Last Modified: November 1, 2001
Dear OncoLink "Ask the Experts,"
In a few months my Blue Cross & Blue Shield insurance policy will change to a BC&BS *HMO* policy. The policy I am holding now will no longer be offered by the company I work for and as I understand it, by Blue Cross itself.
I need to know the things I can do to safeguard my health during this transition. I am a breast cancer patient. I am currently in a stable condition yet I was first diagnosed almost 3 years ago in the last stage (stage IV) with metastasis to bone. I am told I am at high risk of recurrence.
I have an extremely good relationship with my current Oncologist and truly believe my survival has been enhanced by him and the varies doctors I have found for treatment. I do not wish to go into an HMO, but see no other choice.
We suggest that you contact your various physicians to determine if they participate with the HMO. If not, see if they participate with other plans offered by your employer, assuming that your employer is giving you a choice of plans.
If your physicians are not participating with the HMO, and there are no other alternative plans offered by your employer, then contact the HMO and obtain a list of participating specialists. Take this list to your physician(s) and seek their advice and guidance as to who they recommend you see for your continued care.
In addition to selecting specialists, you will more than likely have to select a primary care physician who will manage all of your care, hence the term "managed care." Many HMOs utilize this primary care physician as a "gatekeeper." The role of the gatekeeper is to control and direct your utilization of services. Many HMOs require their primary care physicians to issue referrals for services which are beyond the scope of their specialty. A referral is simply a form which specifies the services you are to receive. Because the primary care physician you choose will have responsibility for controlling your access to specialists, it is very important that you choose a primary care physician with whom you are comfortable. Even though certain specialists you now use may participate with your new HMO, your primary care physician will decide when and to which specialists he or she will refer you.
Specialists are required to provide only the services specified on the referral form. If additional services are required, (i.e. the specialist determines that you need additional tests) you will have to go back to your primary care physician to obtain the necessary referral(s).
The fact that you will be insured by an HMO should not lead you to assume that the quality of your care will be marginalized. You may need to be much more assertive in making your needs known. In addition, you may be spending more of your time engaged in the process which can be frustrating. If you are not satisfied with the level of your care, then voice you concerns to your primary care physician and the HMO's Subscriber Relations Office. If you are still dissatisfied, then voice your concerns to the HMO's Medical Director, your employer or your state's Insurance Commission.