HMOverdose

April 10, 1995|By CASEY THOMAS

I didn't want to join a managed-care plan. I loved my Blue Cross-Blue Shield plan, but it didn't love my employer and dropped us like a hot potato one year when ''not enough'' employees had chosen it. So I got stuck in Tufts Associated Health Plan. It was the only one of the choices my employer offered that would let me stay with the two doctors I had seen for years.

I'm not sick, fortunately. I have routine and relatively trivial ailments, and one not-serious chronic problem for which I take a daily pill. I've gradually discovered what all those managed-care advocates mean when they say managed-care plans are more efficient and cut out unnecessary expenditures. They mean they shift their costs onto me and my doctors. They mean I get less care, but that's OK because the decrease doesn't show up in their accounting systems. On paper they look great.

For my chronic problem, I get checked out twice a year by a specialist to make sure that nothing's changed and that I'm still tolerating the medication without untoward side effects. But since I was forced into Tufts, neither my specialist nor I can decide whether and when I should have a checkup. Only my internist, the person Tufts calls my primary-care provider but who is also its gatekeeper, can authorize a visit to the specialist. If these are to be covered, I have to seek a ''referral'' from Dr. Gatekeeper. Three years ago that was a nuisance, but still relatively easy. Dr. Gatekeeper handed me a referral form, good for three visits with Dr. Specialist.

But things got more complicated. Tufts said a referral form was good only for three months. I don't need specialist visits often -- only every four or six months. So I started having to procure one of those forms for each visit to the specialist. At first, I could get a form with a phone call to Dr. Gatekeeper's office, but his staff got swamped with all this paperwork and asked me to send a written request with a stamped envelope addressed to the specialist, or I could come in and pick up the form. The little costs to me of Tufts' cost-saving strategies were starting to add up. I can't begin to calculate the costs to Dr. Gatekeeper as more of this and his staff's time went to referral paperwork.

Then there was the matter of my once-a-day pill. Last year I went abroad for two months and wanted a 60-day supply of pills to take along. But when my pharmacist tried to fill the prescription and bill it to Tufts, Tufts denied the request, saying it allows only a one-month supply, and will not pay for another refill until 28 days have elapsed. I contacted Tufts, explaining my situation. I got an unhelped response: Sorry, we can't bend our rules, but you can pay for your second-month stock now and file for reimbursement later. More time and money costs to me.

Once I learned of the one-month supply rule, I couldn't help but notice how it creates lots of waste, too. My pharmacist has to take the time to prepare 12 labels in a year, fill 12 bottles and file 12 claims, when she could just as well give me a year's supply, were it not for Tufts' cost-saving rule. She has to use 12 plastic bottles and caps, instead of one large one. I have to make 12 trips to the pharmacy. Does anybody think these costs are counted when the economists and health plans tote up all the savings from efficiency and good management in managed care?

Recently I hurt my knee and needed physical therapy. It was a specialist who examined me and prescribed physical therapy, but in order for my insurance to cover the treatment, I had to have a referral from Dr. Gatekeeper. Since I've rarely managed to procure a referral with fewer than two phone calls to the internist's office, I expected delays. So I went directly from my specialist to Dr. Gatekeeper's office, prescription for physical therapy in hand, to collect the precious referral. A clerk looked at the prescription (three times a week for three weeks, it said), filled out a form and told me she would have Dr. Gatekeeper sign it and would mail it to the physical therapist.

By the time of my third physical-therapy visit, the referral still hadn't arrived. I called Dr. Gatekeeper's office. The physical therapist's office called. Eventually a referral came, but it authorized only three visits. Meanwhile, the physical therapist, in self-defense born of experience, was having me sign an agreement before she treated me each time, saying I would be financially responsible for the services should my insurance not pay.

It turns out that the maximum number of visits Dr. Gatekeeper can authorize on one referral form is six. I'm way behind. I've already had seven visits, only three of which have been authorized, and I clearly need lots more.

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