I'm sorry Mrs. Smith, but your managed care plan only allows you to go to St. Other's ER unless it's a life threatening emergency. St. Other is across town. You have no transportation. Try giving Randisha Tylenol for her ear pain, and we'll see you tomorrow when our clinic opens. After the patient vents her frustration and confusion, I chalk up another patient who appears clueless about what being a managed care patient means.
Several reasons come to mind.
First, the managed care system is so fundamentally different from the system most of my Medicaid patients used previously that it is hard to absorb. Before, Medicaid patients could be seen at any emergency room or clinic that accepted Medicaid patients. Now Medicaid patients must sign up with a managed care system that assigns them a primary care giver. This primary care giver must then serve as a gatekeeper monitoring ER and clinic visits, labs, referrals to specialists, and hospitalizations. While serving as a gatekeeper, the gatekeeper must also try to offer optimal medical care for the patient.