Frustration: Access to Outpatient Ostomy Care in the HMO Environment
This online exclusive will feature a variety of topics on care management — from unique case studies that offer useful information about hard-to-treat cases to the challenges of reimbursement. Your contributions are comments are welcome. Send email to The Editor: firstname.lastname@example.org. For those of us lucky enough to have health insurance coverage, we pay our premiums or a portion of the premium on a monthly basis and access the healthcare system as necessary. The premium amounts are usually substantial, especially with the recent fee increases from many of the insurers. In return for these substantial fees, we expect to have access to and receive appropriate healthcare services. On more than one occasion, I have received inquiries about providing ostomy care for a patient who is covered by some type of HMO insurance plan. In general, this does not appear to pose a problem; however, if there are no ostomy services available in an outpatient setting where all HMO member patients can access regardless of their primary care provider (PCP), rendering ostomy services to these patients can be frustrating. Many HMO plans are based on the premise that the PCP is the gatekeeper of services and the patient can see only the specialists their PCP has chosen in his/her group. This may not be a problem for the very large HMO environments — they often offer specialty clinics where all patients can access care. But problems can arise in small IPA/HMO-run groups where there are no specialty clinics open for all patients. So what is the answer? Should the patient have to pay cash for these services even though they already pay monthly premiums for health insurance? Should they have to wait and continue to have problems such as leaking pouches, irritated skin, and poor quality of life while additional avenues are investigated with the insurance carrier or the IPA/HMO? In California, family nurse practitioners and other advanced nurse clinicians are not considered entities in the HMO environment for primary reimbursement in providing services such as ostomy, wound, or continence care. In other states, this type of entity exists and eliminates many of the frustrations in providing timely care to patients. These same clinicians have difficulty in getting provider agreements accepted at major health plans; additionally, there are questions regarding who is responsible for the services. Reimbursement for care of the patient at home may come from the health plan itself; whereas, outpatient clinic visits are a responsibility of the IPA/HMO run group. Who is responsible for the supplies? How do we care for the non-homebound individual who may be working and functioning on a daily basis but has some difficulties with his or her ostomy and needs some form of care? Home health services are ordered for these patients at times and are not appropriate. Why should OASIS paperwork be filled out on these types of individuals where precious time is taken on documentation requirements when an outpatient visit is all that is needed. As ostomy care providers, we are ready and willing to assist individuals with their ostomy needs and because so many quality-of-life issues may be at stake regardless of reimbursement, we do our best to help. As we start the new year, let these issues light a spark to renewed interest in participating with our professional organizations in offering a voice or opinion on how we may better serve and provide care for our patients.