Abigail Trafford (The Post)

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Everybody seems to hate managed health care. But just about all medical care in the U.S. is "managed care" whether it's administered by an HMO, a PPO or a more traditional form of insurance.

Are you satisfied with your health plan? A new Showtime television movie -- "Damaged Care," which airs on May 28 and May 29 -- suggests that health insurors deny needed care and prioritize profits over patients' needs.

What do you think? Yesterday we talked to Dr. Linda Peeno, a critic of managed care who is featured in the movie "Damaged Care."

Today, join Post Health columnist Abigail Trafford and her guest Susan Pisano, director of communications for the American Association of Health Plans, to talk about the importance of managed health care.

Send your questions now or during the discussion.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: Hello everybody. What do you think of your health care plan? Here's your chance to ask your health plan everything that you were afraid to ask before. Send in your comments and questions.

Abigail Trafford: Hello and welcome to Health Talk. Bashing managed care has become standard fare in film. The latest is the showtime movie "Damaged Care" which describes the experiences of a physician who worked as a medical reviewer in several managed care plans. What is your response to "Damaged Care?"

Susan Pisano: Our view is that the movie fits more into the old kind of health care debate ... fingerpointing, blamegaming ... and that this is a time when people want real solutions like independent review of plan decisions by physicians. Today, people are very worried about the uninsured and patient safety and caring for people with chronic disease and how we are going to pay for all of this. Our goal is to offer constructive solutions, and not to get mired in the old kind of debate.

Chevy Chase, Md.: Dear Ms. Pisano and Ms. Trafford,

Can you explain something I've often wondered? Why are doctor visits so expensive, even if you don't have tests done?
If see a doctor in the Washington area, it'll cost about $120 for a 10-15 minute visit. This works out to something like $400-$600 an hour. Also, why do doctor costs vary so much by location? For instance, when I lived in the Northwest, it cost maybe $60 to see a doctor, and many worked on a sliding scale.

Susan Pisano: One of the things that physicians are struggling with today is the high cost of malpractice insurance. Our health care system is so focused on lawsuits, and this has had a detrimental affect on everything from quality of care, to the doctor/patient relationship to costs. Lawsuits are one of the major factors adding to the new dollars that are being put into health care, and we think that something needs to be done about this.

Abigail Trafford: Critics of managed care argue that plans spend too much on administration including high salary packages to executives and not enough of the premium dollar in covering services for subscribers. Is there a kernal of truth here?

Susan Pisano: People often compare the administrative costs of hospitals and insurance companies and doctors to the costs the government incurs under Medicare ... or about 3%. What folks don't often realize is that the government's administrative cost calculation doesnt include all of the administrative expenses from each and every doctor's office and hospital. So this misleads.

Health plan administrative expenses are not a major factor in the increases in health care costs ... In fact, they don't even make the list of the high contributing factors. And, health plans are using technology more and more to keep administrative expenses down and improve service, which is a major goal of our community.

Abigail Trafford: Tell us more about the malpractice insurance problem. But then, how else can consumers get services that the health plan has denied?

Susan Pisano: With respect to the malpractice crisis, we are seeing an increasing number of states where the problem is so bad that doctors are fleeing the state, and even one where a governor had to call a special session of the legislature to deal with the issue. This is because of suits and the fear of suits and what it is adding to the overhead in physicians' office.

In 42 states, there is now a way for patients to appeal decisions health plans make. It is called independent medical review. We favor this. We want patients to have peace of mind knowing that this exists and that they can have an independent panel of physicians assure them about the decision. In a health care system where it is important to get the best care and get it on time, it is also important to keep health care affordable. We understand why, in that environment, patients may sometimes want to know more about how a decision was arrived at.

Abigail Trafford: And a followup to Chevy Chase: How do doctors set their fees. It's a different fee depending on the managed care plan. For example, one check up with the eye doctor was over $100. But the doctor was on my plan so I paid a co-pay and the plan about 50 dollars. What happens to the missing $50? Does the doctor eat it? And then, people who don't have health insurance have to pay the full price--more than 100 dollars-- out of pocket. That doesn't seem fair. What the "real" price of a doctors' visit?

Susan Pisano: This will vary from service to service, and from plan to plan. In the situation you describe, your portion of the fee was $50, and the physician probably also receives some portion of payment from the plan. Only a physician's office could tell you what the "real" cost of the visit is. The physician's overhead will be included in this, and factors like whether or not the office is automated, how much the physician pays in malpractice, etc., also come into play.

Abigail Trafford: In the movie, a man who requests payment for a heart transplant dies. Dr. Linda Peeno, who is played by Laura Dern, believes that she is responsible because she denied the claim. In reality, the man apparently went on to live another two and a half years. He didn't die on the operating table waiting for a donor heart. But the physician recommened the heart transplant as a life-saving procedure. Who decides in these cases? What happens to "close calls?" Does the managed care plan have the final say?

Susan Pisano: First, it is important to remember that the movie is a dramatization. And, that the events apparently took place some 15 years ago when heart transplants and coverage for them weren't as common as today, when most people have that coverage.

Today, a health plan would work very hard to encourage an employer to include coverage for transplant. If a patient, or the patient's doctor believed the patient should have a transplant, and there was disagreement with the plan, the patient could appeal this decision to the plan, and then to independent medical review. These decisions are required to take place in a certain amount of time, and very quickly if the patient's condition would suffer from a delay.

There is also a broad question raised here about how we can make certain that employers can afford to provide coverage with these important services included as costs continue to rise. We believe it is important to address this question, especially in light of the report released yesterday by the prestigious Institute of Medicine that indicated how those without insurance are suffering.

At My Desk: I think that the way we view health care needs to change. I have had Kaiser Permanente for ten years. People need to be proactive in their own health care. Thankfully I have had no major illnesses, but I did break my thumb several years ago and needed surgery to set it correctly. Yes, they put me off at first. Yes, they took an xray and never called me with the results, but I was persistent and got all of the care I needed. The doctor's themselves were great. Friendly and informative. You just can't sit back and expect the administration to go out of their way to care for you. I have always gotten the level of care I thought I needed. But I control my health care.

Abigail Trafford: Is this what consumers have to be in the new world of health care? You have to be the smart, activist consumer?

Susan Pisano: I can't comment on the specifics here, but I think it is extremely important for people to be active in their own health care. We should ask questions, and expect, and if necessary demand answers. I am always struck by the fact that people go to their doctors, listen, and then call family and friends to ask what the doctor meant. We should always know what the doctors is recommending and why, what the other options are and why the doctor isn't recommending them, when we will here from the office, when we should call if we haven't heard, and what should prompt us to take action.

This is true regardless of whether you have a managed care plan or don't, whether you are covered by Medicare or Medicaid, whether you are old or young. And, if necessary, take someone with you to the doctor who is more comfortable with all of this.

Mt. Rainier, Md.: I had been satisfied with my health provider, the Kaiser HMO. Now I am less satisfied, possibly because I need it more as I work further into middle age. Appointments with doctors are hard to get, so I end up settling for a nurse practitioner - but the N-P is operating under the same skinflint rules, so I get very few minutes of her time and no diagnostic tests. Still in pain, I wait for a doctor's appointment. More attention, but still no diagnostic tests to verify her guess as to what's wrong (damaged rotator cuff?). Now I'm in therapy for the rotator cuff that may be the source of my pain and taking mega doses of ibuprofen, which can cause kidney damage but what the hey. If still hurting in three weeks, THEN I'll get an MRI. Thanks, Kaiser, a whole bunch. I can't get an estrogen patch because it's not in their pharmaceutical and they can't (won't?) prescribe anything not in their book. OTOH, when I was dying from poison ivy gone septic, they saw me within the hour on a Sunday afternoon.

Susan Pisano: Again, I can't address specifics, but I think your health plan might appreciate knowing that you have had difficulties. I find that the plans that succeed in our industry are those that listen carefully and act on complaints. You will actually be doing the plan a favor by showing them this courtesy and allowing them the opportunity to fix something if that is what is needed.

By the way, I happen to think that being able to rely on getting service after "normal" hours is very important. I think most of us go into selecting a plan based on an assumption that things will go by the books. I almost never get sick from 9 to 5 on a weekday.

Washington, DC: Hi, do you have any advice for dealing with insurance companies when contesting a decision. I recently was reimbursed for services, and the company then turned around, said it wasn't covered, and turned it over to a collection agency. Someone in my office had exactly the same care about a year ago, and it was covered. The booklet describing our coverage is very vague. My last experience contesting the company's decision turned out ok, but I had to have my claim rejected two times before speaking to someone who said that I couldn't be charged.

Abigail Trafford: I think it's terrible you had to be put through all this. Susan, what about this?

Susan Pisano: Given the level of difficulty you describe, I would recommend asking whoever you deal with at the plan whether or not they are in a position to fix your problem. Get a commitment from the member services' person. If they say no, that it is ablve their level of authority, ask to speak to someone who has the authority to help you. I have actually found that to work ... and not just in health care, but anytime I am having a service problem.

Los Angeles: This might be too broad of a question, but I feel it's very sad that something on the scale of 30-40 million Americans don't have health coverage. Naturally, most if not all of these millions are the poor and elderly. That said, I totally abhor the socialist-style solutions so often promoted by groups in Washington and elsewhere. The last thing we need is more government in healthcare, as evidenced by the total failure of the Hillary Health Plan in the 90's.

Though I recognize the right of HMO's to make a profit, HMO's have fought tooth-and-nail to bring the poor into some sort of health insurance plan. This is totally immoral and unsustainable to people like me. I trust the free market, but if it means at the expense of the poor and elderly, something must be done.

Abigail Trafford: I think you speak for more and more people. There's a rising level of anxiety and anger about the inequities in health care. Your thoughts, Susan?

Susan Pisano: We've had a debate for five years that focused on managed care. I think that people are now beginning to focus on the problems of the uninsured and patient safety and quality. This is really important, especially when we are seeing reports telling us that there are disparities in health care between and among groups of people, and especially in light of yesterday's Institute of Medicine report that told us, human terms, what the toll is from not having insurance. We have proposed a number of steps for a new kind of agenda. Addressing the problems of access to care for the uninsured, and those covered by Medicare and Medicaid, is a major need.

Anchorage, AK: The basic issue will always be the incompatibility of health care and profits. Those of us who are healthy rarely have major issues with insurance companies, it's when we are sick and at our most vulnerable that we must not only garner our strength to fight our disease, but to fight for our medical benefits. We are bombarded with technicalities, like the hospital got pre-authorization for my husband's emergency admission not me personally, so the $15,000.00 fee won't be covered. Even the hospital tells me that insurance will eventually pay, they are just going to make me sweat it for a while. You can imagine how welcome this agony is when added to watching my 45 year old husband die. And by the way, we have "excellent" coverage.

Abigail Trafford: I am so sorry for your loss. And the problems with your health plan only make the agony worse. I hear stories like yours all the time. (I also hear some stories about how a plan helped families deal with the major illness of a loved one) But mostly I hear about the pain. Susan, why does this happen? What can be done to make managed care plans more compassionate and less hassling in circumstances like this?

Susan Pisano: I, too, am sorry to read of your loss and the issue of "technicalities," especially at this time.I know personally how difficult it is to deal with paperwork when you are sick, or when someone you love is sick.

I'd suggest calling the plan (and in case you didn't see my earlier response) asking if the person you get on the phone has the authority to help you. Get a commitment from them to do just that. I have found that when I do that, people become my advocate. If they say no, ask them to transfer you to someone who does have the authority to help.

If that doesn't work, I'd recommend filing an appeal with the plan. If you and your husband had reason to believe that there was already a threat to life or health when you went to the ER, it is likely (given your description of your plan) that it is covered. You have indicated that there is a lot of money at stake, and you shouldn't have to worry about it over a long period of time.

Abigail Trafford: Let's talk about the role of the employer in choosing a plan and setting benefits. Many firms only offer one plan, so there's no choice for the consumer. Another trend is to offer a cafeteria-style benefit package. This is a way to keep costs down for the employer and make the employee's contribution more affordable. The downside is that many people with insurance are "underinsured." They are the ones caught by fine-print surprises. That's like the man in "Damaged Care" who was covered by a plan that excluded heart transplants. It seems that health coverage should be protection against unforeseen events. You can't know what you're going to need when you select a benefit package. Shouldn't there be a standard benefit package to guard against fine-print surprises?

Susan Pisano: You are asking a very important question. We haven't had a debate in this country about what a "standard" benefit package should include.

Rather, we have a series of debates, one after the other, about whether x or y or z benefit is worthy, and should be required by law. Usually the answer, when taken one by one, is that they seem worthy. But we never compare them, or consider the science that tells us whether or not something works for patients. We need a way to do this because what has happened is that the benefit packages have so many requirements, and people are having to pay more and more out of pocket as a result.

Also, employers don't have too many options when costs are rising so quickly. We need to address some of the underlying drivers of health care costs. PriceWaterhouseCoopers recently did a report for us that showed more than 25 cents of each new dollar going into health care is for lawsuits or regulation or mandates or fraud and abuse. That is a good place to start to targeting the problem

Abigail Trafford: Back to administrative costs. What really galls people are the high executive salaries and $million dollar bonus packages when the costs of premiums are going up 10 to 20 percent and people are having a hard time finding AFFORDABLE insurance. In the movie, one managed care plan spends thousands of dollars on a sculpture for its lobby while limiting payment for services. This doesn't seem right????

Susan Pisano: Research indicates that administrative costs at health plans are NOT what is driving the cost of health care. Of course, there are factors we already knew about such as the aging population and new technologies and drugs, and the increased cost of providers. While we need to make sure that the drugs and technologies are affordable, we do want a system where we have access to those that the science shows are working.

What a new report done for us has said is that more than 25 cents of every new dollar going into health care is for lawuits and regulation and mandates and fraud and abuse. These are prime areas to target as we begin to try to get a handle on rising costs, and all that those costs bring with them. We know, for example, that every time the cost of health care goes up just one percent, 300,000 people lose coverage across the country. And we now know that people fare much worse when they don't have coverage. They are more likely to die, and they are more likely to suffer if they don't have health care coverage. The Institute of Medicine put a human face on that issue in a very compelling way with its new report yesterday.

Arlington: I see the common thread with the answers here is "call your health plan" "try to file an appeal with the health plan." I think the real solution is at the first sign of trouble, people should have the right to call an attorney. When HMO's start losing lawsuits due to their greed will real reform come about. An HMO denying coverage to a sick patient is no less criminal than auto company's hiding defects which cause accidents and deaths.

Susan Pisano: We have been answering questions from people who have indicated they are having a problem. Most people actually are not, according to most surveys. That is an important thing to keep in mind. I haven't said that because I have been trying to give my best answer about how to get help as quickly as possible.

I couldn't agree less about calling attorneys. We can't sue our way to a better health care system. What we need are ways for people, when they do encounter a problem (which will happen in an arena as complex as health care) to get them fixed and fixed quickly. We think that is independent medical review. And, doctors and hospitals are actually less likely to identify and address problems because they are worried that those who do will face lawsuits.

We need solutions, not more time in the court room.

For administrative problems, one of the promising things is that technology is helping us to improve service.

Columbia, MD: I am extremely frustrated with my healthcare plan (Aetna/US Healthcare). It seems as if they are trying to say what's best for the patient, and not letting the doctor do so. For example, my doc prescribes a medicine, that finally works (for arthritis-like symptoms) and the plan goes and says it's no longer covered, try the over-the-counter options. If they worked I wouldn't have gone to the doc in the first place. Not to mention the limited physical therapy visits I am entitled to, which severly limit the treatment. It is preventative treatment, to avoid needing surgery. But I guess they'd rather pay for the surgery and the extra pt visits afterwards. It is very frustrating and time-comsuming to have to keep harping after the insurance to get the care I need. Why don't they trust the doctor's diagnosis and let it be treated as it needs to be?

Susan Pisano: We don't have too much time left, so I am going to give a quick answer here.

I don't know the details of your health plan, but most health plans will have a way for a doctor to get a medicine if one of the preferred medicines isn't working for you. You might want to ask your doctor or health plan about that.

Rockville, MD: Hello? How about addressing the "Platinum Parachutes" that the executives are getting? Or their astronomical salaries?

Susan Pisano: I know that there are questions about how much these items add to the cost of health care. PriceWaterhouseCOopers just did a study for us that showed what the drivers of health care costs are. This was not among them. The major drivers are new technologies and drugs, costs increases from doctors and hospitals, etc. AND, lawsuits and regulation and mandates and fraud and abuse are contributing significantly to each new dollar being spent on health care.

These are good prospects for targeting if as a nation we are serious about addressing the cost of health care.

Interestingly, this same study also showed that the nation would be spending more than $150 billion more over the next five years if it weren't for managed care.

Virginia: I'm concerned that so much of this discussion (well, most complaints about health care) are that people aren't covered for all the services they want/need. Why don't people realize that the more things you are covered for, the more insurance costs, and that someone has to draw the line somewhere to keep a basic level of coverage affordable? HMOs get all of the heat for being the ones to draw that line, but someone had to do it and apparently it's not going to be the government. There is no entitlement to health care coverage in this country (unless you qualify for public programs) and people are clearly not willing to pay the increased premiums it would take to provide coverage for everything everybody wants.

Susan Pisano: I agree that we haven't had a good debate about what should be in the benefit package. And, government regulation keeps adding more and more requirements, making the packages that are available for employers sometimes too expensive.

What health plans try to do is to make more benefits more affordable. This has made them a target, and I believe, has deflected attention away from the actions that we need to take to make certain more people have coverage, and that the coverage people have is good coverage.

Vienna, VA: I saw my primary care physician for the first time three months ago for an ear infection. Prior to the office visit I supplied my identification. Upon leaving I paid the co-pay. So far so good. But now:

Two weeks after the visit I got a bill in the mail. I called the HMO customer service office, was on hold for 25 minutes and then talked with a representative. My question was simply why did I get a bill when office visits are fully covered with the co-pay. I was told that the charges by the physician exceeded their reimbursable.

After about 20 calls to various people and after receiving several severely worded mailings from the HMO, the matter was corrected. No apology.

Meanwhile I got sicker and scheduled a second office visit. I had these ear infections as a child and on the second visit asked to see a specialist.

A referral was not given. I am aware of witholding pools in the industry and am not happy about that either.

What a mess. Unless your an exec or CEO then those millions of premium dollars from group policies almost seamlessly make their way into your pockets.

Susan Pisano: I think you might consider asking for someone in a position of authority in customer service to deal with the first issue, but the second would be where I would put my energy right now.

If I understand you correctly, you asked your doctor for a referral and did not get one. This is unlikely to be because of a physician payment issue. Frankly, if you do need a specialist, it isn't in anyone's interest, financial or otherwise, to deny that.

I'd follow up with the doctor's office. If the referral has been denied, you have a right to know why ... Perhaps the answer from your doctor will reassure you, or you may need to take on an appeal. That is available to you.

I'm answering a little indirectly only because it wasn't clear to me why you didn't get the referral. But I think the best place to start when trying to fix most problems is at the closest level.

what about mental health parity?: I bet Susan loves that idea!

Susan Pisano: I think there is a lot of agreement about the need for access to good mental health benefits. What we have said is that we need to look closely at what is being proposed right now.

When most people think of mental health parity, they think what is being proposed is parity with respect to serious illnesses, and those where there is good science upon which to base treatment. But in the bill currently proposed, employers would be required to provide coverage for things like "jet lag" and hundreds of other diagnoses.

Many of the people who have taken part in this on-line chat have been upset about how much health care costs. I think we need to have an open and honest discussion about what this will cost and exactly what is meant by "mental health parity."

Abigail Trafford: Our time is up. sorry not to get to all your questions. We'll be talking about these issues again. Thank you all for joining.

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