CC #307 This material has been developed by and is presented by The Sandwich Generation ® Conversations With Carol #7
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Is your own primary care doctor a participating physician? If not, do you really want to change? |
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Specialists: |
If you have specific chronic illnesses, are the specialists you now use part of the network? If not, do you really want to change? |
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Hospitals: |
Which hospitals participate? Is the one you would normally use part of the network? Are the doctors you use connected to that hospital? If your doctors are not connected with that hospital, think twice. |
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In relation to these three items, if you spend part of the year in another part of the country on a regular basis (for example in the winter) and/or visit children in other parts of the country, will you be covered -- and how -- for doctors and hospital expenses? This is very important! |
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Does the HMO pay for prescription drugs, dental care, eyeglasses, hearing aids, routine foot care? |
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Premiums: |
What does the premium cost? If you have Medicare, does the HMO accept the 95% rule or do you have to pay anything extra? |
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Co-Pay: |
What is the co-pay (the amount you have to pay) for office visits and various other services? If you use a doctor outside of the network or in another part of the country, how much do you have to pay? Keep in mind that with traditional Medicare the patient always pays only 20%. |
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Senior Sensitivity: |
Is there a gerontologist on the staff? Can the gerontologist be your primary care physician? If not, why? |
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Be sure and talk with seniors and their families. Some HMOs will not refer the elderly to specialists or recommend certain tests. The older and sicker the person is, the more likely this scenario is to develop. |
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What are the covered -- and even more important -- what are the uncovered services? How many office visits are you "allowed" each year? Make sure all the patients medical conditions and problems are covered. |
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If someone is not happy with the doctors or the care, what is the procedure for returning to Medicare or changing to another HMO? How long does the process take? And what happens to your medical needs during that transition period? Besides getting this information from the HMO, a call to Medicare is also warranted to confirm what the HMO says. Is there a cost to change? If so, what is it? |
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Where is the HMOs office located? How easy is it to get to? What is the parking situation? |
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Do any friends belong, and if so, how do they feel about the care and services? What are the reputations of the owner/administrator and the doctors on staff? Besides talking to others in town, including the current primary care physicians, call the state American Medical Association to see if there have been any charges or law suits filed against any of the doctors. |
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Most states license HMOs. But is there a periodic review and re-evaluation process? If so, how often does this occur? Has the state found any deficiencies or made any charges? Have there been any patient complaints about the |
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What are the criteria for referrals and what are the limitations? What is the appeal process if a patient wants to be referred to a specialist and is refused? What are the state regulations in reference to referral refusals? This is especially important for those over 80, who are more vulnerable to illness. Older patients more often get turned down in specialist referrals or testing situations than younger people |
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You have moved to a new home in another city, joined an HMO and been assigned a primary care physician. However, you do not like him/her and want to change. Can you? Or are you locked into that one doctor? |
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If the specialist is in the network, does the primary care physician make the referral once and then the patient is able to go as the patient and specialist feel necessary? Or does the primary care physician have to make an official referral for every visit? And if a referral has to be made for each and every visit, does the patient then have to physically go to the primary care physicians office for either the referral order or an examination? Also is the primary care physicians fee reduced if he refers "too many" patients to specialists "too often?" |
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Physician payment: One of the most important elements to look at is how the doctors are paid. Are they paid a set fee per patient regardless of the number of visits each year or paid a set amount per visit? A doctor who gets more money if he gives less care could be motivated not to work in the patients best interest. By the nature of the HMO system, the fewer services they give, the more profit the HMO makes.Physician Incentives: Are physicians monetary bonuses based on quality care and medical "outcomes" or on a low usage basis? Are physicians penalized if their patients have a high utilization rate and exceed the average number of visits factored into the HMOs financial plan? Is there a quality assurance program, and if so, how is it implemented? Medical cost ratios: What percent of the premium (received from Medicare or the insurance company) goes to direct care and how much to administration? At least 75% to 80% should go for direct medical care. If the administration ratio is higher, are there other non-medical services provided, such as patient transportation? Visiting nurses? Educational programs? Refusal to treat: One of the toughest elements involves whether or not the current physician will continue to care for a patient if the patient switches to an HMO. Physicians have been known to refuse to treat a patient who switches to an HMO, if he/she had been a Medicare fee-for-service patient. This is a definitive possibility if the physician is paid a flat fee per patient as opposed to per visit or is penalized money wise if the patient has frequent doctor visits. Weve had a long visit today. Tomorrow well talk abouta happier subject-- pets -- and how they can bring happiness and better health to everyone, regardless of age. This material is copyrighted by Carol Abaya Associates and cannot be reproduced in any manner, print, or electronically. |