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ARCHIVED  June 4, 1999

Baby boom or bust?

Reproductive health tackles cost vs. choice

Talking to doctors and managed-care representatives about health care is like getting a group of sightless people together to describe an elephant. Each individual’s perspective is different, depending on his or her exposure to a particular piece — every individual has an opinion based on what is before them.

In no case is that analogy more fitting than with regard to health care benefits. Insurers insist that they are trying to provide the greatest access to services, for the most people, at the lowest cost. Physicians are concerned that the level of services they are able to provide under managed-care contracts is not adequate. They feel the constraints of managed care — constraints they say adversely affect patient care.

And patients are stuck in the middle, seeking affordable health insurance but also wanting access to everything available to keep their families healthy.

Reproductive health care services, including family planning, prenatal and maternity care, and infertility services, make up a large portion of the services available to managed-care subscribers. They also account for a substantial chunk of the insurers’ financial outlays over the course of a year.

“Managed care has provided a higher standard of reproductive health care for women than traditional medicine,´ said Blue Cross Blue Shield of Colorado spokesman Neil Westergaard. “There is an emphasis on doing things appropriately in prevention, with diagnostic tests and early detection of disease all covered under the insurance umbrella.”

That is true, acknowledged Dr. Joshua Kopelman, an obstetrician-gynecologist who is also treasurer for the Colorado Section of District VIII of the American College of Obstetrics and Gynecology, which evaluates health care services for the entire western United States, excluding California. However, just because the services are there doesn’t mean that physicians have enough time to spend with their patients to ensure that those services are being properly administered.

“The single biggest failing of managed care, in terms of reproductive health care, is that there is no way in which we can bill time spent with our patients doing counseling that applies to their reproductive health,” Kopelman said. This includes counseling for the effects of infertility, menopause, parenting and other pregnancy-related issues.

Another big problem with managed care, Kopelman noted, is that costs seem to be the overriding issue when providing care — not medical treatment.

“What began as a service that tried to provide good care at a lower cost has been perverted into how cheaply [managed care] can provide services and still make a profit,” he said.

There are certain basic services for reproductive health that are provided by all managed-care organizations. Most organizations base these on the standards set by the American College of Obstetrics and Gynecology and on federal laws that mandate things such as the length of time a woman is able to stay in the hospital after an uncomplicated delivery.

“We have to stay competitive with other health plans, so there is pretty comparable coverage between health care plans,´ said Dr. Michael Paddack, PacifiCare’s medical director for Northern Colorado. “It is also required for us to have a certain level of care, according to the state Division of Insurance, which dictates what we should and should not be doing. We all try, I think, to cover as much as possible so that we can do as much preventative care as possible, to prevent illnesses that are dangerous and also expensive in the long run.”

Additionally, employers who offer managed-care plans to their employees must, under federal law, attain standards set by HEDIS, the Health Employers Data Information Set.

“Those standards make sure that health care providers are doing everything they can to ensure consistent quality of treatment, to ensure that patients are getting everything they need that we can provide under the terms of their plans,” Paddack said.

Prenatal visits including an ultrasound and access to family planning including some oral contraceptives are all covered by the major managed care organizations working in Northern Colorado. Elective abortions are also covered by many group health care plans, although certain forms of infertility treatment are not.

“There has been a huge philosophical debate as to whether it is appropriate for society as a whole to have health care premiums increased to help a small population to stimulate pregnancy,´ said Jim Hertel director of HealthCare Computer Corp. “The concept of insurance originally was to pool money so that if anyone came down with an illness or medical problem, it could be taken care of, not to cover matters of convenience for patients, or things they themselves elected to do.”

Neither PacifiCare nor BCBS will cover many of the complex infertility treatments that are currently available, primarily because of cost.

“These treatments can cost in the tens of thousands of dollars and are not even guaranteed to work any better than some of the easier and less-expensive treatments,” Paddack said. “Is it right to increase everyone’s premiums so that one couple in a thousand can use extreme measures to try and get pregnant? Sometimes [managed care] gets accused of trying to play God, but I think in reality we are just trying to provide the best care for all.”

Sloans Lake takes a different perspective on infertility, determining that because infertility services, unlike most medical services, result in other, sometimes higher costs, it is in insurers’ best interests to offer coverage.

In a 1998 St. Anthony’s Health Care Risk Contracting Report, Sloans Lake director of business development and government affairs Judith Jung explained that market pressures required the company to cover artificial insemination to a cap of $3,000, although the more complicated treatments, including in vitro fertilization, were not eligible services.

Eligibility for coverage of certain services is also based on the assumption that an insured person is a member of a group plan, and not buying his or her insurance independently. Again, this is an issue of cost-effectiveness. Money put into a capitated pool and then allocated as needed to individual members of a group plan is preferable to insuring an individual and hoping that he or she will not require extensive medical treatment.

Therefore, BCBS and PacifiCare will not cover any maternity services for their individual, major medical plan members. Providing the “best care to all” appears to be contingent on where that “all” is, admitted both Paddack and Westergaard.

“To be perfectly honest, we don’t offer it [as an individual plan option] because it appears that our clients don’t want it,” Westergaard said. “They don’t want to pay a higher premium for services that they don’t think they are going to use.”

Of the 445,000 BCBS subscribers in Colorado, 35 percent have coverage through individual plans, mainly because of the cost.

“We can get someone covered with catastrophic insurance for around $70 a month,” Westergaard said. “They have a high deductible and don’t have a lot of the services available to them, but they made that choice and can add benefits as they choose to. But adding benefits means paying higher premiums, it is just common sense.”

Many people, however, choose individual policies because it is all that they can afford, not because they don’t need medical attention. For them, there are few alternatives to paying the astronomical fees required by hospitals in the area.

Megan Dill, a clinical assistant at Planned Parenthood, said that many of her clients have limited, often only catastrophic, insurance coverage and pay out-of-pocket at Planned Parenthood because it is more affordable than a monthly insurance premium would be. Some long-time Planned Parenthood clients who have changed their employment situations and health care coverage have been unpleasantly surprised when they’ve tried to use Planned Parenthood’s services through their new insurer, she said.

“We have enormous trouble trying to bill managed care, to the point where most of our clients give up and just use the services we offer, paying what they can when they can,” Dill said. “Insurance billing can be a nightmare for us, and we simply don’t have the resources to devote the amount of time it requires to ensure that our patients get reimbursed, which means that sometimes, we have to eat the cost of treatment.”

Dill said that 95 percent of Planned Parenthood’s clients are private-paying, even though a greater percentage of them are still members of some managed-care plan.

“Of course, some women come to Planned Parenthood because they don’t want anyone to know about some of the reproductive health choices they are making for themselves,” she said. “But still, it seems sometimes that managed care is standing in the way of women having affordable access to the kind of health care they need.”

The average premium a woman of child-bearing age will pay as a member of a group health care plan is $150, half of which is paid for by her employer. Under this kind of plan, it will cost her only a $100 copayment to have a baby, but if she wants to take a birth-control pill that is not approved by her managed-care organization’s formulary, it could cost her more than $80 each month.

“Limiting women’s health care choices to what is most cost-effective is dangerous, because it limits her control over her body,” Dill said.

“Those decisions should be made by a woman and her doctor, not by someone who has no concept of who she is and what is best for her,” Kopelman agreed.

But in a country where a national health service still looks like a less-practical alternative to managed care, a shift in people’s priorities is necessary, Kopelman continued.

“Look, we as a society spend 10 to 15 times more on entertainment than on health care every year,” he said. “If it is important to us to have access to as much health care as we think we need, we have to change the way we spend our money and direct our efforts.”

On this point, finally, then, the doctors and insurers agreed.

“Insurance is not a Disneyland E-ticket,” Westergaard said. “If healthy babies are what society believes is the most important thing, then maybe other things should be excluded from coverage, like hip replacements or other surgeries. But demanding we provide as full a palette of services that some people think they need without raising premiums is like asking why doctors and hospitals don’t provide [those services] for free.”

Reproductive health tackles cost vs. choice

Talking to doctors and managed-care representatives about health care is like getting a group of sightless people together to describe an elephant. Each individual’s perspective is different, depending on his or her exposure to a particular piece — every individual has an opinion based on what is before them.

In no case is that analogy more fitting than with regard to health care benefits. Insurers insist that they are trying to provide the greatest access to services, for the most people, at the lowest cost. Physicians are concerned that the level of services they are able…

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