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.
HMO doctors are salaried. They get bonuses on how many people they treat and how little they cost the organization--meaning that they prescribe fewer tests or refer on for further consults--which, the plan member pays very little for, but the insurance plan pays a lot for, which is why it is hard to get referrals in HMO's. A broken hip is emergency care, that is not what I'm talking about. Had she gone in to see about getting a hip replacement, that would be a different story. I can tell you story after story about people who have been misdiagnosed or refused care because of how their HMO operates. One was a 6 year old boy with kidney stones--he was in terrible pain but they would not refer him on to a nephrologist to find out why a 6 year old boy has kidney stones-nor would they do anything for him because it should just "resolve itself". Another friend's mom went in to her PCP with vague stomach pains that just would not go away. He didn't do any testing, no labs, nothing. Told her to take antacids and sent her on the way. She went back to him 4 times and he refused to do any more. She finally went to a dr outside of her HMO, paid for it out of her pocket, and was on the operating table within 30 minutes of walking into that dr with stage 4 ovarian cancer--she died a couple months later---but had the dr taken her seriously and done a simple ultrasound, she probably would have lived. Her family did sue that doctor--and rightly so. My uncle was sent home after going to his PCP doctor with chest pains and was told to rest more. He had a heart attack about 30 minutes after arriving back home and died.
As for "recent" information--it's all recent. Is the HMO model of how they operate. It's just a different way to run a medial practice.
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.
Not all HMO plans use salaried doctors. In fact, Kaiser Permanente is the only one I can think of off the top of my head.
HMOs may require that you get all or most of your care from a doctor in the network for the plan, but the doctor is still paid a fee at a contracted rate. A referral from your primary care doctor may be needed to see a specialist, and if you go out of network, the plan may not pay anything.
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.
HMO care has been less than successful in practice, but some HMO operations work just fine and there is nothing intrinsically wrong with one. I grew up in a military family and military care is basically an HMO. There is little complaint from service personnel about the health care they receive in service. My Dad and I were once in the same hospital with the same ailment and in beds next to one another!
Here are some basic differences between HMO's and PPO's. Just about all employer based care--and even most individual policies--are "managed" care.
Quote:
Which health care providers must I choose?
HMO: You must choose doctors, hospitals, and other providers in the HMO network.
PPO: You can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more.
Do I need to have a primary care physician (PCP)?
HMO: Yes, your HMO will not provide coverage if you do not have a PCP.
PPO: No, you can receive care from any doctor you choose. But remember, you will pay more if the doctors you choose are not "preferred" providers.
How do I see a specialist?
HMO: You will need a referral from your PCP to see a specialist (such as a cardiologist or surgeon) except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.
PPO: You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.
In addition, HMO's cover drug costs using a "formulary" plan. Now some PPOs are beginning to do the same. It's important to understand what that means.
Quote:
HMOs use drug formularies as a way to control costs. A formulary is a list of prescription drugs that an HMO has approved for its doctors to prescribe.
Formularies aren’t regulated. Each HMO may decide which drugs to include on its formulary. If an HMO doesn’t cover a specific drug, network doctors may prescribe a similar drug that is on the formulary.
Most HMOs must cover any prescription drug – even if it’s not on the formulary – that your doctor prescribes for a chronic, disabling, or life-threatening illness, as long as
the illness is covered by the plan
your HMO offers prescription drug coverage
the drug is approved by the U.S. Food and Drug Administration and recognized in a prescription drug reference book
the drug has been approved in peer-reviewed literature for treatment of your illness.
The primary difference between an HMO and a PPO is in getting a referral to a specialist. HMO's manage that, just as most single payer systems in the world do. The opposition to HMOs here in the U.S. has a great deal to do with wealthier individuals who do not want doctors controlling their "right" of choice--regardless of how expensive it is to the nation as a whole.
With regard to emergent health care, even HMO's allow folks to temporarily go "outside" network, but transfer back into network asap. However whether or not it is covered may depend on the diagnosis given. If what you think is a heart attack turns out to be a case of indigestion--no coverage.
Consumer driven plans--PPOs--continue to be on the rise, primarily because we are a nation of people that chooses choice over utilitarianism, and one which is run by advertising as opposed to professional decisions. And it's another reason our care continues to bankrupt the nation.
Quote:
Aon Hewitt’s survey shows 58 percent of nearly 2,000 U.S. employers offered a consumer-directed health plan in 2011, compared to 41 percent in 2010. Meanwhile, 38 percent offered an HMO in 2011 compared to 41 percent in 2010.
Thanks for the info. HMO doctors being on salary uniquely caught my attention because it's not standard "welcome packet" information. I am particular interested in this type of information that is not on the insurance company's website. Differences in provider incentives/disincentives between current HMOs and PPOs fall into that category as well. Clearly golfgal (correction: golfgal's uncle and friends) had a bad experience. Mom and others have no complaints. I can talk her into changing if I need to. I rather be over-educated today than sorry later.
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.
Your original question seems to have gotten lost in another interminable thread about political opinions.
I assume your mother is on Medicare. And - since you mention HMOs - I also assume she's in a Medicare Advantage (MA) plan (although perhaps she's a Medicare/Medicaid patient). MA plans come in many different flavors. And many involve co-pays/deductibles for various kinds of medical care (including SNF care). Co-pays/deductibles may also depend on whether the providers were in/out of network. I suggest you check your mother's plan to find out what is covered/not covered - and how much she'll owe (she may owe nothing - but I think that's unlikely). Robyn
Your original question seems to have gotten lost in another interminable thread about political opinions.
I assume your mother is on Medicare. And - since you mention HMOs - I also assume she's in a Medicare Advantage (MA) plan (although perhaps she's a Medicare/Medicaid patient). MA plans come in many different flavors. And many involve co-pays/deductibles for various kinds of medical care (including SNF care). Co-pays/deductibles may also depend on whether the providers were in/out of network. I suggest you check your mother's plan to find out what is covered/not covered - and how much she'll owe (she may owe nothing - but I think that's unlikely). Robyn
Thanks, I guess I moved onto a different question in an attempt to regain control of the thread. I know how the plan's copays and deductibles work. But someone mentioned incentives/disincentives (for example). It's a Medicare Advantage plan. What are they not telling Mom that would make Mom consider dropping them? Again, I rather be over-educated today than sorry later.
Thanks, I guess I wasn't clear. I know how the plan's copays and deductibles work. But someone mentioned incentives/disincentives (for example). It's a Medicare Advantage plan. What are they not telling Mom that would make Mom consider dropping them? Again, I rather be over-educated today than sorry later.
I don't know what the insurance company isn't telling your mother. But - with some MA plans - patients can run up some pretty hefty out-of-pocket costs.
Also - are all of these providers "in network"? Those "in network" will have negotiated rates with the insurer - but those that aren't "in network" won't have negotiated rates. In that event - they'll be able to charge at least the Medicare "allowable" (and perhaps more) - which is usually higher than the negotiated rates.
In any event - I'd call up both the providers and the insurance company if you don't understand the bills and/or you think they're too high. In my experience - providers just don't send you 3 sets of bills with different amounts. Although they well give you an initial statement of charges with a follow-up showing what the insurer owes/has paid and what the insured owes. Robyn
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.
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.
