Webcast KMCO Archives

The Basics of Managed Care

(Originally webcast January 26, 2000, 1:30 pm CST)

Q. Good morning everyone. We're really happy that you are with us. This is Faye Eldar from the University of Illinois School of Public Health. I'm the family coordinator for the Quality Community Managed Care project. Our project is funded by the Maternal Child Health Bureau and our goal is to work with the Title V Children With Special Health Care Needs agency and with managed care organizations to improve systems of care for children who have special health care needs. I'd like to introduce our two participants today on the webcast and ask them to each share a little bit about themselves, the work they do and their families with us. The first speaker is Karen Gugliuzza. Her background is in nursing. She is with Midland Management in Rockford, Illinois, which is in northern Illinois. Karen.

A. Hello, nice to hear again from you Faye and nice to talk to you Lynn. As Faye had mentioned, I am a registered nurse and my title is community care manager. I've been in the managed care industry for anywhere between 10 and 14 years and hopefully, I'll be able to share some information that will be beneficial to you, Lynn, and to those who are tuning in.

Q. Well, that's wonderful. Thank you Karen. Lynn Doolittle is a parent of 3 children who are 13, 11 and 7 years old. One of her children has special health care needs. She lives in Roscoe, Illinois and she works in the early intervention system in her region. Lynn, could you share a little bit of information about yourself and your family please?

A. Well like you said, Faye, I live up in northern Illinois, the very most northern part, and my youngest child is the one with the special health care needs. He was born 11 weeks premature and had a lot of medical problems from that. Some of his disabilities are cerebral palsy, shunted hydrocephalus, a seizure disorder and bronchopulmonary dysplasia which now it's being managed more like asthma. He gets daily treatments for that. I'm the parent liaison for Child and Family Connections and I'm also the local interagency counselor coordinator for our area and so I get to talk to a lot of families about different concerns that they have and one of them is their health insurance. Our early intervention helps play into that piece of benefits for their children with special needs.

Q. Lynn, could you please explain to us what is Child and Family connections and also what is early intervention?

A. Okay. Early intervention services are services for children from birth up to age 3 that have developmental delays. Child and Family Connections office was developed and there are offices all throughout the state of Illinois. It's the point of entry where families and physicians or anybody can call if they are having concerns about their child's development. Then we refer them to where they can go for free evaluations and assessments. We get them started and then we get them places where they can access the services for their child and the community.

Q. Well, thank you very much, Lynn. It's wonderful to know that such a valuable resource is available to families and children in our state. Now I'm going to ask Karen to take the first question and that is what is managed care? We hear so much talk about managed care. It seems just about every day there's something about managed care on the radio or on TV or newspaper. But could you tell us exactly when people say managed care, what do they mean and how is it different from the type of health insurance many of us grew up with?

A. There are various...I mean there are HMO's and there are PPO's and their are Point of Service plans. They are all under managed care planning.

Q. You Know Karen this sounds like alphabet soup. What's an HMO? What's a PPO? What is a POS? Today I heard somebody talking about EPO or EOS or something like that. Could you explain to us what these things are?

A. Exactly--alphabet soup. You just named a few that I'm not aware of. An HMO basically the name stands for Health Maintenance Organization. I think it was in the forefront with Managed Care. Realistically, it's a health insurance forum in which members prepay a premium for health services. Generally that would include in-patient and outpatient type of services, outpatient being physician visits, any of those ancillary services that would include physical therapy, that type of scenario. For the patient in particular, it means reduced out-of-pocket costs. In other words, there is generally no deductible that you would have to pay in order for benefits to happen. There generally is no insurance forms and generally there is a small co-payment that the member would have to pay based on whatever their plan sets up for them like a 10 dollar fee that they would have to pay for a doctor visit. The Point of Service plan it's somewhat similar to an HMO but it's referred to as an open-ended type of HMO. The model is in which a patient can receive care from a physician who is not necessarily part of the network. He may not belong to the network for that plan. What the member ends up paying is a little bit more out of their pocket. They are still eligible to see physicians out of their physician group. They have that choice to do that. Their incentive to stay within the network is through a little bit more extended coverage for them. Now PPO, it's Preferred Provider Organization and that's a managed care organization that does have various integrated delivery systems. That means there are several networks of providers that are available. Under the PPO benefit plan, a member can choose to receive services again in the network or they can opt to receive services out of a network. They may have to pay the difference in that coverage. Does that help to explain a little bit of the dynamics in somewhat of a simple form?

Q. Oh definitely.

A. Okay.

Q. It's really helpful to have these spelled out so we can know what the difference is because it does sound pretty confusing.

A. Yes it does. I would have to agree with that.

Q. What is the big difference between managed care the traditional kind of health insurance that we call indemnity insurance?

A. In the traditional fee for service, the actual providers that perform the services are generally paid for that service. In your managed care plan or organization, those providers basically are put on a fee schedule. In other words, they are contracted with the insurance plan to provide the service at whatever the agreeable contract between the provider and insured is. Under a managed care type of plan, those providers that provide health care services are in somewhat of a and I don't want to use the word capitated, but they are somewhat in an arena where there are contract arrangements between the physicians and with insurance companies. They want the members so they will follow the guidelines set by an HMO or a PPO or a Point of Service plan to provide those services. It's basically not to do with the members. It's pretty much involves the physicians and the providers. As far as coverage, it really depends on for the member what their benefit plan encompasses.

Q. Lynn, could you tell us from your point of view and I know you have talked with many families about health insurance and health insurance issues. When you explain to families what is Managed Care and what are these different kinds of health plans, what do you usually tell them?

A. I'm not really familiar with the POS. Most of them are in an HMO PPO type of deal. I encourage them to look at their plan and I give them examples of different strategies that I did with my family as far as my plan such as reading their plan through and seeing what is covered and what's not covered and going to their provider and asking them questions if they have questions about their plan. For example, some of the children that are real medically involved like my son was, going to them and asking them if they have a case manager available.

Q. Lynn, what would you say are the most important things that families need to know about managed care?

A. That there are pros and cons to all of it. Look at what your family's needs are. Faye, you had given me a really good checklist as far as going through managed care and what your families needs are and looking at your insurance plan and what's covered and some of the situations. I went directly to my insurance company and they were very approachable about providing services for my family that weren't covered under the plan and at least looking at it and saying that is a need and maybe looking for those providers.

Q. I do want to let everybody know that what Lynn is talking about is a brochure that was developed by Family Voices which is a national grass roots organization of Families and Friends who speak out for children with special health care needs and connected with this webcast, we will have a resource list on our web site that you can click on to and links to these resources will be available so everyone can take a look at them. There are a lot of helpful resources out there. I just think about some of the basic issues in Managed Care. One of the things that pops into my mind is who decides which doctor you go to and where you go and what's a referral? Karen, would you like to address that first?

A. It's really a member's choice. Now where it's limited to is that number of physicians that are within that organization. If it's an HMO plan, there are certain physicians that they are able to choose from. But if you are strictly in Managed Care, and most of your physicians are like that, if that physician feels it's out of their expertise to treat that child, there is the written referral and I know that is an interesting word because I think to a lot of people referrals are oh no. It's paper shuffling and what it is is a recommendation by the primary physician for a patient to be evaluated or treated by a different physician or specialist. I know basically I'm talking about those children with special health care needs. Maybe they need to see a pediatric pulmonologist or an orthopedist maybe that deals specifically with children. So that's the scenario regarding who makes the decision. Ultimately, it's the primary care physician within the guidelines of the plan. There may be those scenarios they have to opt out of the plan to get those services that may not be in the plan. That's another referral process where the Managed Care physician sets the parameters for guiding in that network or out of the network. Does that sound clear?

Q. Oh yes I think this is something that people ask questions about.

A. Yeah, the referrals.

Q. All the time. This is a really big issue and of course it is something that is really in the minds of families who do have children with special health care needs.

A. Right.

Q. I know there are lots of different ways to find out about options and finding out what's covered by a health plan. Lynn, can you tell us about some of the ways families can get information about what is covered in the health plan and what benefits are?

A. I just encourage them to go to their health plan policy and if they have any questions, there is usually a representative that they can call for questions if they have any questions about that. I know with my plan at the time my son was born, they were self-insured so they didn't cover a lot of the things that he had so I went in personally and spoke with the insurance representative. I had my case manager there and some of the representatives from the insurance company that were paying on the claim so that they had a more clearer understanding about what exactly these charges were for. I encourage them to write any questions they have down at any time so that they can remember them.

Q. Do insurance agents or human resource benefits representatives at people's places of work have a roll to play in helping families find out about these options?

A. In my case, we do have a representative at my husband's work. She usually is there also to help. I always have a question, should I call her or should I call the representative of the insurance company? I never know which one seeing I have had an ongoing with her because there's been many changes within our insurance plans from the time my son was born and she's been kind of a constant. Since she was an employee there when my son was born, I prefer to go to her. I don't know if that is right or wrong but that's where I go to and that's where I have expressed concern with her is that sometimes the plans are ever changing. Every year the employer is always looking for a better deal for the health insurance. So our plans are changing all the time and when you have a child with special needs and you have all these issues that you have to look over and a lot of them aren't covered in your plan especially things like therapy and even specialists, It's hard to always keep on top of things to know what exactly is covered. We've had two changes in two years and it takes a lot of my time to go through and find out what is covered whenever I'm having a concern or the doctor is having a concern and wants a referral. Plus with the specialists that he's seen, I mean he turns 7 in October, there is an ever-changing way as far as the way referrals are made. The requirements are always different depending on the insurance plan and sometimes depending upon who you talk to within the insurance. For example, sometimes at some points, well the referral to the specialist, even though he has been seeing them on an ongoing basis since birth are only good for 3 months. So you have to have that pediatrician make that referral again in 3 months or 6 months. Trying to keep track of all that stuff is really difficult not only for myself but also for my physicians. But just recently I called because we had gotten this new plan and I questioned her about it and she said it depends on how my son's primary physician writes the referral. It can be open-ended if it's on an ongoing basis because he sees the neurologist and the neurosurgeon and different doctors like that. So that has made it more helpful for me. But it's just making sure that my physician is writing it appropriately for my child.

A. I was just going to interject I agree with you, Lynn, the organization I work for is a group of physicians that we contract out to different insurance companies or HMO's or whatever and it's interesting you raise the question about referrals and that's one of the things we've identified in trying to work with our physician group and make it easier for these health plans is to identify those children with the needs that may need somewhat of an open-ended referral that's going to need a specialist for longer than 3 months. So that is interesting that you raise that question because that's one of the focuses or one of the key areas we identified and we would like to try and work through that piece of it also. It's very valid I think.

Q. I'd like to switch to a little bit different topic now and Lynn, I wonder if you can tell us what are the benefits to a family whose child has special health care needs to be in a Managed Care plan?

A. One is having the very low cost of the health care. I feel that usually my co-payments are reasonable and doable for our family so the lower cost is one of the key things for my family. But then also knowing that when my son has to go to the doctor to the pediatrician, which he has to go to more often for colds, pneumonia and different things like that, under my plan those visits are covered at 100 percent. So it doesn't deter me from going to see him. Whereas before when my other children were younger, it was only if they were real sick or had gotten hurt bad that I would choose to go take them to the doctor because I knew that it would be costing a lot of money for us to go so it's made it nicer for us to be able to go. Another big thing for us is the well baby checkups and the immunizations and things like that and knowing what our co-payments are up front. The paperwork is much better. I believe there is a lot less paperwork. I still do have some forms to complete but they are usually just on an initial basis. Usually in the plans, the care is more coordinated. My physician gets all the reports from my son's specialists. Sometimes it's harder when they are out of network, but the ones that are within the network are really good about getting the information passed back and forth to each other.

Q. So it sounds like there are a lot of benefits both in saving money and saving time and saving hassles and getting better medical care for the child.

A. Right.

Q. What are challenges to families who have children with special needs in Managed Care plans?

A. I would say getting someone within your network so you're not having that extra expense is a real big one for us. Sometimes getting a doctor's referral for out of network or out of network when I am not happy with an in network provider like you might have one pediatric specialist. If you are not happy with that specialist, trying to convince the insurance companies that you are not happy with them and that you have to go out of network.

Q. Now you mentioned that in the last couple of years, your family has had to change insurance companies several times. Have you had any challenges related to finding a primary care provider?

A. There was a point where I had wanted to change my son's pediatrician and there wasn't anybody who felt that they could take him. So families have to do a lot of leg work to go and interview the physicians. I know that that's been hard for families to try to find somebody just as a primary care physician sometimes.

Q. It sounds like you were able to provide families with some good strategies for working within the system though.

A. Yeah.

Q. I think that's really positive. Karen, now I have a question for you. How are decisions made about what gets covered and what does not get covered?

A. From my organization's perspective is we implement the policy and procedures by whatever health plan that we are performing services for so if our physician panel has a member under an HMO plan, we have to incorporate the benefit structure in place for that member. In a Managed Care organization and HMO, the Managed Care company, they have various governing bodies and they are all professional medical persons who would make the first line decision. Is it something that they can provide services in network? We would go there. The member always has a right to appeal a decision and take it to the higher level if it's a benefit issue.

Q. Well again this sounds complicated but it's something that is really important for our families no doubt.

A. It is. I think one way for them to be aware is to do as much as well I know it's difficult for all of us. I even have the benefit package handbook to know what's covered and what's not. But I think what i am hearing is what Lynn is saying. There are a lot of scenarios that you face that may not be covered for that child with special needs. So it is something I would suggest knowing what your benefit package is. Understanding your benefit plans is what's hard because sometimes it's not clear in the documentation benefit plan to know actually what's covered and what's not and what is considered cosmetic and what's not and what's medically necessary and what's not. It's a complex thing but the decisions basically ultimately are made by whatever the plan design is.

Q. I think you both have touched on a lot of really important points and you both have a lot of information to share with us. We have to get ready to wrap up this webcast. Lynn and Karen, I want to thank you both really much. You're both really knowledgeable and I think it is fortunate that you are both located in the same region of Illinois so you can continue to be a resource to one another.

A. Right. Good.

Q. Well thank you.

A. You're welcome and thank you. I really appreciate your willingness to devote your time and expertise to us in our discussion today about the basics of managed care for families who have children with special health care needs. Thank you very much.

A. You're welcome.

A. Thank you. Goodbye.

Q. This concludes the first webcast in the KCMO series on managed care and children with special health care needs. Thanks for logging on to our first webcast production. We are very interested in your comments and questions regarding our webcasts and we invite you to contact us at cade@uic.edu, our e-mail address. Our voice number is area code 312-996-2233 and our fax number is 312-413-0367. We hope that you've enjoyed this broadcast and that you will join us for the upcoming broadcasts scheduled for the fourth Wednesday of each month at 1:30 p.m. Central Standard Time.

Please note that once a webcast has aired for the first time, it will then be archived on the QCMC2 webite and can be accessed at any time. Our Internet address is http:/www.uic.edu/sph/cade/qcmc2 and it features the archived webcast's extensive lists of webcasts related to children with special health care needs and Managed Care. Links to opportunities for on-line training and courses, information on our project staff and activities and our featured web site of the month and much more. Our upcoming webcasts include How To Select A Health Plan for Your Family And Your Child With Special Health Care Needs, which will be on February 23rd, 2000 at 1:30 p.m. Central Standard time. Understanding, Accessing And Appealing Your Health Care Benefits will be on March 22nd, 2000 again at 1:30 p.m. Central Standard time and our April program will be on April 26, 2000, Health Care And The Law again at 1:30 p.m. Central Standard time is the broadcast time. Each webcast will feature a member of the QCMC2 staff, a professional and a parent of a child with special health care needs.

Thank you for joining us and have a healthy New Year.  

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