What Ails You: Choosing the best health insurance plan

Today we are going to talk about Health Management Organizations, HMO’s. 

Health Management Organizations are a more popular choice because of the apparent savings to you. Whoever is providing your insurance, your employer or Medicare, surrenders your premium to the HMO. The HMO then goes out and contracts for the cheapest possible care for you.
When choosing a health care plan you might choose a Preferred Provider Organization. With PPO’s, you have the choice of going to an “in-network” provider who provides your care at a discounted rate or a provider outside the network at a greater cost,
PPO’s are among the more expensive plans to have. The trade-off, of course, is in your freedom to choose the medical care you wish to receive. You can go to any doctor, physical therapist, lab or scanning facility that you want allowing you to make quality care your primary concern. 
Some folks have an HMO with a PPO option. These folks may receive a majority of their care within the HMO, but, on occasion, may opt to go to an outside provider. When they do, the insurance reverts to the more traditional payment provision making you responsible for a greater portion of the bill.   

Whenever you buy insurance, you are gambling that you will get sick while the insurance company is gambling that you will not. Your priority is to spend as few out of pocket dollars as possible. The insurance company or HMO has exactly the same goal: collect more in premiums than they spend on care for you. When choosing insurance plans, what you pay for is exactly what you get. If you select a plan that costs you very little or nothing, that may be exactly what you get back out of it.  

If you are a member of an HMO, your care is overseen by a “gatekeeper,” your primary care physician (PCP). This physician requests all tests, studies and ancillary services like physical therapy. Even if you are referred to a specialist, the services of the specialist and any other services that specialist would like you to receive, has to be ordered through your PCP. Even though your PCP may agree that you need physical therapy or some other test or service, the HMO has folks carefully screening your PCP’s referral. These folks checking your needs against uniform guidelines decide whether or not you can actually receive the care your doctor has requested.

There are times when the clash between your goal to receive the best quality care and the HMO’s goal to save money can have a nightmarish outcome.   

Take for instance; imagine you are dependent on city transportation due to age or injury and your physician requests physical therapy. Your HMO authorizes the services, but you must go to Victorville to be treated. They would expect you to depend solely on public transportation to get back and forth to your appointment. You would have to call Dial-a-Ride, then a Greyhound bus, then another bus in Victorville just to make the appointment. By the time you get back home, your entire day is gone and you are exhausted. Now do this entire process three times a week. 

This is horrifying and should trigger outrage in all of us, but my intent in sharing the scenario with you is rather to drive home the importance of careful consideration in making your insurance choices. The cheapest solution is not always the best for you. It might be worthwhile for you to take your insurance options to your preferred caregivers and get the input of the office managers there on which are the better plans to guarantee your family’s well being. 

ABOUT THE WRITER:
Jackie Randa is a physical therapist who owns Back on Track in Barstow. She can be contacted at jranda@aol.com