Which health plan is right for you? Which is right for a family?
The best single piece of advice may be this: If you have a plan that has been serving you well, and a doctor or doctors who have been serving you well (in both cases make that "reasonably well," reality being what it is) stick with them.
If you are dissatisfied with your plan or your doctors, or if there is some current impending change in your medical or personal situation, think about a switch.
What kind of personal change might warrant choosing a new health plan? Marriage. Pregnancy. A physical or emotional problem. Impending surgery. Aging. Retirement. Less income. These are among many possibilities that might make you want to find a plan that might be better for you.
The choice today is basically between: Traditional insurance of the Blue Cross-Blue Shield type or an employer's own plan, which pay at least part of the cost of medical and hospital bills, usually after some deductibles (you pay the first so many dollars for your care) and co-payments (something additional you must pay for certain services). Group or "staff" HMOs (such as Group Health, Kaiser, George Washington University, Columbia) with their own doctors in their own facilities. You (and/or your employer) pay a set sum every month or two weeks. IPA-type (individual practice association) HMOs, where you also regularly pay a set sum but go to private doctors who have signed up with the plan. PPOs (preferred provider organizations), a cross between an IPA and private insurance. You may go to any non-plan doctors and hospitals and be reimbursed, but at a lower rate than if you went to one of the plan's selected doctors and hospitals, its "preferred providers."
Many of the plans have similar names, and some -- like Health Plus and Health Win -- also offer employe groups either an IPA or PPO contract. Make sure you know what kind of plan you're considering. It may not be easy to tell from an ad or brochure.
If an IPA's combination of prepaid care with private practice doctors appeals to you, ask if your present doctor has signed with any IPAs, or if he or she knows some good doctors on an IPA's list. Some IPAs have been listing their doctors in ads or other literature. Ask if the plan can provide such a list.
Ask friends and fellow workers about their experiences with their doctors or plans, both the kind of care they have had and their experiences with payment.
HMOs or IPAs often cost more per month than traditional insurance but may wind up saving you money if you need a fair amount of care. They also provide a stable way to budget health costs. The best ones have only modest co-payments, mainly for office visits, emergency room use, hospital admissions, prescriptions or mental health visits, a few or many of these, varying greatly from plan to plan.
Traditional insurance -- depending on the plan -- may provide far better benefits for mental health care, including in some cases care for drug or alcohol abuse. And with traditional insurance, you may go to any doctor or specialist you please.
The young, healthy and childless may pay an HMO more than they get back in care. But a couple with young children, or expecting children, may save money with an HMO. HMOs commonly offer routine examinations for children and well-baby care, as well as periodic physicals, depending on age, for adults. Persons with chronic ailments and the elderly may do well in an HMO.
All these suggestions are only general. Every plan has its own exceptions, rules and quirks. Or generosities.
Ask: How much will the plan cost?
With many plans, you can either buy a high option or low option (euphoniously termed "standard option"), depending on your view of your needs and your budget. A careful comparison might save you as much as $1,000 a year.
In considering possible costs and savings, also ask about deductibles, co-payments and excluded items. Eyeglasses, dental care and prescriptions, which can all be big ticket, are often excluded. Some plans have cut back in these areas.
If a plan seems to have cut its premium this year or kept it even, look particularly for any new exclusions or co-payments. There could be a few downplayed surprises, and a plan with a seemingly "low" premium might actually cost you much more.
Does a traditional health insurance plan have limits on what it will pay doctors for various procedures? These plans generally do. Your doctor may charge much more. Ask a doctor if he or she will accept a plan's fee as total fee. Some will. But some ostensibly "low cost" plans may pay doctors so little that you may be irrevocably stuck with big bills. Are all my dependents covered? To what age? Can I renew every year? Can I be canceled? What happens after I'm 65? What if I leave my employer or group? What if my spouse has the coverage and I'm divorced?
If you're near retirement age or thinking of changing your job or personal status, questions like these become particularly important. How can I be sure of being covered in an emergency? What happens when I'm out of town and need care?
Most plans cover emergency care no matter where it occurs, but some may define "emergency" very narrowly. Find out whether you need to phone for approval if you seek care outside the plan's area or designated sites.
If you are thinking of joining an HMO or similar plan, there are more questions to ask: Who will my doctor be? Or: how do I choose one?
This is the most important question for an HMO, IPA or PPO member. Your doctor will not only be your physician in good health or poor but can also be your gatekeeper -- the person who can get you to a specialist or into the hospital -- your guide through the system and your friend.
Many persons in HMOs and similar plans find a good doctor and are happy with that person. Many do not. HMOs urge new members: Choose a personal physician right away; use him or her for an initial examination; get to know that doctor. In studies of "disenrollments" -- patients who quit -- HMOs find that the most dissatisfied patients are those who have never taken the trouble to establish themselves with any doctor.
In most HMOs, the personal physician may be either a family physician, internist or pediatrician. A few permit women to choose an OB-GYN doctor as primary doctor.
Some HMOs will give you a list of doctors with photos and capsule biographies. In the absence of other information or a friend's hearty recommendation, see if a doctor is "board-certified" or, if young, at least "board-eligible" (recently out of training and not yet finished with specialty board examinations).
Generally speaking, HMO doctors are all up to a certain standard, or the HMO gets rid of them. And HMOs are able to find high-quality young doctors in this day of many doctors emerging from medical schools. But ask, if you can -- visit one of the plan's facilities and get into a few conversations with receptionists -- "How long do the doctors stick around?" If a plan is a revolving door for doctors, you may constantly be searching for a new one.
In some HMOs you may often be referred to a nurse-practitioner first or even instead of a physician for many simple kinds of examinations or care. You should always be able to see the physician if you want. Many persons come to like and depend on a careful and caring nurse-practitioner. Some can't accept this. If you're concerned, ask whether, and how often, this might happen. What if I need a specialist? How difficult will it be to get a referral?
Those who join an HMO or IPA must understand that their doctor is not idly called the gatekeeper. One price the patient pays for the plan's advantages -- and hopefully affordable premiums -- is giving up the ability to go to any doctor and be covered.
But that doesn't mean a patient need be a sheep if convinced that specialist care is necessary. There is no question but that some patients do better in an HMO than others. This is the person who learns to use a bureaucracy, who is not afraid to speak up or complain but who knows how to use diplomacy as well as complaint.
In the words last year of one Kaiser patient, "You do have to squeak sometimes. It's the wheel that squeaks that gets the oil." Where will I get my care? Is it convenient? Attractive? How about hours?
The group practice HMOs like Kaiser and Group Health now operate from many sites throughout the metropolitan area. Their brochures list them and their hours. They usually include evening hours. When you pick a doctor, ask: What are his or her hours? What hospitals can I go to? And my children?
Washington's excellent Children's Hospital, a national leader, is launching a series of ads to tell parents -- though not quite this bluntly -- that some HMOs are reluctant to send a child to Children's except in severe circumstances. Children's suggests asking: "If I want my child to go to Children's, what services will your plan cover?" And not cover? Can I get you on the phone when I need you? This is a very big question for any plan, according to letters from scores of readers. Patients in many plans tell stories of hanging on the phone until they feel sicker than when they called.
Group Health Association, not immune from this problem, according to patients, advises:
"When making appointments, it's best to call your medical center Tuesday through Friday after 2 p.m. -- unless it's an emergency situation -- when the phone lines are less busy."
Group Health says that if you do call during "peak calling times -- which include Monday mornings, days after holidays and lunch times -- please try to be patient. The volume of calls may cause frequent busy signals and long holding times."
Hardly reassuring, but at least they're being honest. ::
Too many things to consider?
Consumers' Checkbook, a local magazine, has sensibly said:
"Try to focus your decision on two or three key questions. Either you are willing to join an HMO or you are not. Either you expect big bills for a particular problem such as maternity or surgery, or not. Either you really want to have a particular type of benefit . . . or not. Either you can afford a big premium to get the benefits you want, or you cannot and must pick a plan that has a low premium even if it exposes you to bigger risk."
In other words, ask yourself: what's most important to me? Next Week: What patients wrote us about their health plans.