Health care is really expensive. We spend 14% of our national income on health care. So what does that mean to you?
It means that to get a handle on costs, the system is changing. You may have fewer choices about the health care providers you see. In other words, your access may be restricted. Why? What is managed care anyway?
Managed care is a system of health care delivery that attempts to control costs while maintaining quality. Managed care organizations, the companies that insure you, can take on many forms. They are often called "plans." Originally, plans limited the amount of health care services that were provided while they maintained quality standards. Now, plans are also attempting to streamline the services they provide.
One way to keep your premiums low, to encourage less use of health services and to make service delivery more efficient is to limit the health care providers you can see. Managed care organizations, like HMOs and PPOs, try to "manage" your care by setting up contractual arrangements with doctors and patients. These "arrangements" are supposed to make health care more predictable and less variable. There is some evidence that these arrangements help to lower costs because the managed care organizations can arrange volume discounts with a group of doctors for the health care services they provide. In return, the group of doctors is assured a steady stream of patients in their practice, even though they have agreed to discount the price of their services.
But that means that you, the HMO-insured patient, must agree that for a certain monthly price, you’ll see only the doctors listed in your insurance manual as "participating physicians." Some plans, described below, allow you to see someone other than the "participating" doctors, but you usually have to pay extra to see them.
You may also wonder why you have to see a primary care doctor before you see a specialist. Many managed care organizations have implemented "gatekeeper" systems of patient care, where the physician with a general knowledge base (the gatekeeper) must first determine whether your case warrants that you visit a subspecialist. These systems cause controversy because of the individuality of each patient and the incentives to avoid specialist referral that managed care organizations often place on primary care physicians.
HMOs organize, pay for, and deliver care
An HMO usually only permits its members to see doctors and use hospitals in its network. If treatment is provided outside the HMO's network, the cost of care will not be paid for unless the care was authorized ahead of time by the HMO or determined to be an emergency.
PPOs allow more choice
A PPO plan shares some of the features of both ordinary health insurance and HMOs. PPOs encourage you to use physicians, hospitals, and other health care providers that are part of a preselected network. PPOs pay more of the cost of your care and usually require only a small fee, called a co-payment, when a member sees their doctor. If you use doctors or hospitals that are not in the PPO network, the plan pays less of the costs. PPOs usually let patients see medical specialists without getting permission first from a primary care doctor.
Preserve your ability to choose
"Point-of-service" plans can preserve your freedom of choice. One way to keep your ability to choose your medical specialist is to seek out and join a "point-of-service" HMO or PPO. These plans are growing quickly because they are less restrictive than ordinary HMO plans and patients have freedom of choice.
Point-of-service plans will usually cost more than an ordinary HMO or PPO plans, but will allow you to visit doctors not in the plan. You can use this freedom of choice at any time, which is important if you want to see a specialist.
With a Point-of-Service plan, care is available from HMO or PPO network doctors and hospitals, you'll have little or no deductible, and only a small fee for a visit. If you decide to go outside the plan's network of doctors and hospitals for care under the point-of-service option, you will have claim forms to complete for reimbursement; bigger out-of-pocket expense, known as a deductible; and you'll be responsible for part of the rest of the cost, which is called co-insurance.
Things to consider when choosing a plan.
Access to Care
- Will I have my own doctor?
- Can I see him or her at each visit?
- Other providers. Does the plan use primary care providers that are not doctors such as nurse practitioners, registered nurses, and physician assistants to give routine care?
- Convenience. Are the plan's doctor offices and other services such as physical therapy nearby?
- Appointments. How soon can I get an appointment if I am sick? For routine care?
- Admissions. What do I have to do for admission to a hospital?
- Hospital. Does the plan use a hospital nearby?
- Emergency. How quickly will I get care in an emergency? Who decides if my problem is an emergency or not?
- Existing conditions. Will I be covered for any medical condition? How long will I have to wait?
- Limitations. Are there limits on how long I can get services or the cost of services? What services are not covered?
- Specialized care. Will the plan cover the full range of specialized care for me and provide highly advanced treatments for all conditions?
- Routine exams. Are there restrictions on who can perform routine examinations? For example, if I am a woman whose primary care physician is not an obstetrician\gynecologist, can I see a gynecologist for routine gynecological services, or must I see a primary care physician for those services, or get permission to see a gynecologist?
- Maximum benefit. Is there a maximum lifetime benefit or a dollar limit on any specific type of care?
- Type of care. Does the HMO make its doctors give the least expensive treatment first and, only if needed later, give other treatments or stronger drugs that may cost more?
Quality of care
- Report card. Does the plan have an up-to-date "report card" describing its indicators of quality and rating its performance? Can I have a copy?
- Certified physicians. What percentage of primary care doctors and medical specialists in the plan's network are board-certified?
- Satisfaction. How many members left the plan last year and why? Can I see the patient satisfaction reports for the plan?
- Complaints. How many members in the plan filed formal complaints last year? How does this compare with the year before? What were the complaints about? What was done about them?
Choice of physicians, hospitals
- Point-of-service. Does the plan include a point-of service feature? Cost?
- Eligible doctors. Is my current doctor on the plan's list of doctors? Can my doctor get on the list? Is my hospital on the list?
- Excluded care. Is there any care I get now that I could not get if I was in the plan?
- Referral. Can the doctors in this plan refer me to a specialist? Can I go to specialists without the permission of my plan's doctor?
- Incentives to physicians. How is my doctor paid by the plan? Do doctors get paid in any way to cut back on tests, referrals to specialists, and hospital admissions? Do primary care doctors working for this plan make more money if they reduce referrals to specialists?
- Filing a complaint. What can I do if I don't like my care, or if my primary care doctor refuses to send me to a specialist when I think I need it?
- Out-of-state. What happens if I need care when I am out-of-state or out of the plan's area of coverage? How much of the cost of my care will be paid by the plan?
- Premiums. How much is the premium (the monthly cost you pay to be a member of the plan)?
- Co-payments. How much is the co-payment (the amount of money you pay for physician office visits, prescriptions, or hospital services)?
- Deductibles. How much is the deductible (the share of the health care expenses you pay out-of pocket before any insurance coverage applies)?
- Extra costs. Are there extra costs to pay for emergency care or services I receive from out-of-plan doctors?
You will find answers to some of these questions in the printed materials available from the plan. You can get other answers by asking the plan's representatives. For example, you can talk to people in the customer relations or member relations offices of the plans you are thinking about. If you can't get answers to these questions or others you may have, you should carefully consider whether the plan is the best health care plan for you and your family.
For information on health care please see Tip #26: Consumer Guide to Health Care Plans. E-mail any questions you may have to firstname.lastname@example.org
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