Personal Business: BENEFITS
HOSPITALS: CHOOSING WELL TO GET WELL
Sunshine filtering through a skylight bathes the lounge as the pianist plays an old favorite. People congregate in small groups or sidle up to a buffet cart loaded with fruits and pastries. It could be any Marriott at teatime, except that many of the guests are wearing pajamas and some are in wheelchairs or hooked to intravenous drips. They're patients of Columbia-Presbyterian Medical Center's McKeen Pavilion, a hospital floor in New York with the amenities and ambiance of a hotel. Managed care? On this floor--where rooms cost $250 more than the regular $1,290 per day--care goes to those who can manage to pay.
Facilities such as McKeen point up a dichotomy in American health care. Managed care has compelled hospitals to cut staff, shorten inpatient stays, and shift treatment to ambulatory settings. Yet competition has also forced them to find new ways to cater to the needs of patients, especially those who have discretion over where they go for treatment. "You are seeing two pictures," says Dr. Arthur Kaufman, a physician who evaluates medical practice at Veterans Administration hospitals. "One is focusing on individuals and their satisfaction with the hospital environment. The other is getting them to come in and get out fast."
PREVENTION. Given this reality, the big question is how to get access to the best hospital care possible. Few people are completely unrestrained in their choice. Where they receive treatment will be limited by the parameters of their health plan and ability to pay. But even in this age of managed care, people should evaluate their options. Once they do, some patients, in reverse of customary practice, actually select a hospital first, then sign up with an affiliated doctor. "Whatever you do, don't wait until you are sick to investigate because that's when you are vulnerable and anxious," says Geraldine Dallek, director of health policies at Families USA, a Washington (D.C.) consumer group.
Traditional fee-for-service health insurance offers the greatest freedom to choose. A typical plan pays 80% of hospital costs after a deductible of about $500 per person, and 100% after the patient has spent $1,500 out of pocket in a year. Although the hospital you select ceases to be an issue, fee-for-service patients cannot just check themselves in at will. Many procedures and tests require clearance from the health plan's utilization manager first. And it's important to make sure that hospital charges fall within the insurer's guidelines for reasonable costs. Otherwise, the hospital might bill you for costs the health plan won't cover.
If you belong to a health-maintenance organization, your choice will be restricted to hospitals under contract with the HMO. The plan will usually pay 90% to 100% of all costs for an approved facility. If you have the option to leave the network, you'll generally be reimbursed for 70% of the costs, and a deductible of several hundred dollars may apply.
ENOUGH NURSES? In picking a hospital, whether from a preapproved list or not, be sure to check out doctor recommendations, hospital reputation, and published data on medical outcomes, death rates, numbers of board certified staff, and the ratio of registered nurses to beds. You'll find these in the Consumer's Guide to Hospitals ($12, Center for the Study of Services, 800 213-7283) and America's Best Hospitals ($19.95, John Wiley & Sons). You can also contact the Joint Commission on Accreditation of Healthcare Organizations (708 916-5800), which makes the results of performance reports available for $30 apiece.
If you don't already have a favorite primary physician, whittle down the list of network providers with an eye toward their admitting privileges at specific hospitals. Keep in mind that most doctors will refer you to specialists at the same hospital they admit you to, notes Robert Krughoff, president of the Center for the Study of Services, a Washington (D.C.) consumer group. To avoid limiting your options, try for a physician who has admitting privileges at more than one place. One could be a large medical center that provides acute care and is well equipped for complicated illnesses, such as cardiovascular disease. The other could be a community hospital that's capable of treating less risky illnesses and is situated closer to home.
Find out if your health plan requires that you use one of its designated "centers of excellence" for unusual or complex cases, such as transplants or cancer therapy. The centers are usually teaching hospitals affiliated with major medical schools, and many health plans will pay travel expenses for the patient and a family member. Treatment at such a hospital often provides access to the highest levels of medical knowledge. But it also means you will be examined by teams of medical students or residents, and that a significant portion of your care could be delegated to these trainees. That's a major drawback for some people, warns John J. Connolly, editor of How to Find the Best Doctors, Hospitals and HMOs for You and Your Family ($9.95, Castle, Connolly Medical).
DON'T BACK DOWN. If you want to receive coverage from a hospital that's outside of your plan, you must make a convincing medical case that you will benefit. For this purpose, it helps greatly to have a primary doctor who will go to bat for you. Also be prepared to wage a letter-writing campaign to the health plan as well as the hospital. Sometimes you can get the facility to cut a deal under which it will accept what your insurer normally pays. You have a better chance of getting your plan to be flexible if you're not going to cost it more money.
To get an idea in advance of how customer-conscious a hospital is, walk in the front door and see how well you are treated. Call the hospital to see if it makes customer-satisfaction surveys available. Then try to find people you know who were treated for the same types of illnesses. Were calls for assistance answered promptly? Are patients lost in the shuffle? Were the nurses caring and supportive?
Many hospitals have comfortable private rooms for an extra charge of $100 or more. At Columbia-Presbyterian's McKeen Pavilion, a concierge is on hand to assist with errands, and the dinner menu includes such items as roast salmon in a porcini crust. Tea is served daily at 3 p.m. in the glass-enclosed lounge. Health plans refuse to pay for private rooms unless there is a medical reason, but Columbia-Presbyterian finds patients who are willing to dig deep for the added comfort of McKeen. Catharine Kelly, 70, who suffers from cardiovascular disease, recently returned to McKeen for treatment of a serious foot infection. She says the care and comfort speeds her recovery--and for that reason "the best, in the long run, is the least expensive."
State teaching hospitals have less costly private and upgraded rooms. For example, the University of Illinois at Chicago Medical Center has a carpeted, wallpapered VIP suite in a quiet corner of most of its floors, says Sidney Mitchell, executive director. It costs $120 above the hospital's regular daily private-room rate. At the Medical University of South Carolina in Charleston, the 42-bed Palmetto Pavilion has wood-trimmed walls and early American furnishings. A room costs $450 a day, the same as the other rooms in the hospital, which are all private. A two-room suite costs an extra $50.
HEALING PETS. Instead of seeking luxury, you may want a hospital that focuses on your emotional health. St. Luke's Episcopal Hospital in Houston encourages patients to take up art as part of a program to provide a healing environment. For people who need cheering up, it arranges visits with dogs and rabbits. Such special support services have helped David Atchley, a 52-year-old oil refinery maintenance manager, through the ordeal of waiting since last July for a donated heart.
Very few healthy people like to dwell on the possibility that they may need hospital care one day. But evaluating choices ahead of time can make a huge difference. You may get the kind of treatment that leaves you feeling more like a respected guest--and less like a helpless inmate.EDITED BY AMY DUNKIN BY RICHARD KORMANReturn to top