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Getting the Best Care from Your Health Plan


In the new world of health care, you may be picking your own doctor, drug plan, even your health insurance--and then paying for it with the help of an allowance, perhaps partially funded by your employer. Even if you remain under an all-encompassing HMO, being a smarter health-care consumer couldn't hurt. With drug companies pushing their pills on TV and word of the latest treatments coursing over the Internet, it helps to bring some patient savvy to the examining table.

You still have to research some decisions the old-fashioned way, with advice from friends about doctors and calls to drugstores to check the price of a needed prescription. But these days, thousands of medical Web sites are also out there to help you. The sheer volume of Internet information can be daunting. Type "high blood pressure" into Google's search engine, and links to 1.4 million sites and articles pop up. Not all of that info is reliable, so we'll lead you to some good places to start. Your best bet is often sites run by government agencies or by recognized organizations such as the American Medical Assn. or Mayo Clinic. Be especially skeptical of sites sponsored by drug-industry groups or companies that are trying to sell you a particular drug or treatment.

Lots of important research still can't be found on the Net--or from other public sources. Need a rheumatologist to treat your arthritis? You usually have no way to compare their treatment-success rates. And the only way to get even rudimentary price information is by calling doctors' offices one by one. Hospitals? Medicare does collect treatment-success rates for the 65-and-older crowd. But, under industry pressure, the government stopped publishing that data years ago. Now, they're available only through secondary sources that may charge you for them.

Still, Web sites can help you cobble together a lot of useful info. And some government and nonprofit groups are working to fill the gaps.

-- Looking For Drugs. One of the most promising projects is under way in Oregon, where the state, led by a physician-governor, has taken on the task of comparing drugs based on their effectiveness. The first reports have just started coming out, and a more accessible Web version is expected to go up on the state's health-policy site (www.ohppr.state.or.us) by June. It could take two years to evaluate all 25 classes of drugs being examined, says Kurt Furst, executive adviser for prescription drugs for Oregon Health Plan. The information will provide consumers with a unique tool for deciding if a more expensive drug is worth the cost.

Right now, you can log on to a site such as the one that links to California's Internet Formulary Reference (www.ca.mcodrugs.com) to get an idea of which drugs are commonly prescribed for your ailment. (You'll still need to find out if a generic or suitable over-the-counter medication is available.) Then, you can call local pharmacies or go to online pharmacies such as www.cvs.com and www.clickpharmacy.com to compare prices. Just make sure any Web pharmacy you use has a VIPPS (Verified Internet Pharmacy Practice Sites) certification from the National Association of Boards of Pharmacy. You can find a list of certified online pharmacies at www.nabp.net.

You can usually find more than one drug to treat a problem--and often a cheaper generic version is available. A private site, www.rxaminer.com, will, for an annual fee of $12.95, suggest less expensive alternatives to brand-name drugs. Consider such info advisory only--your doctor may have a specific reason for prescribing more costly medication. But it can't hurt to ask.

You may be tempted to buy one of the prescription-drug cards offered by drugstores, discounters, and drugmakers. Consumer-advocacy groups such as Consumers Union have doubts about the value of these cards. Patients must crunch the numbers to determine if the potential savings on the drugs they use will outweigh the card's cost, which can run from $10 to $84 a year per person covered. Giving your prescription info to card vendors, which are neither health providers nor insurers, also raises privacy issues. And consumers complain that some pharmacies don't honor the cards.

-- Picking A Doctor. Finding a good primary-care doctor and or top specialist is usually the starting point for a health-care consumer. Ironically, this is the area in which the least high-tech help is available. The federal Centers for Disease Control & Prevention publishes a detailed report on the success rates and number of procedures performed by fertility clinics on its Web site (www.cdc.gov). New York, New Jersey, and Pennsylvania collect outcome data for heart-bypass surgeons. Those results, as well as some other procedure-linked information, can be found at www.healthcarechoices.org.

In general, the traditional collecting of recommendations from family, friends, and doctors you know may still be the best way to find a local doctor. Physicians who teach at a medical school and can send patients to its top-notch hospital are often good choices. It may be useful to know how receptive a candidate is to communicating by e-mail. Also, find out how quickly a doctor returns phone calls and can work you in if you're sick. For specialists, ask how often the doctor has performed the procedure or surgery you need and see if there's a measurement for success rate.

Make sure the doctor you're considering is board-certified in the appropriate specialty. The sites of the AMA (www.ama-assn.org) and American Board of Medical Specialties (www.abms.org) offer that information. Others, such as www.docboard.org and www.healthcarechoices.org, can help you find out about disciplinary actions against a doctor. Some paid sites, such as www.bestdoctors.com and www.checkbook.org, provide ratings based on recommendations from other doctors.

-- Checking Out Hospitals. The Consumers' CHECKBOOK site and the free www.healthgrades.com draw on the Medicare data about fatality rates and the percentage of procedures with poor results. They also factor in a new quality measure known as Leapfrog, which judges hospitals based on whether they use a computer system that can check for errors when patient drug orders are entered, whether they have appropriate specialists available for their intensive-care units, and whether they perform a minimum number of certain procedures. CHECKBOOK adds doctor ratings as well as hospital reviews by the Joint Commission on Accreditation of Healthcare Organizations. Patients can find those reports and check for deficiencies at www.jcaho.org.

-- Looking For Coverage. If you have to find your own insurance, know that an HMO will have lower co-payments and may encourage better preventative care. A preferred provider organization (PPO) will come with low co-pays as long as you stay in its network of doctors and hospitals, but will give you more flexibility to go outside the network. Fee-for-service will be more expensive but may cover treatments the other plans do not, as well as providing maximum flexibility in deciding where you can go for care.

The National Committee for Quality Assurance (www.ncqa.org) is the best-known group evaluating health plans. You can find price quotes by visiting www.ehealthinsurance.com. But you won't get the real rate until you apply for the insurance and give your medical history. If you want human help, an independent insurance agent can give you the merits of different plans.

You'll need to read the policy's fine print to figure out what deductible you must meet before the plan will pay, and what your co-pay will be after that. Find out what your maximum out-of-pocket expense could be, as well as the policy's lifetime-reimbursement cap. Avoid plans with annual caps. Check which conditions or treatments will be excluded and what the payment limits will be for things such as psychiatric care and physical therapy.

-- Getting Smarter. These days, it's good to do research on any medical condition you have. Doctors don't always know about the latest findings. And as an informed patient, you may get more time and attention from your doctor.

The Medical Library Assn. (www.mlanet.org) is a good place to search for recommended medical sites. At government-run sites, info has been vetted by professionals and is free from the influence of advertisers and health-care sponsors. The U.S. National Library of Medicine's site, www.nlm.nih.gov, provides links to medical articles and abstracts. Much of it is tough reading, since it's written for doctors. But the library's MEDLINE-plus link adds valuable information on diseases and medications that's more accessible to the layman. If you want to get supersavvy, browse the treatment guidelines doctors refer to at www.guideline.gov. To research an ailment, check out the National Health Council's www.nationalhealthcouncil.org. It has links to groups that focus on particular illnesses.

It's a complicated world, but that doesn't mean you can't live a healthy life in it. By Carol Marie Cropper


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