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RE: [IP] HMOs, & etc.

I happen to be having major frustrations due to the fact that
the company I work for discontinued its PPO health insurance
program at the end of last year, meaning that I had to switch
to the HMO plan. I was referred for my yearly dilated eye 
exam over three weeks ago and still haven't gotten approval. 
I've already spent at least an hour on the phone trying to work 
this out. 

My endo isn't in the plan, so I have to either switch endos or
pay out of pocket to see him. This would also mean paying
out of pocket for all of my prescriptions and pump supplies,
up to a $3000 yearly cap. I'm trying to find out whether I
can get my primary care physician to prescribe all this stuff
so that I can get it covered. If not, I'm going to have to switch
to another endo that I don't know, that is much farther from 
both my house and my workplace, and that I won't be able
to get an appointment with for about two months. (Not to 
mention that his office staff have been really rude to me on
the phone when I've called to ask a few questions.) Or I could
switch to a new PCP who doesn't have an endo in his or her 
medical group, in the hopes that s/he could refer me back to 
my old endo. Of course, this would mean finding a doctor,
getting an appointment sight-unseen, getting a referral, having
all my medical records transferred....

Blah blah blah. I'm sick of this!!!!!

>Second is the demand for high end services, often when 
>not needed.  A surprising number of people use emergency 
>rooms for non-emergent treatment, and many people use 
>the ER in place of having a regular primary care practitioner.

One of the reasons this happens is that it's often very hard 
to get a timely appointment with a PCP. In my experience,
it's usually weeks, if not months. Sometimes it's easier if
you have an acute problem, but one of my co-workers told
me about an episode a few years ago when she was not able 
to get in to see her doctor because the receptionist didn't 
believe she was really sick. Eventually, after being prescribed 
(over the phone) several medications that did nothing, she 
went to the ER where they confirmed that she had a sinus 
infection and prescribed antibiotics. (She is a young, well-
educated, middle class woman.) My own PCP's office is
so backed up that when I called in late January to make an
appointment for my yearly gynecological exam they said 
I couldn't get an appointment until May, unless I agreed to
see the NP instead of my PCP. My appointment with the NP
is in the first week of April. I managed to get a couple of other
medical appointments (endo, podiatrist) the same day. I was
hoping to squeeze in the opthalmologist that day, too, but noooo,
I'm still waiting on the bureaucracy.

Systems are not set up to work for people who have 9-5 
jobs. No weekend or evening appointments. I have to take 
time off work to go to the doctor. On more than one occasion 
(two different doctor's offices) I've arrived at the doctor's 
office to find that my appointment isn't in the computer and 
the doctor can't see me. So I've taken off work for nothing.
Now I always call the day before to confirm that the 
appointment is scheduled properly. (This has nothing to
do with HMOs, but it does reflect on some of the ways
that frustrated people respond to barriers to getting care.)

/Janet L.
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