The ABCs of HMOs

Awhile ago, I mentioned that I would address the topic of HMOs and why they are not necessarily the enemy of quality medical treatment. This is the topic of this posting.

Disclaimer: I can only speak from my experience and about my particular HMO, and I am not a paid promoter of HMOs.

OK, now that we got that out of the way, let's delve into the world of managed care, as well as how you can best make the HMO work for you.

Advantages of HMOs over PPOs

As one of the people lucky enough to have medical insurance, I am very happy with my HMO. Some primary care physician groups do not have quality doctors, I'm sure, but I selected my primary care physician based on a group affliated with a first-rate hospital.

Unlike the horror stories you hear in the media, my HMO doctors are outstanding.

Through my HMO, I was able to get all my cancer treatment -- chemo, surgery, radiation, etc. -- free of charge. Trust me, I saw the statements of all the charges I would have owed -- enough to give anyone heart trouble and a new set of specialists -- and I know that with a PPO I would've had to pay a certain portion of it, and a small portion would've still been a ga-zillion dollars.

Also, what PPOs don't emphasize is that they have a ceiling, where they won't pay anymore after a certain amount of funds are exhausted. The cap is a high amount, so it's not a problem for routine problems and conditions, but cancer treatments and reconstructive surgery would have driven a sledgehammer through a PPO's ceiling, and expenses would've gone through the roof.

HMO: That's A-Okay

Another little-known fact is this: many HMOs will cover a medically necessary procedure done by out-of-network doctors -- if the primary care physician, also known as the gateway doctor, advocates on your behalf. That is why it's so important to have an excellent relationship with your gateway doctor and to hire the best one for your needs.

When you have an excellent gateway doctor, the HMO experience can be wonderful. That's the key: finding and hiring that gateway doctor to help you help the HMO meet your needs.

In my situation, I needed a double mastectomy with reconstruction. Because I was young, fit, and active, a double tram flap procedure was not an option because too much abdominal muscle would be removed, and I might not ever be able to sit up on my own. According to my doctors, the procedure I needed to reconstruct both breasts was a Diep flap, a more cutting-edge surgery (pun intended), designed to preserve as much of my abdominal wall as possible.

One doctor of reconstructive surgery who was recommended to me by many medical professionals was out of my HMO network, although affiliated with my hospital. I wanted him as my surgeon, but as he was out of network, my gateway doctor said that in order to make a case to the HMO that I needed the skilled Diep flap surgeon, I had to first see the in-network plastic surgeon to ask his recommendations. While I dreaded this pain-in-the-butt step, it had to be done, explained my doctor, as she and my oncologist were drafting their letters on why I needed the Diep flap procedure.

Here was the key on which my fate would turn: If the in-network plastic surgeon could do the Diep flap, then he would be my surgeon. However, when I saw him, he said I needed the Diep flap, but he is not skilled in this arena, and I'd need to go out of network. He drafted a letter on my behalf to the HMO, stating that I needed this procedure that he did not perform.

A few weeks later, the HMO came to its conclusion: It would cover the ENTIRE cost of the Diep flap, hospital stay, and all followups as needed. And, because my surgeon needed a doctor skilled in this type of surgery to help him (also out-of-network), the HMO paid for that additional surgeon as well.

Cost to me: 0 cents. Cost to my quality of life: priceless.

Whether you have an HMO or PPO, though, the key is to have the right doctors in place, so if a time of medical need arises, they will advocate for you.

Beth L. Gainer is a professional writer and has published an essay on her breast cancer experience in the anthology Voices of Breast Cancer by LaChance Publishing. She teaches writing and literature at Robert Morris College in the Chicago area. She can be contacted at bethlgainer@gmail.com and gainercallingtheshots@gmail.com. She also blogs on the adventures of her cats, Hemi and Cosette, at http://www.catterchatter.blogspot.com/.

The Gateway Doctor

My grandmother always told me, "If you have your health, you have everything." As a child, I didn't understand the truth in these words. I didn't heed these words as a healthy young adult: I came from very genetically healthy stock -- people in my family die of old age for goodness sakes, even the ones exposed to asbestos, lead, and various other toxins!

I didn't heed my grandma's words until I was diagnosed with breast cancer. Because let's face it: I, as so many people, took my health for granted -- until I didn't have it.

Now I'm going to spin my grandma's words to suit my medical-advocacy purpose: "If you have a great gateway doctor, you have everything."

Besides you, the most important person managing your health care is the "gateway doctor," also known as the primary care physician, internist, general family doctor, etc. Whether or not you are healthy, whether or not your family has had the same physician they have felt comfortable with for decades, whether or not your doctor is well-versed in all of the new medical technologies, whether or not your doctor has had an established practice with a good reputation, it all boils down to this:

Do you trust your family doctor with your life?

If the answer is anything but a resounding, enthusiastic "YES!," find another doctor immediately. Your life is too precious to take a chance with incompetence and mediocrity.

I measure competent doctors by their medical and emotional know-how. They must be medically competent (sounds like I'm stating the obvious, but it needs to be stated) and they must have your best interest at heart. The latter point means more than just bedside manner: I have had doctors be pleasant to me during an examination, but mere pleasantries are not enough.

You must LOVE your doctor.

As is the case with specialists, the ideal gateway doctor cares about you as a patient and will work as hard as possible to advocate for you. Another perk is that a great family-practice physician tends to keep company with other excellent doctors -- and that opens the gateway to outstanding medical care.

I was lucky to have an outstanding gateway doctor in place before I got diagnosed with breast cancer. She was my physician for years because we had great patient-doctor chemistry.

Let me tell you what she did for me during my breast cancer journey:

She called me often, coaching me through the diagnosis and prognosis. She listened to me, and validated my concerns. She encouraged questions and provided prompt answers. She returned my phone calls, often on the same day that I left her a message. And she was working behind the scenes and putting an excellent team in place for me. She landed a great surgeon, steered me toward a fantastic medical oncologist and radiation oncologist. These top-level professionals all worked tirelessly to save my life, but they didn't treat me as if I were a mere patient.

They treated me like family.

And they were all HMO doctors.

(In a future blog, I will dispel the myth that all HMO doctors are bad.)

And even though I had a medical team of specialists who were unbelievably outstanding and kind -- like off-the-charts brilliant and sweet people -- I probably wouldn't have crossed paths with them, had it not been for my gateway doctor, whom I have called my guardian angel.

So now that I've waxed poetic about my gateway doctor, here are some litmus tests that can help you find the doctor that's right for you. These tests also apply to specialists, but you need a great PCP in place before you can even consider a specialist.

You'll need to set up a routine exam, perhaps with several doctors, to find the right one so please be patient.

Litmus test one: During your meeting, give an emotional prompt, like: “I’m afraid of blood tests.” Observe the doctor’s reactions. Is he/she emotionally vested in you? Reassuring? If not, find another doctor.

Litmus test two: Sometime in the week following your exam, call the doctor to ask a question. Does the doctor call you back promptly? Does he or she communicate with you clearly and patiently? Does he or she take your concerns seriously? If the answer to any of these is “no,” find another doctor.

Litmus test three: Based on litmus tests one and two, do you LOVE your doctor? If you are feeling badly about him/her or just so-so, find another doctor. Don’t settle for mediocrity because if there were a medical crisis, a doctor you love and who cares deeply about your welfare will be the one who fights for you.

Litmus test four: Does the doctor play “ring around the patient,” where he/she continuously throws statistics to impress you with his or her know-how? Does he/she come with print-outs of pages from the Internet to illustrate these statistics? Do you feel confused during and/or after the session?

Run – do not walk – away from this doctor.

Litmus test five: Does the doctor use scare tactics, telling you all the terrible things that can happen to you? Is he/she dismissive of your emotional and physical needs? Does he or she sound like a doctor who has watched too many ER or Grey's Anatomy episodes? If so, this is not the doctor for you.

All in all, trust your instincts and be persistent in your goals to find a great doctor. You will know whether a doctor is a good fit for you. Also, if you suspect something is wrong and a doctor does not give you a satisfactory answer or solution, then continue advocating for yourself. Don’t accept answers like, “You are too young to get cancer.”

Demand to be treated with respect and, if need be, be difficult to those who treat you unfairly. You have an amazing power to demand to be treated with respect – whether from doctors, nurses, and office personnel. If someone treats you with disrespect, such as rudeness, talk back.

You are nobody’s doormat, and they need to know it.