Today’s Health Plan Choices

J. Greene


       It’s that time of year again, complete with all the sights and sounds of the season. That must be jolly old Saint Nick struggling with his big bag of toys down the chimney.
       No? Well, then those grunts and groans must be coming from Ma and Pa dumping a huge packet of brochures and forms on the dining room table. It's time to pick a health plan for next year, and they don't sound all that jolly about deciphering the HMOs from the PPOs from the POSs.
       Sometimes it seems you'd need a graduate degree in medical economics to navigate today's health-care system. But that's not so. To be an informed consumer, just figure out what variety of plan you have and what that means. Educate yourself just as you would when choosing a car mechanic or buying a new pair of walking shoes.
       Review your health plan materials and bug the plan's service people until you can answer these types of questions:

bulletDo I have to choose a primary care doctor?
bulletCan I see any specialist I want?
bulletDo I have to pay a percentage of the fee when I see the doctor?
bulletIs there a dollar limit on the amount of prescription drugs covered?
bulletHow do I get care in off hours?
bulletDo I have to notify the plan before using a hospital emergency room?
bulletWhat do I do if I want to challenge a coverage decision?

       Of course, you also have to know what you want out of a plan to make a good decision. You may have strong opinions about whether you want a single doctor making referral decisions for you, or you may have to give it a trial-and-error approach. In that case, give the HMO a try one year, then go back to a more choice-filled environment if you don't like it.
Actually, with the market in such turmoil, you may have no choice about changing plans. With luck this will all even out in the next few years so people can establish a long-term relationship with a family practice doctor or group and enjoy some stability. There are definite advantages to having that kind of relationship, whether it's forced upon you by the plan or whether you find a doctor on your own.
To help you sort out the choices you’re offered, here is a rundown of the basic health plan types, at least for the moment.

       HMO (Health Maintenance Organization): Pros: Lower cost,  free preventive care, a centralized system for monitoring your health. Cons: Restrictions on which doctors you can see and hospitals you can go to; can be much more bureaucratic than traditional insurance.

       PPO (Preferred Provider Organization): Pros: Gives you a longer list of doctors to see than an HMO. Cons: Less choice of doctor than traditional health insurance, higher cost than HMO.

       FFS (Fee for Service), or “indemnity” insurance, or good old-fashioned health insurance: Pros: Freedom to see any family doctor or specialist you want and any hospital you want. Cons: You pay more than in an HMO.

       POS (Point of Service): This is a new hybrid that is basically an HMO that has relaxed the rules so you can see any specialist you like without having a referral from a primary care doctor. Pros: The chance to find the best specialist you can. Cons: Costs a little more.

       Each year it seems these definitions get more fuzzy as health plans morph into versions of one another. So don't get too caught up in acronyms — it's more important to know the answers to questions like those posed above.
It's also good to know how your employer pays for insurance. You probably assume the company is just buying insurance plans for everyone. But maybe not. If it's a big company or organization, chances are it self insures. That means the company actually pays your medical bills out of its own pocket and hires an outside firm, often with an insurance company name, to handle the claims paperwork. If your company self insures, then that means the company itself is making many coverage decisions and shouldn't be able to pass off responsibility to the health plan. Bug your human resources department if there's something you don't like about a self-insured plan.
       If you are elderly or disabled and get Medicare insurance, you'll find many of the same choices are coming your way in 1999 as Medicare introduces what it calls Medicare+Choice. The new format introduces some alternatives to traditional fee-for-service Medicare and the HMO option that has been available for several years. However, many of these choices, such as a Medicare PPO or medical savings account, won't actually be available for months or years, until the marketplace catches up and begins offering them.
       Meanwhile, behind the scenes at the big HMOs, a trend has been developing that might seem way too technical for the average person to care about. But it could be quite important to you if you ever get into a coverage dispute with your health plan. Some HMOs are passing on to doctor groups the financial responsibility for their members. That means that while the doctors follow general guidelines about what the insurance policy covers, they have to make the books balance, and must make a lot of decisions about what medical care gets done and what doesn't. This internal game of hot potato has implications for consumers because whoever takes on the risk — doctors, HMOs, — has an incentive to save money and withhold care. They might wisely jettison unnecessary tests and procedures, or they might cut a corner that's very important to you.
       If you know where the medical buck stops, you'll have a better chance of figuring out who to complain to. Instead of writing that nasty letter to the medical director of the HMO, you'd be writing it to the medical director of the doctor group. Let's hope you'll never have to use this newfound knowledge.


Good Health Return
Good Health Return