Managed care and your hands

What you need to know.

The fact that you've reached this page means that you are an informed medical consumer - or would like to be. This page has information to help you make the best choice for the medical care of your hands - in or out of the managed care market.

You have a difficult choice: when reviewing plans, most people are a bit overwhelmed by all the details of coverage and out of pocket expenses for emergency rooms, hospital stays, doctors office visits, coverage for maternity, mental, dental, as well as trying to figure out what is not covered. It's intimidating and difficult for all of us. How do the insurance companies expect us to figure out what we're actually getting? They don't - they simply expect us to buy their health insurance plan.

Every insurance plan is different. Most are acceptable, but some are so lacking that no sane person would sign on if they really knew what they were getting.

OK, OK - How does this relate to your hands?

Hand injuries and other hand problems are very common for people of all ages, and the dirty little secret of some managed care plans is that they restrict certain nonphysician services which may be critical to recovery from a hand problem. Most people have no idea about these restrictions until they are confronted with them in the middle of a health crisis - too late to do anything about them.

The Facts:

Cost containment is a necessary part of modern medical care. Cost cutting is being accomplished in two main ways:
First, without affecting you, the patient, by

Improving efficiency, by getting doctors and hospitals to

Reduce waste and unjustified expenses, and
Fight fraud

Reducing costs directly, by paying health care providers less

Second, restricting your access to health care, by

limiting duration of care
limiting access to specialists and services

if you require hand surgery or hand therapy and your plan in any way limits access

you may have an unnecessarily tough road to recovery

Here is an illustration of how your insurance plan can affect the outcome of your hand injury. A hypothetical example: You have a minor finger cut - 3 stitches in the emergency room, and you are told that you may have cut a tendon.

You don't know it now, but you have indeed cut a tendon, and to get your best possible result, you will need:

surgery within a limited period of time,
custom hand splints, and
hand therapy several times a week for several months.

You talk with your friend, who highly recommends the doctor who did his hand surgery a year ago. Now, assume that you have one of the two managed care plans below and that with either plan it works out that you get the same surgeon and the same therapist. That's all that really counts, isn't it? Find out. Roll the dice. Choose a plan.

Managed Plan A	Managed Plan B
FIND A SPECIALIST • Your friend's doctor is out of town, and you are given an appointment with their associate the following day.	FIND A SPECIALIST • Your friend's doctor is not on your plan. You must first be seen in person in the office of your primary care provider. This person or their assistant tells you that it is common not to be able to bend your fingers after an injury because of swelling, and to check back in a week. • You come back in a week, still unable to bend your finger, and are referred to the general orthopedic surgeon on the plan. • Fortunately, you are able to see the orthopedist later that week. After being examined, you are told that although the doctor does indeed do some kinds of hand surgery, your particular problem really needs to be taken care of by a hand surgery specialist. The doctor, realizing that you are almost out of time to have a proper tendon repair, scrambles around, trying to find a hand specialist on the plan. Most of the afternoon is spent trying to get authorization for one of the non participating local hand surgeons - no luck. You get an appointment with a participating hand surgeon next week in the next county, just 45 minutes away.
HAVE SURGERY • You see the hand surgeon, who goes over your problem, recommends surgery, and explains that you will need a special splint and special therapy after surgery. • That week, surgery is performed at a surgicenter ten minutes from your home. All goes well.	HAVE SURGERY • You see the hand surgeon, who goes over your problem, recommends surgery, and explains that you will need a special splint and special therapy after surgery. The doctor also mentions that because it is now several weeks since the injury, healing has started, which will increase the chances of stiffness after surgery, and makes the possibility of needing two operations more likely. • That week, surgery is performed at a surgicenter exactly a one hour drive from your home. All goes well.
REHAB • When you see the surgeon back in the office, you find out that your therapy and splint fabrication can be set up either at a hand therapy center near your home or near your work, which ever is more convenient. You choose the one closer to home, and are seen that afternoon. A custom splint is made on the spot. You continue therapy there for two months. It is a bit of an ordeal, going so often, but worth it.	REHAB • When you see the surgeon back in the office, you find out that luckily, your therapy has been authorized at a hand therapy center near your home, but the splint has been authorized only to be provided by a group unfamiliar to the doctor, two counties away. • When you are seen for your splint, measurements are taken, and you are instructed to return in a week for the splint. • In the meantime, your therapist works with you, but is limited by the fact that the splint made by the surgeon is fine for right after surgery, but not for the special therapy you need. • Your custom splint is ready in a week. • When your therapist sees your new custom splint, they explain that it is really not quite the splint the doctor ordered, and that the insurance company will not pay for the them to make a new one. You can go back to your splint supplier, try again and wait another week for a different splint, or pay the therapist to make one right where you are. You decide to take a chance, pay cash for the right splint, and get reimbursed later. A correct splint is made, but you never do get reimbursed for it. • You work hard in therapy, and start to make progress, then are notified that your therapy benefits are almost exhausted. You speak with your surgeon and your therapist, both of whom explain that standard therapy usually continues for almost another month after your benefits expire. Deciding between further out of pocket versus doing the therapy on your own, you opt for therapy on your own, and ration out your remaining therapy visits. Your therapist and your doctor work with you on this - it's better than nothing.
RESULT • A year later, you're about as good as you're going to get. You still have some stiffness, but basically are back to normal activities. You wonder - it sure took a long time, but really, why the big deal about a simple tendon injury? - you're doing pretty well.	RESULT • A year later, you're about as good as you are going to get. You still have quite a bit of stiffness in your fingers, and there are some things that you really have trouble doing because of this. You wonder - did the surgery really help? ...all that running around, feeling like you were a second class citizen because of your plan, fighting for authorization each step of the way, the stress, the delays...was it worth it? - your hand is still pretty messed up.

Ridiculous inflammatory dramatization, right? Wrong. I've been the hand surgeon in both scenarios many times and I see variations of these two plots unfold again and again. The patient was hypothetical, but all the details were taken from real people - in fact, I pulled some punches by not having the therapy take three weeks to get authorized, or authorized only to a facility that doesn't do hand therapy, or authorized only to a facility 50 miles away despite there being four local facilities, or having the splint take two weeks to arrive only to find out that it is for the wrong hand - all real stories I've seen arising from the meddlesome nature of some insurance plan restrictions.

Well, somebody really blew it in plan B, and they are responsible, right? Wrong. The patient in plan B got a worse result because of many small flow of care problems working against them - a series of minor delays, communication problems, the forced path from generalist to specialist to subspecialist, strict benefit limits - but no single problem would have made as big a difference if it were the only problem. This is why the insurance company, which was entirely responsible for blocking the optimum flow of care, will remain blameless for its effects.

If hand problems were uncommon, no one would notice, but hand problems are very common for people of all ages. It is a big problem. The trend is to have some medical decisions about your hand care being made by a non medical person with a checklist - and many hand problems don't fit on even a long checklist. Strangers with unknown qualifications who don't know you and haven't met you make personal decisions about your care - that's what you are paying for on some plans. This is done to save money, not to help you. The more that important decisions are made by someone at a distance from the situation, the more likely you will lose a war of attrition from micro - mismanagement and poor flow of care. Talk to any hand specialist who works with managed care - if they don't agree, please let me know.

The system may not sound fair, but we do have choices. Directly or indirectly, we determine which plan we buy and use. It is up to us, the consumers, to push for better plans using capitalism. If we keep buying a bad plan, the insurance companies will keep producing it. If we don't buy enough to make it profitable for them, they will stop producing it, and provide a more marketable and hopefully better plan. Insurance companies have far more political influence than doctor and patient organizations combined, so the only vote that counts is your vote with your wallet - that is the only way the system will change in your favor. Because of private arrangements negotiated with the government over 50 years ago, the medical insurance industry is not controlled by many laws which regulate fair business practice, and their well financed government lobby makes it unlikely that the government will provide a level playing field in the foreseeable future.

What can you do?

Bad news - you have to actually read the plan or have explained to you. Ask three questions, and see the details of the answers in writing. Assume that if the plan explanation is unclear or uses generic terms such as "usual and customary", or "discretion of the insurance plan" you are at real risk for being denied care that you might require for a serious hand problem.

1. Who and where are the hand surgeons on the plan? Are they hand surgery specialists who have completed hand surgery fellowships? If not, are there other surgeons in the area who do have these qualifications?
2. Can I have hand therapy and a custom splint provided by a certified hand therapist near me?
3. What are the maximum number of hand therapy sessions I can have in a year? (3 times a week for 3 months is 40 visits - not unreasonable for a bad injury, assuming all goes well and only one operation is needed that year).

Be informed! You are paying for it, and you should know what you are getting. I see smart, successful people with bad plans every day - who don't know what they are missing. Some just accept incomplete treatment because that is all that is authorized by their plan. Some compensate by paying cash for services instead of letting their plan dictate their care - that's always an option, and one the insurance plans love - they get to keep your premium and don't have to pay for your care. Great!

Look into it. Don't get stuck with a bad plan. Learn what is involved. If you are concerned, make sure you are on a plan you understand. Recovery from hand problems can be quite demanding, and your hands are too important to assume that your plan will allow everything to be taken care of in your best interest.

Good luck!

Charles Eaton MD