By Lawrence J. Harms, MBA, FACMPE, Clinic Administrator

Although patient choice and managed care restrictions have been in the media lately, we still see a continued effort to restrict patients’ choice of providers, particularly specialists. This is also true with Medicare HMO plans, and if you are a Medicare patient, you will soon be faced with a number of new plans beginning in 1999. You may already have received information from Medicare. Before making any changes, you should study the alternatives carefully and please call your doctor if you have any questions.

Managed care plans usually involve either a health maintenance organization (HMO) or a preferred provider organization (PPO). In the case of an HMO, you are normally required to select a primary care provider (PCP) who contracts with the HMO. The HMO pays the PCP a monthly capitation payment. The PCP receives this whether or not you ever need any care while you are enrolled in the plan. The PCP does not receive any further payment when you do need care and if you are referred to a specialist or for care outside of the PCP’s office, the PCP or plan must pay for that out of the monthly capitation payment. Some people argue that the primary care provider thus has an incentive to withhold care and restrict outside referrals, since she/he will benefit by retaining more of the capitation payment. However, others maintain that the PCP has more of an incentive to keep patients as healthy as possible in order to avoid the more costly care that comes with advanced disease or illness.

With the PPO, you may also be asked to select a primary care provider, but plans differ as to whether you can refer yourself to a specialist without obtaining a referral or approval from your PCP. In the case of both the HMO and PPO, you will usually always need prior approval for diagnostic tests and x-rays, referral to another specialist, or for surgery or hospital admission. More HMO’s and PPO’s are now offering a ‘point-of-service’ option. This allows you to seek care from specialists outside of the plan network if you are willing to pay more out of pocket.

At SOFC we attempt to participate in as many plans as we can, in order to be available for as many patients as possible. In recent months, however, we have found that if the patient has selected a PCP who belongs to a large group practice or clinic organization that also has orthopaedists, they frequently receive a lot of pressure to use the ‘inside’ orthopaedist instead of being referred to SOFC. This is true even if our group participates in the same health plan. To protect your right to see the specialist of your choice, before you select a plan, you should do the following:

Ask a plan representative or your employer for a list of approved specialists and hospitals. Check with the primary care provider you plan to select to see if they will refer you to the specialists you want.

Contact your specialists to see if they participate in the plan you would like to join. Make sure the plan includes a point-of-service option to seek care outside, if you desire. Finally, you need to be assertive in demanding the specialist of your choice. If you are denied, most plans have an appeal process. If your PCP still refuses to refer you to the specialist of your choice, you may need to find a new PCP who will, and we can help you with that as well. Remember, you must take an active role in your health care decisions.

SOFC Welcomes Dr. Maurice D. Skeith

We are very pleased to announce that Dr. Maurice D. Skeith joined our group in August this year. After many years of practice in rheumatology and internal medicine in Seattle, he joins us for the practice of medical arthritis (rheumatology). Dr. Skeith specializes in the non-surgical treatment of joint and muscle disease. He has had fellowship training in rheumatology, and a long time experience in the treatment of inflammatory conditions of the musculoskeletal system.

According to SOFC President, Dr. Charles A. Peterson, “The addition of Dr. Skeith enhances patient care at SOFC with the ability to provide a broader range of services for musculoskeletal conditions.”We also welcome the addition to our staff of two of Dr. Skeith’s long-time employees, Sheree Bullock, R.N., M.S.N., and Marilyn Jones.

Dr. Skeith grew up in Nebraska, and is a graduate of the University of Nebraska College of Medicine. He received his internship and residency training at the University of Washington, where he finished as Chief Resident in Medicine and instructor at Harborview Medical Center. Dr. Skeith has an interest in and long experience with the treatment of diseases such as rheumatoid arthritis and non-articular rheumatism (fibromyalgia). Early and intensive treatment of these disorders can make a dramatic difference in the outcomes for the patient. Dr. Skeith prides himself on the attention patients receive from him and his staff.

He is a member of Alpha Omega Alpha, the American College of Rheumatology, the American College of Physicians, and the King County Medical Society, and is a past President of that organization. He has also served as Chief of the Medical Staff at Swedish Hospital. Dr. Skeith and his wife Shirley are the parents of three grown sons, and have three granddaughters. They have lived in Seattle since 1960.