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Lois Henry: Get pushy with HMO to get things done
| Sunday, Mar 2 2008 8:51 PM
Last Updated: Sunday, Mar 2 2008 8:51 PM
If penicillin were invented today, would your HMO balk at letting your doctor prescribe it for a “routine” infection?
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Can’t you just hear their response? “Soap and hot water are the standard of care. Penicillin may only be used when reviewed by your provider group and deemed medically necessary.”
Oh, you SO know they would.
Why am I down on HMOs? Because I just had to go to the mat with mine to get an OK for a digital mammogram screening instead of the traditional film screening.
I won, but only after two days of pushy and demanding phone calls to my medical group.
I’m not writing to crow about my success, but to lament that I had to go through this exercise at all. And I’m also wondering how many women, who are far less belligerent than yours truly, just take what they’re given by their medical groups and don’t know they can and should demand more.
Of the four medical groups I talked with, only Golden Empire Managed Care automatically allows digital mammograms without requiring any special approval, and has done so for the last few years. Both Bakersfield Family Medical Center (my group) and Kaiser Permanente require patients to have their doctor request a digital mammogram based on “medical necessity,” and that request is then run through the group’s review process and may or may not be approved, according to customer service reps.
Even at Kern Family Health Care, a private group that administers Medi-Cal locally, patients have to go through those extra — and I say unneeded — hoops, according to customer service.
Not only that, customer service told me they only allow screenings once every two years. That’s in spite of the fact that Medi-Cal automatically covers both digital and film mammography annually. Hmmm. Maybe that’s how Kern Family stocked up that $70 million reserve fund and was able to buy that fancy building on Stockdale Highway that county supervisors recently grilled them over.
And, ironically, “Cancer Detection Programs: Every Woman Counts,” a state program for women who don’t qualify for Medi-Cal and don’t have private insurance, does not pay for digital screenings. What’s in a name, right?
Now, I’m not saying digital mammograms are on par with the discovery of penicillin in the medical world, but they can be a better tool for finding problems earlier. Studies have clearly shown that digital screenings are better for women under 50 and those with dense breast tissue.
Some radiologists still prefer the traditional method, and oncologists I spoke with said the old way is still very effective. In fact, one doctor said the quality of the radiologist is more important than either manner of screening. And, of course, neither method will help if you don’t get it done every year or, at the very least, every other year starting at age 40. So GET IT DONE!
All things being equal, however, the cancer doctors told me digital mammograms are more helpful in understanding what is happening inside the breast tissue, as they are clearer and the picture can be rotated to give the doctor different viewpoints.
That means the doctor has a better chance of detecting cancer early, hence a better shot at saving that woman’s life.
I know getting emotional with an HMO is an act of futility. These are businesses, after all, and treatment costs are a bottom-line issue.
Allowing digital screenings, however, makes sense even on a purely financial level.
The cost difference for digital is negligible — about $70 more for cash customers and those covered by Blue Cross, $56 more for Medi-Cal patients and about $53 more for Medicare patients, according to Truxtun Radiology.
But the cost difference for treating cancers at their early, versus advanced, stages is astronomical.
That alone should spur managed care groups to go digital.
When I asked why I was being allowed to have a digital mammogram without my doctor requesting approval based on “medical necessity,” I was told BFMC does allow them for squeaky wheels like me. (Take note, ladies!)
And, because of other similarly “adamant” patients, BFMC planned to gather its policymakers last week to discuss and possibly re-evaluate its rules on digital screening. Kaiser also told me they were sorting out their policies, and I heard Kern Family is considering a change to automatically allow digital screenings.
They should all know by now where I stand.
Lois Henry’s column appears Wednesdays and Sundays. Comment at people.bakersfield.com/home/Blog/noholdsbarred, e-mail her at lhenry@bakersfield.com or call her at 395-7373.