And It's About Time There Was Some Support For Cushing's!
To get top care, get pushy
If your health plan won't send you to a leading hospital, seek allies
By Susan Brink
Brilliant doctors at world-class institutions don't always have the clout they once did. And they hate it. Take John DiPersio, chief of the division of oncology and deputy director of the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital in St. Louis. His title alone might once have been the proverbial 800-pound gorilla. But these days, he must sometimes accept "No" for an answer from those he may well consider to be, relatively speaking, pipsqueaks: insurance company payment reviewers. In a frustrated aside, more realistic than arrogant, he says: "My beef with reviewers is, how can they possibly be more expert than we are?"
But even though DiPersio sometimes loses the fight to get a patient's insurance company to pay for a procedure at his facility, he still chalks up a lot of wins. And for patients who critically need a cutting-edge treatment at one of the world's top hospitals, it pays to recruit the likes of DiPersio to the cause.
Of the nearly 152 million Americans who are insured through their employers, 86 percent have some sort of managed-care plan. In one way or another, those insurers cut discount deals with specific hospitals. In exchange, they agree to send their patients to those hospitals. So sometimes, seriously ill patients and their doctors might be certain that one of the world-class hospitals listed in the pages of this guide is the best place to get lifesaving care. But if a patient's insurer doesn't agree, the battle to get coverage could rival the fight against the disease itself.
Enlisting the aid of a physician inside the hallowed halls of a top-notch hospital is perhaps step two, three, or even four in a patient's battle plan. Step one is to choose a health plan that offers as much flexibility as you can afford–because choice in health care costs money. Look to see that the doctors and hospitals you want are on the plan's list. Most plans contract not only with hospitals that can provide the basics, like an uncomplicated delivery or an appendectomy, but also with "centers of excellence" that offer specialty care for urgent needs. But in health plans, the devil might be buried in the details, as Terry Early, 46, discovered when a hospital on his plan's list turned out not to be approved for what he needed.
Mind bender. Early spent six years getting care at Johns Hopkins Hospital for cirrhosis due to hepatitis C. He called his doctors and nurses by their first names, endured extensive laboratory tests in preparation for the liver transplant he will inevitably need, and brought his daughter, Karen, 23, in for evaluation as a potential donor. "It's a mind bender, to look at your daughter and wonder what the surgery is going to do to her," he says. "I was a nervous wreck." During that time, his employer switched insurers twice. The first time, Early and his physician, Paul Thuluvath, medical director of the liver transplant program at Johns Hopkins Hospital, negotiated with the new insurer, and he remained at Hopkins.
But he wasn't so lucky after the second switch. The newest plan listed Johns Hopkins as a preferred provider, so Early thought he would be covered. He had missed the fine print. "Later, I found out [Hopkins was] approved for kidney transplants but not for liver transplants," he says. Early says he wanted to stay at the place he had come to know and trust. "When you have a good relationship with a doctor, it's hard to leave." But the insurer said "No." He and his daughter now must be re-evaluated by a new team of experts at a different hospital.
To increase options, people can buy a plan with what's called a point-of-service option. That means, for an extra premium cost, a patient can go outside a plan's network. But the higher costs don't stop there. Going outside the network means paying more out of pocket, making payment for high-cost procedures exorbitant.
If it comes down to fisticuffs with the insurer, line up your allies, starting with your local doctor. Most top hospitals have physician-to-physician referral lines, and your local doctor might help find a specialist at Mayo Clinic, for example. If your doctor and the top hospital's specialist agree that you could uniquely benefit from care at the institution, you've got a good team to help argue with your insurer.
Even if your local physician balks at helping, or if you're reluctant to ask for your physician's help, you might find a doctor on your own at the hospital of your choice. Most top hospitals have patient referral lines staffed with people who can advise you, help you select a specialist, and brief you on costs. Hospitals can also help patients begin the negotiations. "It can sometimes be as basic as giving them the name of the right person to connect with in an insurance company," says Nancy Connery, director of admitting at Massachusetts General Hospital.
Hitting them with the facts. In rare cases, administrators all the way up the institutional hierarchy can get involved in negotiations with an insurer. But more often it's the specialist who helps, by walloping the insurer with the facts. John Wain, surgical director of the lung transplant program at Massachusetts General Hospital, recalls the first time he helped fight for payment for a new procedure, a living lung transplant. "The insurance company said, 'This is crazy,' " he says. But he noted that the patient would not survive without a transplant and gathered reams of research papers indicating that the procedure offered real hope. It came down to a head-to-head confrontation between two institutional honchos. "Our chief medical officer called the insurance company to explain to [its] chief medical officer what this is all about. It was like someone flicked a switch," said Wain. Payment for the first procedure was approved, and later cases have been easier to argue.
In some HMOs, such as Kaiser Permanente, the nation's oldest, getting coverage for procedures at nonplan hospitals can be especially hard. Called closed-panel systems, such HMOs have their own laboratories, pharmacies, physicians, and, often, hospitals. They've historically run on the principle that high quality can be maintained at lower cost if all care is provided within their own system. Some of these HMOs, including Kaiser, do cutting-edge research to measure the quality of care. You won't need to fight to get outside the system if your plan shows you that it has equally good experts and outcomes. And even Kaiser Permanente will make rare exceptions, says Robert Pearl, chief executive officer of the Permanente Medical Group. "If we felt that there was another physician someplace in the nation who could do a better operation for a particular problem, we would send the patient there," he says.
In some ways, the struggle to get to the right place in a time of dire need is getting easier as doctors, hospitals, and patients figure out how to arm themselves with the data they need to convince an insurer. But fights still happen. Patricia Brown, acting president of Johns Hopkins HealthCare, says, "There's a payer fight, I would say, weekly."