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Get Best From Managed Care

In this age of managed care, Americans have to fight like never before to get the care and coverage they need and deserve, says Dr. Bruce Barron.

In his book Outsmarting Managed Care, he offers a unique perspective and shares on CBS News This Morning his secrets to getting the health care you want.


Dr. Barron is an associate professor of clinical gynecology at Columbia-Presbyterian Hospital in New York City and a former medical director of Empire Blue Cross/Blue Shield, where he made policy decisions regarding coverage.

Having been on both sides of managed care, he advises being aware of what managed care can do such as: disallow treatments, limit doctor choice and the hospital you can go to.

And in his book, he highlights three important areas of concern: knowing what you're covered for, dealing with a bureaucracy, and realizing all doctors - and hospitals - are not created equal.

There are many procedures that you may assume are covered that are not, notes Dr. Barron. For example, some companies don't cover reconstructive surgery after a mastectomy. Some don't cover physical therapy after a stroke.

Managed care companies are organized to frustrate and intimidate, but you can't allow either, he says.

Move up the hierarchy. If the first person you speak with doesn't give you the answer you want to hear, ask for a medical director, he suggests.

Whenever Dr. Barron has helped a patient challenge a coverage decision, the managed care-company has caved in, he notes.

Get your doctor on your side. It really helps when your doctor can go to bat for you to explain why you need a treatment or should go to a certain hospital, he says.

Talk to your case manager and ask a lot of questions:

  • How many times has the doctor done the particular procedure?
  • What are the complications from the procedure?
  • Who will do a follow-up with you if the operation is on Friday?
  • Will your doctor be around?
Do your homework. Check out a doctor's credentials, the medical schools attended, board licensing and any associations with a major hospital or teaching institution, he suggests.

Some state medical boards will give out a doctor's history regarding malpractice insurance, he adds.

Don't get a doctor's name through the yellow pages or a television ad.

Congress is working on a final version of a patients' bill of rights, but Dr. Barrons says patients suing managed health care organizations is not the best way to resolve managed care problems.

"What good does a lawsuit do if the patient has already been maimed?" he asks. "We really need an independent review of decisions made by managed care companies."

Expect to see a cafeteria-style approach to health care, he notes. "We'll see some people on Medicare, others happily enrolled in managed care who don't mind sacrificing choice for savings."

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Outsmarting Managed Care

"Flexible spending accounts will become more common; these accounts are the kind where you put your pretax dollars into an account for your medical bills," he predicts.

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