Getting an insurance claims education...not sure I want it (prescriptions, cancer)
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
I am sorry you had a bad experience with an HMO. I would probably have worse feelings about HMO's if I were in your shoes.
I have to say I really never researched how HMO's work, and didn't know about doctors being salaried. I assumed (maybe wrongly), that the list of HMO doctors was not mutually exclusive to the list of non-HMO doctors. For Mom's benefit (and possibly others reading this thread), I did a few seconds of Googling. I thought this document from the American College of Physicians might shed some more light on the types of HMO models in existence and how providers get paid:
In Mom's case, she says "all he (the HMO primary) does is refer me to a specialist." It doesn't seem to matter whether Mom and her husband's health care is emergency or non-emergency...over the years I never heard of them having a problem getting a referral to a specialist. I'll keep researching and I may start another thread about how HMOs work.
One thing you may not (or perhaps you do) understand is that if you go "out of network" in a MA plan - you will probably have to pay a (much) larger co-pay/deductible than if you stay "in network". I've never heard of a MA plan that won't pay anything if you go "out of network" - but it's possible they exist. Robyn
It's a Medicare Advantage plan. What are they not telling Mom that would make Mom consider dropping them?
Your mother is 90 y/o and was just hospitalized??? Highly unlikely she'll ever be able to replace this carrier with other coverage - even during open enrollment - unless you are in a really competitive market. Health questionnaires are de rigueur when switching Medigap/MA plans.
ACA does not negate outright denials of coverage due to preexisting conditions for Medigap/MA coverage outside of a Guaranteed Issue Period. Your carrier would have to drop her (i.e., its service entirely in your area) in order for her to get other coverage with no denial for preexisting conditions. In that event, any other carrier has to take her.
FYI- Medigap plans are usually more expensive than MA plans - but do have more flexibility as to doctors. If you aren't stuck with a lot of out-of-pocket charges because of noncovered or out-of-network carriers, and she has had no trouble getting the care she needs, she's probably better off with what she has most likely.
If you decide to switch her this fall during Open Enrollment to a Medigap or another MA and you are successful with her medical history, please post back with the details.
MA's can be HMO's requiring use of their "in-network" doctors. In my area these doctors are NOT on salary, but are in private practice or on staff at a wide variety of hospitals. MA's also can be POS or PFFS. UHC MA in our area was a POS before it became a pure HMO in 2014.
Quote:
Originally Posted by Robyn55
One thing you may not (or perhaps you do) understand is that if you go "out of network" in a MA plan - you will probably have to pay a (much) larger co-pay/deductible than if you stay "in network". I've never heard of a MA plan that won't pay anything if you go "out of network" - but it's possible they exist. Robyn
UHC just changed the MA plan I left (for hd-F Medigap) to a pure HMO - with NO out-of-network coverage. They were very clear about that. At this point, however, they still allow self-referral to specialists. Patient does not have to see PCP for a referral. I expect that will change soon. UHC has incrementally, each year, been further restricting options under their MA in our area.
Because, at the moment, UHC MA has such an extensive network in our area, I suppose they felt they could impose the HMO - "NO out-of-network." Only exception to NO out-of-network would be emergency services out of state primarily.
Max out-of-pocket went to $4,950 for 2014.
Last edited by Ariadne22; 01-19-2014 at 02:49 PM..
Don't confuse an HMO health plan or a PPO health plan with an actual HMO...while many HMO's have doctors that are not their employees, a true HMO only allows doctors in their employ...
A PPO is a type of health insurance plan and has nothing to do with how the dr's practice is run.
The model of employed physicians doesn't show up much anymore--and hasn't for over a decade. How about Kaiser, the largest HMO in existence:
Quote:
Kaiser has long argued that its approach offers distinct advantages, but it has begun to bow to the pressures of the marketplace. The health plan has been assembling its own networks of outside physicians, and today they outnumber full-time Kaiser doctors in the mid-Atlantic region by almost 4 to 1. Moreover, Kaiser has begun marketing a plan that lets patients seek care outside the HMO, albeit at a reduced level of coverage.
Again, please note the opposition to HMOs is an absolute driver of increased cost for health care.
Quote:
Physicians, like any other professional group, tend to locate in those areas in which they will maximize their incomes, other things equal. Previous studies have found that managed care reduces the earnings of physicians, particularly specialist physicians, by reducing the demand for specialist care both absolutely and relative to generalist care (Simon, Dranove, and White 1997, 1998; Hadley and Mitchell 1999, 2002).1 Several studies that analyzed data from the late 1980s and early 1990s suggest that specialists have responded to these incentives. The studies found that the number of specialists grew more rapidly in areas in which a relatively low percentage of the population was enrolled in health maintenance organizations (HMOs).
--------------
We present evidence consistent with previous research that shows, other things equal, that there is a negative relationship between changes in relative HMO penetration and changes in the specialist physician-to-population ratio.
Again, the heavy "specialist" population of physicians who are generally opposed to HMOs, are some of the primary drivers of increased medical costs. There was no relationship between PCP and HMO penetration.
More specialist equals higher health care costs, more tests, more procedures, and frequently poorer outcomes due to the increased utilization of unnecessary tests/procedures that often lead to more harm as opposed to better care.
Sorry, I just don't buy that seeing a specialist is all doom and gloom, nor is it "driving up" costs. I love my primary care dr, she's great, but she also knows what she knows and for more complex issues, she refers on. She, and any good PCP, knows that they didn't spend the extra years learning their specific craft and they don't see the cases the specialist do.
Again, would you want your divorce attorney handling your murder trial??? How is that any different?
Your mother is 90 y/o and was just hospitalized??? Highly unlikely she'll ever be able to replace this carrier with other coverage - even during open enrollment - unless you are in a really competitive market. Health questionnaires are de rigueur when switching Medigap/MA plans.
ACA does not negate outright denials of coverage due to preexisting conditions for Medigap/MA coverage outside of a Guaranteed Issue Period. Your carrier would have to drop her (i.e., its service entirely in your area) in order for her to get other coverage with no denial for preexisting conditions. In that event, any other carrier has to take her.
FYI- Medigap plans are usually more expensive than MA plans - but do have more flexibility as to doctors. If you aren't stuck with a lot of out-of-pocket charges because of noncovered or out-of-network carriers, and she has had no trouble getting the care she needs, she's probably better off with what she has most likely.
If you decide to switch her this fall during Open Enrollment to a Medigap or another MA and you are successful with her medical history, please post back with the details.
MA's can be HMO's requiring use of their "in-network" doctors. In my area these doctors are NOT on salary, but are in private practice or on staff at a wide variety of hospitals. MA's also can be POS or PFFS. UHC MA in our area was a POS before it became a pure HMO in 2014.
UHC just changed the MA plan I left (for hd-F Medigap) to a pure HMO - with NO out-of-network coverage. They were very clear about that. At this point, however, they still allow self-referral to specialists. Patient does not have to see PCP for a referral. I expect that will change soon. UHC has incrementally, each year, been further restricting options under their MA in our area.
Because, at the moment, UHC MA has such an extensive network in our area, I suppose they felt they could impose the HMO - "NO out-of-network." Only exception to NO out-of-network would be emergency services out of state primarily.
Max out-of-pocket went to $4,950 for 2014.
Thanks for this informative post (especially about the out of network UHC MA coverage where you live). I know it's a "feature" of some ACA plans - but didn't know it had extended to some MA plans too.
For some reason - most people here (the majority of whom are on Medicare) are only interested in arguing about their philosophies of health care coverage - instead of trying to answer specific questions people have. Which is not only a shame - it's downright boring (reading the same stuff again and again and again). Perhaps these old people don't have anything better to do with their time? Robyn
Sorry, I just don't buy that seeing a specialist is all doom and gloom, nor is it "driving up" costs. I love my primary care dr, she's great, but she also knows what she knows and for more complex issues, she refers on. She, and any good PCP, knows that they didn't spend the extra years learning their specific craft and they don't see the cases the specialist do.
Again, would you want your divorce attorney handling your murder trial??? How is that any different?
You don't have to believe the earth circles the sun either. But the facts about specialists and the cost of health care has been just as obvious for over a decade to those in the health care business.
Quote:
Conversely, the U.S. has a higher ratio of specialists than other countries, which can serve to drive up spending. Specialists have more advanced training than primary care doctors, and are paid far more.
You don't have to believe the earth circles the sun either. But the facts about specialists and the cost of health care has been just as obvious for over a decade to those in the health care business.
hmmmmm....and the HMO that released these "findings' didn't have an ulterior motive for doing so....
I don't believe they are. But for your edification:
Quote:
"We have a system that encourages more and more complex services to be provided, whether or not that is necessarily the best or most appropriate care, partly because of how we reimburse our physicians in the hospital," said Gail Wilensky, a senior fellow at Project HOPE, a non-partisan international health education foundation that is involved with humanitarian assistance. "We have an American public that is very used to having an open easy-access system to specialists in new technologies and easy availability for all that." The focus, experts say, is not always on the quality of the treatment, which should be the case. Instead, the current system in many ways rewards those medical care providers who prescribe more tests and services than those who focus on quality.
The biggest driver of the gap is spending with specialist doctors, which is 3-6 times higher in the U.S. versus peers. This difference is mainly due to much higher prices in the U.S., which are driven by both higher per-procedure rates paid by both public and private payers, and larger proportion of higher-paying private payers in the U.S. By comparison, public per visit rates for U.S. primary care doctors are at the high end of the range for peer countries and private rates are slightly above the range, and primary care doctor incomes are higher than peer countries, but less than half of the incomes of U.S. specialists. Primary care doctor utilization is comparatively low in the U.S., which keeps overall spending on primary care down. This is not good for overall health care costs, however.
How about a report from Merck aimed at health care professionals?
Quote:
Overuse of specialty care:
Specialists are increasingly providing more care; reasons may include a decreasing number of primary care physicians and an increased desire by patients to see a specialist.
Specialty care is often more expensive than primary care; specialists have higher fees and may do more testing (often pursuing less common diagnoses) than primary care physicians. Also, evaluation and treatment of a patient who could have been managed by a single primary care physician may require more than one specialist.
From a study by a woman comparing PCP reimbursement to that of Orthopedics physicians:
Quote:
In the U.S., the actual difference in earnings is much greater—primary care physicians earn $186,582 while orthopedists earn $442,450 here. That translates into a difference of $255,568 per year, which is more than the difference in education costs.
Over and over, a primary--not only--driver of high health care prices are specialists. Instead of reaching conclusions by what one "thinks" perhaps research would be a little more enlightening. Somehow all these other sources reached the same conclusion as Kaiser.
At about the two minute mark, this physician, being interviewed by right-winger Gov. Huckabee, says it is doctors that are our problem. He says we need more PCPs.
That's like saying "who uses the most gas" people that drive cars....
You don't go to a specialist for a hang nail..you go because you have something more serious than an family doctor is really qualified to treat. In order to figure out what is wrong, the specialists do test...it's really not that hard to understand.
That's like saying "who uses the most gas" people that drive cars....
You don't go to a specialist for a hang nail..you go because you have something more serious than an family doctor is really qualified to treat. In order to figure out what is wrong, the specialists do test...it's really not that hard to understand.
You are writing without reading the posts. People are CHOOSING specialists, and, as pointed out, specialists charge more money. In the case of the study by one woman the orthopedic physicians were charging outlandishly high fees, more than double, compared to a GP. More than the difference in the cost of their education would warrant. If there were a true NEED for more specialists, then all the other nations in the developed world would have our backward percentage of three specialists for every GP. Instead it is the other way around. They know how to spend their dollars more effectively.
But I see you are so in love with your uninformed opinion that no amount of data or reports will ever change your mind. You may pat yourself on the back for being part of the health care cost problem in the U.S.
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
