose a problem with specialists as well.
Eldrin Foster Lewis, M.D., M.P.H.
Brigham and Women’s Hospital
Both Drews and Lewis agree that the time is better spent if patients come prepared.
“You wouldn’t think of visiting an accountant and asking if you’ll get a tax refund if you have not provided the appropriate receipts,” Lewis said. “Why would you handle a doctor’s visit any differently?”
Medicines cause a major concern. Doctors cannot prescribe a new drug without knowing what a person is already taking. “Less than one–third of patients will know what they take,” Lewis said. “Others will have just a general idea, but don’t know the name or dose of the drug. They assume that I know.”
Trying to get the details from some patients doesn’t always work. “The response — ‘The heart doctor gave me a new pill. It’s white.’ — is not much help,” Drews said. “ ‘Let me call my wife at home. She can read the label’ — is better. But that doesn’t tell the entire story.”
He offers a solution: “Put all your pills in a bag and bring them with you.”
That helps in more ways than one. Not only can he determine what you’re on, he can determine what you’re no longer on. People tend to keep medications they stopped taking — or they have three different doses of the same medication, according to Drews. “It helps to have the actual bottles,” he said.
He makes a larger point. “This is a national safety issue,” Drews said, referring to the thousands of accidental overdoses and allergic reactions to all types of drugs.
Lewis agreed that he prefers to see the medications directly and not rely solely on the medical record. “It could be wrong,” he noted.
He knows his time is limited. In those 20 minutes Lewis must hear and interpret a patient’s problems, ask questions, perform a physical examination and develop strategies for treatment. “You don’t want to lose ten minutes trying to figure out medications,” he remarked.
Both doctors mentioned pet peeves or irritations that impede good care: not taking medicine but thinking that you’re going to get better; not telling the doctor when you don’t understand; being too embarrassed to raise an issue; showing up late for appointments; relying on a family member’s advice instead of the doctor’s.
For his part, Drews does his homework to make the most of his time and he expects the same from his patients. During the visit, he expects participation and good interaction from his patients. He encourages questions. And he expects honesty. Hiding information and providing just part of a picture can be detrimental. He welcomes a family member or friend at the visit to help fill in the gaps.
For the patient’s part, it takes three steps to achieve the ultimate visit. The first is preparation. Don’t go to the doctor empty-handed. Take your drugs with you — including over-the-counter and herbal drugs, and vitamins; write a list of your symptoms and complaints; and prioritize the three or four most troublesome.
The American Academy of Family Physicians recommends developing a health journal that includes a history of illnesses and injuries, hospitalizations, surgeries, allergies and drugs.
The second step is the actual visit. Discuss your complaints; update the doctor of any changes since the last visit, including life changes, such as divorce; answer questions honestly; ask questions if you do not understand and write down information.
The third step is follow-up. Call if you experience problems after the visit, such as side effects from medications, deterioration of your symptoms, or failure to receive the results of tests.
Lewis emphasizes the need for patients to take charge. “Most treatment occurs in between doctor visits,” he said. “You have to understand what you’ve been told and then do it.”
Be a part of the team. Ask why you’re taking the drug. If you are on three different medications for apparently the same diagnosis, ask why. When you have your blood pressure taken, write down the results. “That’s a patient’s job,” he said.
He finds that some people are a little bit more involved in their care, but not as much as he’d like to see. People of African American descent, he noted, tend to not ask questions as often.
One thing he stresses. If you and your doctor have a relationship that works, that goes a long way. “You don’t have to be friends, but you should feel secure that he or she has your best interest,” he said. “If not, find another doctor.”
Apparently, Matthews’ fastidiousness and her close working relationship with Drews have paid off. She sees the improvements.
“My A1C — a test that reflects the average blood sugar level for the past two to three months — used to be in the 9’s,” she said. “Now it’s in the 6’s.”
It is recommended that the A1C for diabetics not exceed 6.9.
Matthews is living proof of several studies that suggest that African Americans can improve blood glucose levels when in strong partnership with their doctor.
She relies on her doctor for expertise and support but relies more heavily on herself to follow through with “her” health plan.
She says that Whittier Street Health Center is good at calling her to inform her of test results. If they didn’t, she explained, she would anyway.
“I’d be too scared not to,” she says.