Is Kaiser the problem or is it Oregon Health Plan? (Portland: dermatologists, insurance)

[flowerbloomer]

Hi everyone,

I recently moved to Portland & was approved for OHP so I chose Kaiser as my provider. I had two previous health issues in my former state where I moved from (not Oregon) where Kaiser was treating & willing to properly treat the issues.

So far, Kaiser in Portland has denied my referral to see a dermatologist for a medical skin condition which I was being treated for in another state & has possibly committed fraud by refusing to treat my painful fibroids due to their claim on the severity.

The ultrasound from my former hometown showed multiple fibroids that they were open to properly treating & Kaiser in Portland did the same test & claims there is only one fibroid so they refuse to treat it besides a one day visit to physical therapy which is ridiculous!

Based on my experience thus far, the problem is either OHP or Kaiser, as one of them is focused purely on rejecting the medical needs of the patient to keep costs down.

Would I be better off choosing another provider such as CareOregon, or does it not matter as it's still OHP?

[Nell Plotts]

I would contact my primary physician and discuss this issue. You can also contact Member Services.

I have had mixed results with skin problems at Kaiser.

My husband was referred to dermatology and made an appointment which, as I recall was within 60 days because it wasn't an emergency -to look at some moles. He pulled lifeguard duty when he was in the reserves so got a lot of sun on his back. Biopsies were taken, one was cancerous and it was removed within a couple of weeks. He has a divot in his back. : )

I had a rash on my face, my pcp tried to manage it. I didn't get a referral so I switched insurance and got solid advice managing that condition.

What I have learned is that Kaiser hasn't been able to hire enough dermatologists and I am not aware that they have any Nurse Practitioners in dermatology to help handle the demand.

Now is open season, make a move.

[texasdiver]

Kaiser's approach to managed care is to funnel everything through the primary care provider (family doctor or internist) as a "gatekeeper" and then use evidence-based criteria as to whether to escalate and refer care to more expensive specialists. This is how they control costs. It is completely different from PPO providers like Blue Cross where the doctor and insurance company are separate entities and both the primary care and specialist doctors earn more money with quick referrals. The primary care doctors because they get shorter office visits and can see more patients per day if they refer everything complicated and don't get bogged down trying to solve complicated medical issues. And the specialists because they get all the referrals.

Kaiser is great if you are basically healthy or managing relatively uncomplicated chronic issues like diabetes. It may not suit you if you are used to quick referrals to specialists.

[Cloudy Dayz]

Originally Posted by flowerbloomer

Hi everyone,

I recently moved to Portland & was approved for OHP so I chose Kaiser as my provider. I had two previous health issues in my former state where I moved from (not Oregon) where Kaiser was treating & willing to properly treat the issues.

So far, Kaiser in Portland has denied my referral to see a dermatologist for a medical skin condition which I was being treated for in another state & has possibly committed fraud by refusing to treat my painful fibroids due to their claim on the severity.

The ultrasound from my former hometown showed multiple fibroids that they were open to properly treating & Kaiser in Portland did the same test & claims there is only one fibroid so they refuse to treat it besides a one day visit to physical therapy which is ridiculous!

Based on my experience thus far, the problem is either OHP or Kaiser, as one of them is focused purely on rejecting the medical needs of the patient to keep costs down.

Would I be better off choosing another provider such as CareOregon, or does it not matter as it's still OHP?

It could be OHP. I'm starting to get irritated with OHP. Treatment that was unlimited when I lived in California, all seems to have limitations here. I'm not even currently getting any treatment for my primary disability. Recently I was in physical therapy for three months when they ended that, even though I was still making fairly good progress. Since then my condition has been getting worse. So now I have an appointment with a specialist. It looks like I might end up having to have surgery, only because they don't want to give me enough physical therapy. It doesn't even make any sense. The physical therapy has got to be way cheaper then the surgery, and after the surgery I will probably still have to have more physical therapy anyway. Their stupid limits on basic care will probably cost more in the long run.

[texasdiver]

Originally Posted by Cloudy Dayz

It could be OHP. I'm starting to get irritated with OHP. Treatment that was unlimited when I lived in California, all seems to have limitations here. I'm not even currently getting any treatment for my primary disability. Recently I was in physical therapy for three months when they ended that, even though I was still making fairly good progress. Since then my condition has been getting worse. So now I have an appointment with a specialist. It looks like I might end up having to have surgery, only because they don't want to give me enough physical therapy. It doesn't even make any sense. The physical therapy has got to be way cheaper then the surgery, and after the surgery I will probably still have to have more physical therapy anyway. Their stupid limits on basic care will probably cost more in the long run.

Is the Kaiser service one gets through the OHP different from that one would get with a Kaiser plan through a private employer?

I mean if you walk into a Kaiser clinic with an OHP Kaiser card and they swipe it, does that trigger some different level of care than you would get if you have a Kaiser card through an employer plan? Or is Kaiser insurance from one source exactly the same as from any other source?

I don't know the answer. I'm just curious.

[Cloudy Dayz]

Originally Posted by texasdiver

Is the Kaiser service one gets through the OHP different from that one would get with a Kaiser plan through a private employer?

I mean if you walk into a Kaiser clinic with an OHP Kaiser card and they swipe it, does that trigger some different level of care than you would get if you have a Kaiser card through an employer plan? Or is Kaiser insurance from one source exactly the same as from any other source?

I don't know the answer. I'm just curious.

I don't know. I have Trillium Community Health Plan. Which is the only option I have ever been offered.

[flowerbloomer]

Originally Posted by Nell Plotts

I would contact my primary physician and discuss this issue. You can also contact Member Services.

I have had mixed results with skin problems at Kaiser.

My husband was referred to dermatology and made an appointment which, as I recall was within 60 days because it wasn't an emergency -to look at some moles. He pulled lifeguard duty when he was in the reserves so got a lot of sun on his back. Biopsies were taken, one was cancerous and it was removed within a couple of weeks. He has a divot in his back. : )

I had a rash on my face, my pcp tried to manage it. I didn't get a referral so I switched insurance and got solid advice managing that condition.

What I have learned is that Kaiser hasn't been able to hire enough dermatologists and I am not aware that they have any Nurse Practitioners in dermatology to help handle the demand.

Now is open season, make a move.

Hi,

Did you have OHP via Kaiser & what insurance company did you switch to that yielded better results? thanks!

[Wardendresden]

Originally Posted by texasdiver

Kaiser's approach to managed care is to funnel everything through the primary care provider (family doctor or internist) as a "gatekeeper" and then use evidence-based criteria as to whether to escalate and refer care to more expensive specialists. This is how they control costs. It is completely different from PPO providers like Blue Cross where the doctor and insurance company are separate entities and both the primary care and specialist doctors earn more money with quick referrals. The primary care doctors because they get shorter office visits and can see more patients per day if they refer everything complicated and don't get bogged down trying to solve complicated medical issues. And the specialists because they get all the referrals.

Kaiser is great if you are basically healthy or managing relatively uncomplicated chronic issues like diabetes. It may not suit you if you are used to quick referrals to specialists.

I had Kaiser Medicare Advantage in Colorado. Best health care available. No need for referral to specialists. In the U.S. specialists make up nearly 3 out of 4 doctors because specialties charge more than general practitioners. Most of Kaiser’s medical professionals are salaried, so there is no need to refer patients (referral fee), nor charge for tests that may not be needed as is done in “for profit” health care offered by most health care providers. It really does come down to physician judgment, and being married to a former medical staff director I can assure you the judgment of physicians is not always equal.

Kaiser is an HMO and requires one to stay within the system for services UNLESS they don’t have the needed specialist on hand in which case a referral is needed.

I don’t know if their general public plans include PPO’s, but last I looked they are the only five-star Medicare plan in the country. There is no limiting time frame to switch from another company’s senior advantage program to theirs. You can do so in the middle of the year.

My wife worked for four different health care providers over 25 years but not Kaiser. She says in terms of god awful paper work, Kaiser had all four of her employers staring at their dust.

[Cloudy Dayz]

Originally Posted by Cloudy Dayz

It could be OHP. I'm starting to get irritated with OHP. Treatment that was unlimited when I lived in California, all seems to have limitations here. I'm not even currently getting any treatment for my primary disability. Recently I was in physical therapy for three months when they ended that, even though I was still making fairly good progress. Since then my condition has been getting worse. So now I have an appointment with a specialist. It looks like I might end up having to have surgery, only because they don't want to give me enough physical therapy. It doesn't even make any sense. The physical therapy has got to be way cheaper then the surgery, and after the surgery I will probably still have to have more physical therapy anyway. Their stupid limits on basic care will probably cost more in the long run.

Just an update on my situation, if anyone cares. I did see the specialist, and he did put me down for more physical therapy, and some tests that my primary care physician was reluctant to order. Unfortunately I lost a month and a half of physical therapy in the interim. But I think it will all be fine now.

That said, aside from the long waits and difficulty getting them to do anything for me, the doctors and medical staffs here are some of the best I have ever had. I still have yet to need any specialized care, that I can't receive locally. I have been given the option to go to Eugene for it, but I don't see any reason to do that. If I do have to go to Eugene for something in the future that will not be a problem either.

[leastprime]

Before you switch plans, you may want to canvas the availability of PPO primary and specialist care.