MANAGED CARE: PATIENTS WITH RARE DISEASES LACK SPECIALISTS
Although millions of New Yorkers are joining managed careThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
plans, a growing number of patients with chronic or rare
illnesses "say they are being denied desperately needed care,"
NEW YORK TIMES reports. Unlike more mature managed care markets,
where extensive specialist networks exist, few of the players in
New York's and other new and rapidly growing managed care markets
have developed the networks or programs needed to treat "patients
with complicated medical needs." As a result, patients are
often left battling HMOs to get the care they feel they need.
SPECIAL NEEDS: Some HMO patients with rare illnesses say
that their care is of a "hit-or-miss quality" that depends on
whether their HMO has "made arrangements with a doctor
knowledgeable about the particular ailment." University of
Pennsylvania health policy professor Dr. Alan Hillman said that
although 85% of health care is routine, "the gaps in HMOs exist
in the less routine situations." TIMES notes that the dilemma
"is a bit of a chicken-and-egg problem:" patients have avoided
HMOs because their networks do not include so-called
"superspecialists;" in turn, HMOs have refrained from hiring
specialists because there is little demand for them. Often an
HMO "starts small" and does not add specialists until it
experiences patient demand for them. The process, TIMES reports,
is "characterized by intermittent shortages."
CHANGE IS COMING: In the most mature markets, such as
Minneapolis and Southern California, HMOs "have had years to
wrestle with the issue of care for chronic and serious illnesses
and have often grown large enough to enlist superspecialists."
Although TIMES notes that HMOs in growing markets such as New
York and Boston have recently "begun to tackle" the problem,
Hillman said that this "maturation process" can take "five to
seven years of steady growth and concerted effort." He said,
"The gaps in HMOs exist in the less routine situations. And of
course the good organizations seek to plug them, but that can
take years." However, TIMES reports that the same complaints
about specialists exist in areas of the country "where managed
care has been strong for decades, suggesting that even with time
change does not always occur" (Rosenthal, 7/15).