TOPICS > Health

Managed Health Care in Arizona

April 11, 1996 at 12:00 AM EDT

TRANSCRIPT

WOMAN: (talking to patient) And is the insurance through your employer or through your husband’s?

PATIENT: Mine.

WOMAN: Yours.

TOM BEARDEN: Mindy Edwards belongs to a managed health care plan, a plan which sets policies and procedures for controlling the cost and the delivery of her health care. A few years ago, that kind of plan would have been something of a rarity. Today, the majority of patients at this Phoenix area practice are in managed care.

UNIDENTIFIED WOMAN: How are you feeling?

UNIDENTIFIED PATIENT: About the same.

TOM BEARDEN: Enrollment in health maintenance organizations in Arizona has doubled since 1988, from 740,000 to nearly 1.5 million today.

YOUNG WOMAN ANSWERING PHONE: Desert Valley Family Medicine. This is Anna.

TOM BEARDEN: The tremendous growth of all forms of managed care has dramatically changed the way health care is delivered in Arizona. for Mindy Edwards, it meant choosing a doctor from an approved list.

MINDY EDWARDS, Patient: Finding a doctor was real hard off the insurance list. Umm, I called a lot of them. A lot of them had denied the insurance so far. A lot of them weren’t taking new patients. So I only found two doctors out of probably twenty in this area that would take a new patient or take this insurance.

TOM BEARDEN: Finally, she found room here at Desert Valley Family Medicine, located in a suburb of Phoenix. But there were more problems when the doctor’s staff tried to verify her insurance coverage.

WOMAN AT RECEPTION WINDOW: We called your number, and they gave us a different number, and those people gave us a fourth number. So we called four places. The fourth place was the real one, and they’re closed for the day, which means, umm, that we’re unable to verify your insurance at this point.

TOM BEARDEN: Staffers say this is a common problem. Edwards had just changed jobs, and the paper work for her new insurance apparently hadn’t yet been processed. They say insurance companies are sometimes overwhelmed by paper work because many employers change insurers every year. In the end, Edwards didn’t see a doctor, but, rather, nurse practitioner Lois Henderson.

LOIS HENDERSON, Nurse Practitioner: (speaking to Mindy) Hi. I’m Lois Henderson, nurse practitioner. Nice to meet you.

TOM BEARDEN: This too is an increasingly common experience for managed care patients. As a cost containment measure, some insurers now require people to see nurse practitioners and physicians’ assistants for minor ailments that don’t require the expertise of a doctor.

LOIS HENDERSON: They are similar to physicians, but there are also limitations because the fact that we haven’t gone to medical school, so it’s important, I think, as a nurse practitioner, I work within my limitations, but I also draw on my experience and my education to manage a patient’s health care.

TOM BEARDEN: If patients are allowed to see a doctor, managed care has also changed the kind of doctor they’re initially allowed to see.

DR. HOWARD WERNICK, Primary Care Physician: (talking to patient) I’m going to ask you to take a deep breath in and out through your mouth.

TOM BEARDEN: Dr. Howard Wernick is a family practitioner, one of two at this clinic. In managed care circles, he’s known as a primary care physician. For many plans, he must serve as a gatekeeper. He must give his approval before a patient can consult a specialist.

DR. HOWARD WERNICK: When patients are used to specialists where they go to a dermatologist for their skin problem, a gynecologist for their gynecological problems, a pediatrician for their children’s problems, and they’re used to that, one has to really make those patients aware that a family physician that’s trained can do all that. And it’s a matter of educating the patients. Most patients accept it; some don’t.

TOM BEARDEN: If Dr. Wernick has to refer a patient to a specialist, he also has to turn to a list, a list that may not have any names he recognizes.

DR. HOWARD WERNICK: Tell the girls at the front desk that I said it was okay for you to be referred to Dr. Bankatesh for your colonoscopy, and then you set up a time that’s mutually for you and him.

TOM BEARDEN: Under some HMO plans, doctors are given financial bonuses if they limit their referrals for hospitalization or specialist care. There are also capitated plans in which primary care physicians are paid a flat monthly fee per patient regardless of how many times they see them. Dr. Wernick says no matter what the payment incentives, he thinks first as a doctor.

DR. HOWARD WERNICK: I personally feel I will treat my capitated patients the way I treat my private care patients; that there should not be a different mode of handling my medical care.

TOM BEARDEN: Dr. Wernick deals with some 18 different managed care plans.

DR. HOWARD WERNICK: (on phone) I’m not on that particular access list of insurance companies, that’s correct.

TOM BEARDEN: Each of them requires different procedures, laboratories, and medications. Accountant Diane May says all the rules have changed the work load for the staff and have led to a substantial increase in red tape.

DIANE MAY, Accountant: Oh, immense. We have so much paper work, we–you know, the amount of filing that has probably increased tenfold just in the last two years, just in one month’s time we can have, uh, say eight, ten different insurance companies send us updates on their provider manuals with new rules and regulations before we’ve had a chance to memorize the last ones.

TOM BEARDEN: Dr. Wernick says he’s had to hire several full- time staffers to cope with the requirements. That’s substantially raised his overhead.

DR. HOWARD WERNICK: Well, I can tell you that our practice, our overhead, is probably 55 to 60 percent of our gross income. I would think perhaps it may have been 45 to 50 percent before this occurred.

LOIS HENDERSON: (taking Mindy’s blood pressure) Okay. 100 over 64–real good.

TOM BEARDEN: But Nurse Henderson is glad that managed care has returned the family care physician to a prominent role in medicine.

LOIS HENDERSON: So it brings back the old concept of a family doctor.

TOM BEARDEN: And that can save a lot of money.

LOIS HENDERSON: That’s great! I think it helps you, plus the whole family can be seen in one office and it’s really nice to develop that rapport with people.

TOM BEARDEN: But Henderson is still bothered by the fact that insurance companies have the last word.

LOIS HENDERSON: I think that’s always been like a thorn in the flesh for a lot of health care people, that somebody non-medical has sometimes more of a say or is supervising the actual manipulation of numbers when we’re talking about people’s lives or people’s health.

TOM BEARDEN: Mindy Edwards also has some concerns.

MINDY EDWARDS: It might be saving money for, for me in the long run, but I might not be getting the best health care either.