Mastering the Maze: Taking Control of Your Health Care

Published on: September 01, 1997

The movement in health care toward a managed care environment has left many people lost in a maze, confused about terms such as PPOs, HMOs, and capitation, and feeling abandoned and bewildered by the very system that is supposed to help.

What can you, as a medical consumer, do to protect yourself?
Become educated about managed care and have a map to the all too confusing maze of health care.

Choosing Your Coverage
Step One
Choose the appropriate coverage for you and your family. Find out the differences between plans and plan types, whether they be health maintenance organizations (HMOs) or preferred provider organizations (PPOs), so that you can choose what's best for you and your family.

It's important to understand that the goal of any health plan is to manage the costs of health care, not the care itself. Plans often encourage their participants to take proactive, preventive steps through low co-pays and other financial incentives.

Good sources for information about health plans are your family members, friends, coworkers, and other policy subscribers. They can help you if your plan is provided by your employer or if you're starting from scratch.

Step Two
Once you've chosen a plan, or your employer has chosen one for you, take the time to read and understand the "evidence of coverage" handbook. This will be your guide to working with your plan provider and taking control of your own care. It will tell you what you can expect the plan to cover-and not cover. If you don't understand what's there-or what's missing-be sure to contact the organization and find out.

Issues like emergency room coverage, pre-existing conditions, and hospitalization limits will affect the kind of health care available to you. Find out if the plan provides direct access-if you will be able to consult directly with specialists of your choice or request special tests.

One way to ascertain the quality of a managed care organization is to find out if it is accredited by the National Committee for Quality Assurance (NCQA). The NCQA's mission is to improve the quality of HMOs, to show which organizations manage quality, not just cost. You should also investigate whether the hospital and laboratory your physician works with are accredited.

Choosing Your Doctor
It's important to remember the seven "Cs" when it comes to choosing the physician who's right for you. Your physician, in addition to knowing very personal things about you, can help you as an advocate in working with the health care system.

Be sure to investigate the doctor's professional reputation.

Remember that you, as a health care consumer, have a right to a second opinion or to change doctors.

No Conflict of Interest
Be sure that there is no conflict of interest that could compromise the quality of your care. An example of this is capitation, where a doctor is paid a set fee per patient regardless of the care given to each patient. Some fear that this may encourage physicians to limit treatment or tests in order to save money.

A physician's credentials don't guarantee his or her competence. You, as a consumer, should ask your doctor to:

  • Itemize solutions to medical problems
  • Describe the benefits of each solution
  • Describe the risks and downsides of each solution
  • Describe any other options
  • Put all of it in writing

A strong, communicative relationship with your doctor can help separate helpful health information from the harmful. Ask questions.

Your physician should show you respect and demonstrate that he or she sees you as a human being.

Continuity of Care
It takes time to develop a trusting relationship. Having a long-term relationship with your physician will help ensure that you receive the best, most appropriate care.

Problem Solving
What can you do, and where can you turn, if something goes wrong?
All health plans have a grievance process, but it can be slow-moving and may not provide a satisfactory outcome.

Remember that persistence pays off. Talk with your doctor, with your benefits office, and always put everything in writing.

In addition to the grievance process, other resources, such as government agencies, telephone hotlines, local churches, and national organizations, can provide assistance. The Internet can also be a good source to find help.

Remember that you as the health care consumer are your own number one advocate for quality health care. Your physician will work with you, but it is up to you to take control-to master the maze of managed care.

Glossary of Terms

Access:A patient's ability to obtain medical services in a timely manner and where geographically convenient.

Capitation: A reimbursement method where a fixed payment amount per member enrolled in a managed care plan, per a certain period of time, is paid to a health care provider. The provider is responsible for delivering or arranging the delivery of all health services required for the covered person under the condition of the provider contract.

Closed panel: A managed care plan that contracts with physicians on an exclusive basis for services. Members of the plan can only use doctors in the group for their medical care.

Coinsurance: The amount of the cost of care that the patient or covered individual is responsible for. This is usually determined by a fixed percentage, and often applies after a specific deductible has been met.

Copayment: A fixed dollar amount that is paid by the patient or covered individual at the time medical services are rendered, typically for physician office visits, prescriptions, or hospital services.

Cost sharing: Where the patient is responsible for partial payment for services rendered.

Deductible: The portion of a plan member's health care expenses that must be paid out-of-pocket before any insurance coverage applies. This is more common in indemnity insurance plans and in PPOs than in HMOs.

Discounted fee-for-service: A financial reimbursement system in which a provider agrees to provide services on a fee-for-service basis, but with the fees discounted by a certain percentage from the physician's usual charges.

Fee-for-service: The traditional health care payment system in which providers receive payment for each service delivered. Under this system, the total bill increases not only when the fees increase, but also when more units of service are rendered.

Gatekeeper: This refers to a primary care case management model health care plan. The "gatekeeper," usually a family physician, internist, or general practitioner, serves as the patient's initial contact for medical care and referrals and must see a patient before the patient can be referred to a specialist or hospital.

Health maintenance organization (HMO): An HMO is a formally organized system that integrates the delivery and financing of health care services.

Indemnity insurance: A program in which the insured person is reimbursed for covered expenses.

Managed care: A system of providing health care services to plan members through a defined network of health care providers who are responsible for providing "quality" care while controlling resource utilization, use of expensive technologies, and access to specialists. Managed care can include a variety of systems.

Out-of-pocket limit: The total payments toward eligible expenses that a covered person is responsible for. This includes deductibles, copays, and coinsurance as defined in the contract. Once the limit is reached, benefits increase to 100 percent for health services received by the covered person during the remainder of that calendar year.

Preferred provider organization (PPO): A managed care plan that contracts with a select group of participating providers. PPO coverage typically allows members to use non-PPO providers, but higher levels of coinsurance or deductibles may apply to services provided by non-participating providers.

Preventive care: Health care that is designed to prevent disease, to detect and treat it early, or to manage its course most effectively.

Primary care physician: A generalist physician, such as a family practitioner, pediatrician, or general internist, who may act as a "gatekeeper" in a managed care organization.

Referral: A formal process that authorizes a plan member to obtain care from a specialist or hospital. Generally, a plan member must obtain the referral from his or her primary care doctor (also known as a "gatekeeper").

Specialist: A physician or other health professional who has training and expertise in a specific area of medicine; for example, cardiology or dermatology.


Consumers' Groups American Medical Consumers
5415 Briggs Avenue
La Crescenta, CA 91214

Consumer Coalition for Quality Health Care
1275 K Street, NW
Suite 602
Washington, DC 20005

Consumers' Union
101 Truman Avenue
Yonkers, NY 10703

Laboratory Accreditation
College of American Pathologists

325 Waukegan Road
Northfield, IL 60093

Health Plan Accreditation
National Committee for Quality Assurance
2000 L Street, NW
Suite 500
Washington, DC 20036

Hospital Accreditation
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181