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THE "HMO/PPO" DILEMMA For the last several years we have debated the issue of whether or not to join the various managed care plans now offered to our patients. We have always based every decision we make at Spine Care Center on what we consider to be our main responsibilities to our patients. This includes everything from purchasing new equipment, changing our office procedures, techniques, fees etc. These responsibilities are threefold. We feel our first and most important responsibility is to educate as many patients as possible to the importance of the vertebral subluxation complex and how it affects their life and health. We want to be free to teach you how its correction allows you and your family to have a better life. Then we want you to decide based on your knowledge, or lack of knowledge, what is best for you and your family. In other words, we want you to be in charge and manage your own Chiropractic care. We want you to see us as often as you feel it necessary. We certainly do not want some managed care employee, who doesn't even know you, to tell you when you can or can't see us. Our second responsibility is to provide our patients with the best quality Chiropractic care possible. This means specializing in just one thing: "Chiropractic." It also means having dedicated doctors; a well-trained staff, good office procedures and the best Chiropractic equipment money can buy. Our third responsibility is to make this care available and affordable to everybody. We make it available by working long hours into the evening and on Saturday mornings. We make it affordable by having our very special "Family Maintenance" and "Spine Care Plus" programs. These programs are available to all patients and offer them unlimited Chiropractic care for much less than the cost of our regular "Primary Care" program. The fees in each of these programs compare favorably with the HMO/PPO's co-payment and /or deductible. When we researched the various HMO's and PPO's available to our patients today and considered joining them based on each of these responsibilities, we found the following: The most liberal of the managed care plans states they may approve up to forty visits per year. This sounds good on the surface, however, when you look at the fine print, you see they are talking about forty approved visits. It has been our experiences that most managed care programs follow the same guidelines as Medicare. Any visits they approve must be for initial care or for a specific acute problem documented by your doctor. The care for any one problem is limited both in time and in visits. For example, if you have an acute low back or cervical spine problem, they may approve you to see us up to fifteen or so times over a period of five to seven weeks for that particular problem. If you need further care after this period, your doctor must send in additional documentation. Even with the best documentation they may decide to allow you to see us a few more visits or they may deny any additional care. Managed care programs usually do not approve on-going care for any specific condition even when it is deeply chronic. This means that if you have a chronic recurring low back or neck condition that requires some degree of on-going care, such as one or two visits per month, it is not likely to be approved. They often consider this as maintenance care even though you are in pain. They do not approve any maintenance care. Managed care plans limit your choice of doctors. The Guardian Health Care Alliance represents many managed care plans in Georgia including those dealing with the State Merit system. It was reported in the June 2000 issue of the "Georgia Chiropractic Journal" that of the eighteen hundred licensed Chiropractors in the state of Georgia; only two hundred thirty seven were currently providers for the Guardian. The Guardian Care Network was projected to grow only to three hundred members. This means that your choice of Chiropractors under these plans is greatly limited. You can see from the above that all "managed care" plans fall short in allowing us to fulfill our first and second responsibilities to our patients. We can not provide the very best Chiropractic care to you when we can not teach you what Chiropractic care is all about; the correction of vertebral subluxations. They consider this as maintenance care and list it as a non-covered service. Our third responsibility is to make our care more affordable. The managed care plans that we have studied either have a co-pay of ten to twenty dollars and/or a deductible. Some have a deductible of three to four hundred dollars after which they pay somewhere between seventy to ninety percent of the care they approve. The deductible for the State Merit program is three hundred dollars for participating providers and four hundred dollars for non-participating providers. Keep in mind that you no longer meet any part of this deductible by seeing your primary care doctor for office visits. Your twenty-dollar co-pay to him is not applied toward your deductible. This means that under the State Merit program you have to pay your first three to four hundred dollars out of pocket each year before any coverage begins. This applies to each member of your family. How does this compare with our "Family Maintenance" and "Spine Care Plus" programs?
Under our programs, you can see us for about
the same fee as you can see your primary care doctor, you have no
deductible, you can see us as often as you feel necessary and can use our
receipts to help meet your deductible for other non-participating providers. There are of course some exceptions as in some plans that may still have only ten-dollar co-pay. This is true only if your care is approved and you have no deductible. Most of these ten-dollar co-pay plans now have a deductible of at least one hundred dollars. There is no deductible with our programs. After careful study and consideration of the various managed care programs, we have come to the conclusion that our "Family Maintenance" and "Spine Care Plus" programs have much more to offer the majority of our patients. |