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[IP] HMO's and diabetics
I have enjoyed reading this digest but have rarely written in until now. I
very much enjoyed Jim Handsfield's analysis of the HMO situation. I am a
health plan coordinator at a primary care clinic in Portland, Oregon. I
work with four PCPs and process all of the referrals in the place for five
major HMOs and several PPOs as well. It's my job to find ways to coordinate
the patient's needs and wants with the specters of "medical necessity,"
"covered benefits," "contracted providers," and all the rest of the junk
that we have all dealt with being diabetics.
I have experienced the primary care physician who thought he could manage my
diabetes and refused to give me more than one visit per year with an endo --
even though my nephrologist told me my kidneys were operating at about 50%
and were going downhill fast. Also the endo who thought I should prove
myself to her before she would work with me to get an insulin pump -- as if
I had that time to waste! Followed closely by the PCP who asked me twice to
switch from a capitated health plan to a non-capitated health plan because I
was costing her clinic too much money. I switched PCPs twice and endos twice
before I got my pump, and I did it while on an HMO and manipulating the
system to the very limit.
I felt lucky because I had an understanding of how things worked. I feel
lucky now that my job allows me to be an advocate to sick people who don't
understand the insurance system and could have easily been screwed out of
what they had a right to. I think HMOs can be a good thing, but like all
potentially good things (democracy, for instance!) it all depends on the
people who are in place to make them happen. Sometimes I feel like
apologizing for being part of the health care system, and then I think,
well... if people like me (who understand what it's like to be sick and need
something you don't know how to get) aren't part of the system, then it
really will become as bad as everyone is afraid it could be.
My .02$, sorry for the long post, thanks for letting me ramble!
(D x 30 yrs, pumping x 1 month)
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