Have you heard the latest HMO jokes circulating on the Internet?
Q: I just joined a new HMO. How difficult will it be to choose the doctor I want?
A. Just slightly more difficult than choosing your parents.
Or how about:
Q. What happens if I want to try alternative forms of medicine?
A. You’ll need to find alternative forms of payment.
Pretty funny, huh? Unless, of course, you are one of the people trying to negotiate the brave new world of managed care. Then the experience is anything but funny. It can be a medical nightmare.
“You can’t pick up a paper today without seeing something about the unhappiness of patients with managed care,” said Dr. Donald Linker, who estimates that 65 percent of the population participates in some managed-care program. “The bureaucracy has increased. [People] are thwarted by the bottom-line mentality [of] managed care.”
Finding many patients intimidated by the system, confused by what costs are covered or failing the care to which they believe they are entitled, Linker has taken it upon himself to do something about it.
He left his job as an assistant professor of urology at UCSF to become a medical ombudsperson. In lay folk’s language, that’s a patient advocate. People hire him to represent them in claims against their health care provider.
Linker charges patients on a sliding scale from $100 to $250 for an initial consultation. That includes reviewing medical and billing records, and discussing the matter with the patient. If more work is necessary, then Linker charges by the hour.
It won’t make him rich, but Linker feels he is performing a much-needed service.
“I have a do-gooder mentality,” said Linker, who helped staff phones at the recent Super Sunday phonathon of the S.F.-based Jewish Community Federation
Linker’s has volunteered hundreds of hours serving on the boards of Brandeis Hillel Day School, Jewish Family and Children’s Service, the JCF and its predecessor, the Jewish Welfare Federation. He has also served on the board and as an adviser to Marin County’s Buck Center on Aging.
Most of his cases involve the elderly. Because of his experience and medical background — he also has a master’s degree in public health — Linker says he’s in a unique position to represent patients.
“I have a working knowledge of medical care from the inside,” he said. “I know a lot of people in health care. I follow through and people respect that.”
But most of all, Linker said he tries to bring “humanity back to a bureaucratic system.”
Although the details of the cases vary, Linker finds that often the underlying problem is miscommunication or failure to understand what one’s health insurance provides for. His role is frequently that of mediator or facilitator; by talking to all the parties involved, Linker said he can resolve matters and often defuse potential lawsuits.
One common problem Linker deals with is who pays when a patient gets emergency care either at or away from home.
“Most times [emergency care reimbursement] is refused by the managed-care facility,” Linker said. The insurer claims the patient could have waited. “I intercede and point out that it was an emergency as far as the patient was concerned, and it should be reimbursed.”
While he is usually successful, there are some cases that are not emergencies; the patient just wants to save time by going to an emergency room rather making a doctor’s appointment.
Another common problem is access to specialists.
Q. I think I need to see a specialist, but my doctor insists he can handle my problem. Can a general practitioner really perform a heart transplant right in his office?
A. Hard to say, but considering that all you’re out is the $10 co-payment, there’s no harm giving him a shot at it.
Although general practitioners are not performing brain surgery, they are handling cases that used to be referred to specialists.
“[General practitioners] are getting more training so they can handle” cases that used to be referred to specialists, said Linker. While they often can provide satisfactory treatment, Linker is concerned that failure to refer to specialists is a reflection of the bottom-line mentality that is driving health care today.
“The computer can track how many cases are being referred” to a specialist, he said. If a doctor “refers too many, it will be brought to the administration’s attention. That doctor may have to look for another job.”
One function Linker performs is explaining what’s going on to patients and reassuring them if they are getting good care.
“Numerous people have called me just to chat to find out if they are getting quality medical care,” he said. Using Kaiser Permanente as an example, he added that some HMOs have bad but undeserved reputations. “Kaiser in the Bay Area does a good job because it has access to quality [physicians]. A lot of people don’t want to go into private practice.”
Linker said he is currently one of a small number of medical ombudspersons, a field he expects will grow.
He started out with word-of-mouth referrals and some ads in local papers. But thanks to television’s Dr. Dean Edell, he now gets calls from all over the country.
Hearing about Linker’s work, Edell called him. “We chatted and he liked the concept and asked if he could interview me. The show was syndicated across the country.”
Since then Linker has taken on a couple of assistants to help him process cases. He estimates that 10 percent of his cases involve providers — doctors or insurance companies with billing or payment problems.
Generally Linker finds health-care providers to be cooperative.
“Most providers are flexible,” he said. “Providers are very vulnerable because they’re afraid of what the government may do. That’s helpful for me and the patients.”