My Third Laser Treatment    [Plus: The Cost of the Procedure]

Reforms in the New Health Insurance Bill

Epilepsy and Dealing With a Career

Washington Univ. Comprehensive Epilepsy Program

Epilepsy Foundation of Victoria

HOME

WHAT IS TS?

NEWSLETTER ARCHIVES

LINKS

PEN PAL

CLINIC PROFILE

UPCOMING EVENTS

DIRECTORY

GUEST BOOK / COMMENTS

ABOUT US

Whether you are a first-time job seeker choosing your own insurance a plan or somebody looking to change plans, the intricacies of your healthcare options can be overwhelming. With the passage of the new healthcare reform bill, it is increasingly important that you start out with a good plan which you will be able to take with you when changing jobs (see box for details about the new bill). How do you choose the best plan? Below is an attempt to shed some light on the various managed care options.

What are HMOs, IPA, and PPOs?

Health Maintenance organizations (HMO) are prepaid health centers that cover preventive services, checkups, and serious illnesses. Within the category, there are two models: staff/group model and independent practice association (IPA) model. The former is a traditional HMO with salaried doctors who serve only plan members. The IPA model is a network of independent doctors who are paid an annual fixed sum or a per-visit fee for each enrollee. In both cases, plan members are covered only when using the HMO doctors and hospitals. Preferred provider organizations (PPO) are hybrids in which members can choose from a list of doctors who provide care at discounted costs. Under this plan members are free to choose out-of-plan doctors but with a higher co-payment.

What are the advantages of managed care?

Managed care premiums are lower and each visit costs less than fee-for-service plans. Additionally, you need only to make one stop to receive doctor care, prescriptions, and tests in many cases. HMOs like Kaiser Permanente hire their own doctors and staff full service clinics under the same roof. Finally, HMOs are very good with preventive care.

Why does managed care have such a bad reputation?

The biggest complaint of managed care is that patients cannot always see the doctors they want to see and receive adequate care when there is a problem. It is very difficult to obtain approval to see specialists, especially outside the health care plan. Even if the doctors you want to see are on the health plan roster, you may not get to see them as often as you want since the decision will be up to your primary-care physician.

The primary care physician serves as the gatekeeper, receiving huge incentives for keeping costs down. Furthermore, many HMOs and a few PPOs hold them responsible for a portion of extra expenses such as lab tests and referrals to specialists. This translates to an unwillingness to administer costly tests, shortened hospital stays, and refusal to cover certain treatment methods. However some successful managed care companies are changing this traditional incentive plan. U.S. Healthcare for example, has a payment system that is based more on the quality of care that doctors deliver. The intense competition of the industry will hopefully move the rest of the healthcare providers in that direction.

What questions can I ask in choosing the best plan?

While PPOs obviously offer the most flexibility in choosing your doctors, there are still many questions you can ask to screen out poor quality plans. If you already have doctors that you like, ask them if they are part of any managed care groups. You can then narrow your search to plans that include more of your favorite physicians. If you are considering a plan that hires its own doctors, ask for recommendations from the plan's roster and bring the list to your present doctors for their recommendations.

It is also important to ask your employer's health benefits manager or the plan's marketing director about the incentive payments to doctors. Sample questions are: Are doctors paid a set salary that is unaffected by the patient load and amount of care provided? If the cost of care exceeds the doctor's annual compensation, does the doctor have to pay any of the excess? What consequences could your doctor face for standing up for you in a disagreement with the HMO? If you are still undecided you can call the National Committee for Quality Assurance at (202)955-3500 for their quality ratings list of HMOs

(Click here to go to "Reforms in the New Health Insurance Bill")