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Opinion: Open Enrollment and Alternative Health Care

There is nothing more confusing than trying to choose good health care coverage.  People  often ask, “Which insurance is good?” Not only do consumers want quality medical care and coverage for it, they often desire coverage for alternative therapies like chiropractic, massage, acupuncture, and naturopathy. But often, patients are surprised to learn of tight restrictions on alterative therapies with their chosen plan. Some plans allow only specific service providers; others allow only  for a specified number of visits per year, while others like Brown and Toland allow their patients to visit alternative health care practitioners only in San Francisco. Other carriers actually dissuade their members and practitioners from using their benefits, by not covering standard treatments, or weighing down both patient and doctor with bureaucratic paperwork and mandatory preauthorization, and then providing only low reimbursement. The carrier guiltiest of these practices is American Specialty Health Plans (ASHP). Beware of choosing a health plan that uses this middle-management company.

ASHP came on the scene of managed health care about 20 years ago, touting its promise to screen doctors, lower health care costs for employers, and offer employees topnotch care. It seemed utopian. Small at first, securing health care management of companies directly, eventually ASHP took its tactics to insurers themselves. Today, it is one of the largest management companies, servicing large carriers such as Aetna, Blue Cross, and United Healthcare. You will know if it is part of your health plan by looking on the back of your insurance card. You will see ASHP in tiny type. For the patient who seeks alternative health care, it can mean paying many out-of-pocket expenses or not getting the care you need. Why? Because ASHP pays for only very limited services. Any services outside its plan must be paid 100 percent by the patient. These are for regular standard-of-care treatment options, not obscure or experimental options.

Some would argue that ASHP goes as far as to discourage practitioners from giving full, adequate treatement to their patients. ASHP requires heavy paperwork, preauthorization, and low reimbursement. For example, ASHP will pay a prequalified doctor in its plan roughly $20 to perform a chiropractic adjustment. The patient would co-pay perhaps $10 or $15, which means the doctor’s office visit would total about $30 or $35. For that $35 the doctor must write a report, request a certain number of visits, perform an exam, report on that exam, all so that he or she can substantiate another four or five visits for the patient, which may or may not be approved. It is a large-scale game of Mother May I. Meanwhile, the fee is so low that doctors are tempted to overbook their calendars, with patients scheduled every five or 10 minutes, rushing them out of the treatment room.

So the next time you want to ask your doctor a few questions about exercises, or you would like additional treatment or service, but you feel they are rushing you out the door—they are. That doctor is not getting paid for the service you are asking for. Anything not covered on the plan must be paid for 100 percent by the patient. ASHP will demand that the patient complete paperwork acknowledging those fees and agreeing to pay for them out of pocket. If that seems like a hassle, it is. Your doctor really just wants to treat you and make you feel better. Believe it or not, he or she wants to do everything within his or her power to make that happen. Your doctor would love to be able to teach you those exercises and have your insurance pay for it. But ASHP has cut into alternative-care practictioners’ income already up to 50 percent or higher, forcing doctors to have a McDonald’s-fast-food approach, demanding high volume and little face time with patients. It may be permissable for a burger, but not for health care. Both patients and doctors lose out. Insist on something better.

Consider changing our health care system with your choice of carriers during your open-enrollment period at work. Consider avoiding ones that use ASHP and choose an alternative. Choose a carrier like Blue Shield of California, UMR, or United Healthcare PPO, which prescreen all of their doctors, offer a wide selection of services covered for alternative care, and deal directly with both patients and practitioners without handing it off to a middleman.

CYNTHIA LUCE, DC

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