Putting Members First

"We think it would be better if your doctors would not make themselves so available."

Health plans also refer to their enrollees as "members." Does this mean that any given health plan belongs to its members? Hardly. In all but a few cases today, health plans belong to their shareholders in publicly traded companies. In this situation the "members" are really nothing more than "covered lives," an obligation of doing business.

Not too long ago things were different. Health plans were not-for-profit organizations whose sole purpose was to provide medical benefits to enrollees. In this situation, membership had some positive meaning. Blue Shield, Lifeguard and Kaiser Permanente Health Plan still operate this way, but they are just about the only not-for-profit health plans left doing business in California.

We just learned of an example of the sort of thinking that takes place when a health plan changes from a not-for-profit, member benefit organization to a for-profit, publicly traded enterprise. This is a small issue, and no lives were endangered, but it seems to me to cast a harsh light on what "membership" really means in the world of for-profit health plans.

A primary care office decided to increase availability to patients by having limited office hours on certain holidays such as President's Day, Memorial Day and Labor Day. The office manager noted that the CPT Code Book includes a billing code for holiday and Sunday services. So a modest fee was added to regular service fees for patients seen on these holidays.

The office also pays employees time and a half for holiday work and only sees urgent cases on those days. Most health plans paid the extra fee without question, but one of the biggest for-profit health plans disallowed this fee with a comment to the patient that the holiday fee was an "excessive" charge. This led to some discussion between the office manager and the representative of the health plan in question.

"We are keeping your patients out of the Emergency Room on those days," the manager said.

"Our analysis has shown that patients hate going to the Emergency Room, and we feel that most of our members will just tough it out and wait until you are open the next day," the provider representative replied.

"But this provides better service to our patients," said the office manager. "Don't you want that?"

"Actually, we think it would be better if your doctors would not make themselves so available," he said.

What can you say to that?

So here we have in microcosm a statement of what health plan membership means in the year 2000. If you are a "member" of this health plan, you may not get urgent medical care on a holiday. Maybe you should just tough it out and seek care another day. If you are a contracted physician, it means that this health plan would prefer that you "not make yourself so available" to your patients. It doesn't take much to say a lot.

To end on a happier note, membership means something very different when you are a member of SEDMS. Your medical society leadership and administrative staff only work for the SEDMS members. We are here for you.

I hope that all of you who are reading this never need to call on your medical society to help you out with any problems, but please remember your society is always there for you. Sometimes membership still does mean something!

edpmg@inforum.net