Ways to ensure the treatment you need

I have always told my patients, "Take charge of your health." Today I add, "If you don't, nobody else will." That's because in this brave new world of managed care, keeping costs down often takes precedence over providing quality care. Or val Endicott, 48, is convinced that cost was a factor in his treatment when he needed surgery to remove a brain tumor. His HMO approved surgery---if it was performed by one of its doctors, someone who had limited experience doing the procedure that Endicott wanted.
When Endicott discovered this, he and his wife turned to a state compliance officer at the Oregon Insurance Division for help. She discovered that the couple's HMO contract contained a provision that allowed them to seek a more experienced doctor, as long as the doctor would accept the HMO's allowed fee. Endicott's wife had located a California surgeon who had performed the operation hundreds of tmes, and the state insurance division negotiated an agreement by which the HMO allowed him to operate at the plan's contracted rate.
Unfortunately, not everyone is as informed and determined as the Endicotts. Yet never before has patient empowerment been more important than it is today. Almost 80 million americans currently rely on HMOs for their health care---85 percent of the insured work force. What can you do to get the best care from your managed care?

OPEN UP. Ironically, while the science of medicine has flourished in recent years, doctor-patient communication has suffered under managed care. HMOs may place strict limits on the amount of time a doctor spends with each patient. To get good care, you need to make every minute count.
If you're seeing a doctor for the first time, be ready to answer questions about previous medical problems and operations as well as provide a history of diseases that may be linked to family genes, like diabetes and breast cancer. Note when you had your last mammogram, stress test or EKG. Bring a list of medications you're taking, including vitamins and over-the-counter drugs.
Write down your most important questions and your symptoms ahead of time. Be as speacific as possible. Don't just say, "I've been feeling run-down." Explain instead, "I used to jog two miles each morning; now I can barely finish a quarter-mile without becoming short of breath and dizzy." The more the doctor knows, the better he can help you.
Be open and frank---93 percent of doctors in a 1997 survey felt that serious medical conditions could be averted if patients were more willing to talk about their problems.
For years, one 54-year-old mother of four from a Chicago suburb had suffered difficulties with bladder control, but she was too embarrassed to tell her doctor. Since the incontinence worsened when she exercised, she stopped, and by the tme her family was completed, she had gained 25 pounds. When she finally decided to seek professional help, urogynecologist Dr. Linda Brubaker was able to treat her, as well as to provide reassurance that her condition was common in women after childbirth.
Ask for printed material about your condition, whenever available. If you're pressed for time, write down any medical terms you don't understand so you can look them up later. If the doctor has ordered a test, be sure you understand what he hopes to learn and what risks might be involved.
Be assertive. If you doctor is standing with his hand on the doorknob and you're still feeling confused, tell him exactly what it is that you don't understand. You should never leave a doctor's office with unanswered questions.

SURF THE WEB. Elise Needell Babcock learned the importance of doing her homework the hard way. The 37-year-old Houston woman had had two miscarriages and lost a third child when the pregnancy ended in preterm labor.
Babcock became pregnant again and she discovered that a stitch could be inserted in the cervix at nine weeks to prevent miscarriage. From pediatric journals, she learned that women at risk of premature delivery were sometimes given steroid shots to speed the development of the infant's lungs. She asked her HMO doctor to insert the stitch and give her the steroid shots. In due course, she gave birth to a healthy girl.
It was tough emotionally. In a stressful situation a patient wants to be able to rely on an expert, but Babcock knew she couldn't take the "doctor knows best" approach. One research source was the Internet. With more than 15,000 health sites, the World Wide Web offers detailed information on hundreds of diseases, from arthritis to warts. However, it is not without drawbacks. Correct and incorrect information flow onto the computer screen with equal immediacy. To help with this problem, my Web page (www.drkoop,com) has rated some 1500 sites for credibility, content and opportunity for feedback.

LOOK BEFORE YOU SWALLOW. The Internet can also be a good place to begin researching medications. To ensure accuracy, visit the Web sites of organizations like the AMA or the American Diabetes Association and sites like www.healthfinder.gov or www.fda.gov. Getting the right medicine, and combination of medicines, is crucial. since you may be shuttled from doctor to doctor under managed care, it's important to let each one know what medications you're already taking, to avoid possibly harmful interaction.
It's equally important to get the correct drug in the first place. Deciphering a doctor's scribbled handwriting, a busy pharmacist could mistake Norvasc, a calcium channel blocker, for Navane, used to treat psychotic disorders. Cerebyx, an anti-convulsant, might be confused with Celebrex, an anti-inlfammatory drug, or Celexa, an anti-depressant. So make sure you can read what your doctor has written down. When you pick up your prescription, check the nake on the label. If your pharmacist substitutes a generic drug, call your doctor's office to make sure it's the correct substitution.
Since today's time-crunched doctor may not have extra minutes to inform you of all the possible side effects and contraindications of the medicine he prescribes, you need to assume some of that responsibility. The best source of information about medication is your pharmacist. (Patient-information leaflets stapled to prescription bags can be out-of-date.) You local library will have a copy of the Physicians' Desk Reference (PDR), a 3000-page compendium updated every year that provides comprehensive information on almost every FDA-approved drug prescribed today.

PICK THE BEST BRAINS. A second opinion is as important under managed care as it always was. If you doctor orders surgery, you have the right to seek a second opinion. By the same token, if your doctor tells you there's nothing wrong and you disagree, you should also seek a second opinion--a fact Mary Epperson can attest to.
Three years ago, the 45-year-old Texan felt a lump in her right breast. Her primary-care physician referred her to a surgeon, who performed a test and told her it was probably just a cyst. He recommended that she wait six weeks to see if it would go away.
Epperson knew how fast cancer can spread. She wasn't willing to take the risk. she made an immediate appointment with another doctor for a second opinion, even though her insurance company had not yet okayed the visit. The second doctor did a needle biopsy--a test the first doctor had not performed--and confirmed what Epperson had suspected: the lump was malignant. The doctor scheduled immediate surgery to remove the cancerous tissue. Epperson is fine today, but if she hadn't insisted on a prompt second opinion, the cancer could have been fatal.

DON'T TAKE NO FOR AN ANSWER. What do you do when your doctor recommends a course of action--an X ray, a visit to a specialist or surgery--and the HMO overrules it?
Most HMOs have an appeals system, and most honor the request for an expedited appeal if time is of the essence. If your HMO's appeals procedure is not explained in your policy manual, contact the customer-service department. Ask for a copy of your certificate of coverage. This is the contract between you and your insurer and sets forth the service your HMO has guaranteed to provide you--including guidelines on how to file an appeal.
Sometimes you may be asked to file a written complaint. The process can be long and cumbersome-but it can work. Two years ago, 32-year-old Chris Walker injured his knee while jogging in New York City. When routine surgery to repair the damage failed, he was referred to another specialist. In early February 1998, the specialist contacted Walker's HMO for precertification for the surgical procedure he planned to perform. But the HMO denied coverage on the ground that it was an experimental treatment. Walker would not take no for an answer. Over the next four months, he submitted four written appeals to his HMO, each of which wa denied. Finally, he was granted a hearing with the HMO's board of directors. In July 1998, armed with a copy of the FDA license showing the treatment had been approved, along with data proving the procedure's success, he appeared before the board. A week later, theHMO reversed its original denial of coverage. He is curently recovered and pain-free.
Walker's hearing was the last stage of the appeals process within his HMO. If he'd been turned down again, he would have asked the state insurance commissioner's office to go to bat for him--as Orval Endicott did. All states have a contact for health-insurance complaints at www.naic.org/consumer/state/usamap.htm (the National Association of Insurance Commissioners). And more courts are allowing patients to sue an HMO that denies necessary treatment, overruling a 1974 law forbidding such action. With the treat of lawsuits, HMOs are more likely to payprompt attention to a patient's appeal and to change a decision in the patient's favor.
If you've become the educated, informed patient that you have to be under managed care and you're still not getting what you need from your health plan, look for a new one. An HMO is a business, and there's usually competition out there. If your health plan is a company plan, speak to your employer. Mary Epperson's husband, a bank executive, helped persuade his firm to switch to a form of managed care that did not require that patients get permissin from the primary-care physician to see a specialist or get a second opinion.

The day of the authoritative physician and the passive patient are gone. Much of the burden of making sure you get quality care has shifted to you, the patient. Ultimately, you are the one who holds the keys to getting the best your health system has to offer. Take charge of your health!