Rensselaer Polytechnic Institute is going to a managed care health plan
(in addition to offering some HMOs).  You pick a primary care physician
(PCP) from a list and then he must approve any specialists.  From
experience, I assume that they're hiding negative things about the new
program.

For example, Human Resources (aka Personnel) said that the PCP made the
decision, totally on his own, send us to a specialist.  Then it came out
that this is FALSE.  If the proposed specialist is not in the network,
then the plan administrator (Community Health Plan) must approve it, and
they do say no.  They also had neglected to mention that no new
specialists are being allowed to join the net, and in fact gave the
opposite impression to some people.

So, my question, to doctors on the net, or to GE employees in the area,
is what specific questions should I ask Personnel to ferret out any
other restrictions?  Thanks.

If you email replies, I'll post them in a batch, condensed.

------------------------

 ECSE Dept., 6026 JEC, Rensselaer Polytechnic Inst, Troy NY, 12180 USA

                Oh, don't the day seem lank and long
                When all goes right,  And nothing goes wrong?
                And wouldn't life seem exceedingly flat.
                With nothing whatever to grumble at?

                           Princess Ida, Act II

ask if each visit to a specialist must be approved separately.  Find out
how many generalists there are in the program.  ask if they are paid
per visit or are salaried.  If there are few generalists they will not
have a lot of incentive to please their patients, or if they are salaried
they will not either.  If the generalists are many and are paid per visit,
then they will be more inclined to please their clientel, and referral
to a specialist is one way to do that.  these, are, of course, gross
generalizations, and the main advantage of a lot of generalists in the
group is that they will be able to see you with little delay and if
they copmmunicate closely with the specialists, will be able to provide
excellent followup care after the specialty visit.

Steve Holland

Ask if each visit to a specialist must be approved separately.  Find out
how many generalists there are in the program.  ask if they are paid
per visit or are salaried.  If there are few generalists they will not
have a lot of incentive to please their patients, or if they are salaried
they will not either.  If the generalists are many and are paid per visit,
then they will be more inclined to please their clientel, and referral
to a specialist is one way to do that.  these, are, of course, gross
generalizations, and the main advantage of a lot of generalists in the
group is that they will be able to see you with little delay and if
they copmmunicate closely with the specialists, will be able to provide
excellent followup care after the specialty visit.

Steve Holland

   You need to ask "How many visits and for how long a period does a
   specialist referral last?"
   Ours is 90 days and 3 visits, whichever is first.  Not written down.

   Get in specific terms how claims are handled if your spouse has coverage
   elsewhere and uses your HMO all the way.  My specialist wanted to collect
   his whole fee (bills to us) after my wife's Blue Cross paid 1/2 and Cigna
   paid up to their discounted amount.  In other words, if my wife was covered
   solely by my plan, she would have had to pay $10 copay to Cigna HMO.  Because   she was covered by a 2nd plan, Blue Cross, her primary
   coverage, the specialist persistantly sent threatening letters for us to pay
   the amount above the Cigna discount.

Bruce Helenbart
Virtual Realist

Based on both personal and professional experience, I must disagree with
the premise that more PCP's and per-visit compensation equals more
incentive to please the patient.  Depending on the network and the setting
(clinic-based or community-based), it may well be the opposite.  PCP's who
act as gatekeepers for specialty referrals often are quite conscious of
that responsibility, have chosen it (most PCP's choose *not* to act as
gatekeepers) and, if they are salaried, it makes no monetary difference to
them whether or not they refer you (although they will be operating under
network and/or clinic guidelines).  However, in the community, many PCP's
are tired of losing patients to specialists and would rather try to keep
the patient under their roof or at least their closest specialist friend's
roof. Also, community hospitals play out, on various committees, a PCP vs.
specialty turf struggle, leading to decreased chance of ongoing
communication between the two for any particular case, until/unless
hospitalization takes place. The academic medical centers are often
embroiled in "town and gown" games, and a community practitioner generally
has *no* particular desire to refer you to a specialist at a larger
institution and vice versa. In a large, well-organized multi-specialty
clinic, you would certainly have much better communication between PCP's
and specialists, because you would only have one chart.  The bottom line
is, assume the worst and look for options.  If you can enroll in a POS
and/or triple-option plan, do so. Also, ask about how easy it is to change
gatekeepers.

--

Watch out!  There's a gun behind that law.
My comments represent no organizations, organized people, or organizers.