Judging Your Health Plan

      An oncologist and an HMO executive are at the gates of heaven, waiting for their deeds on Earth to be judged. The cancer specialist, lauded for all the lives he has saved, is escorted through the pearly gates. As the managed care HMO executive steps forward, St. Peter tells him he can go too, "but you can only stay three days."
      It's not easy running a managed care health plan these days. You're the butt of jokes, the latest bad guy who's tying damsels in distress to railroad trestles. But it's a little too simplistic to paint the entire industry as evil incarnate. Like any other business, there are good health plans and not-so-good health plans; the trick is knowing which one is which.
      The fact that so many HMO health plans are making life-and-death decisions that answer to investors on Wall Street makes many people nervous. Besides many consumers prefer more choice, they don't like going to a single "primary care" doctor who decides whether they get to see a specialist, or they see the plan as being too paternal or bureaucratic.
      On the other hand, Group Health Insurance Plans boasts a large number of longtime members who appreciate having a long-term relationship with one doctor and one plan. In fact, studies show that the longer someone is in such a health plan, the happier they are with it.
      Another way to judge is by the percentage of money they spend on medical care instead of on administration. This is called the "medical loss ratio," and is often a piece of information you can obtain from your health plan or state insurance department.
      Critics of the medical loss ratio argue that differences in the way plans define what is an "administrative" cost make the number unreliable. In any event, the gap may be narrowing anyway as the HMOs — much to their dismay — may have to spend more on doctors and hospitals and get slimmer returns.
      When picking any health plan, be aware of the issue of the organization and pay attention to all the information available about your local plans, including how well they provide care and whether your favorite doctor or hospital can participate.

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