HMO vs Preferred Provider Plans

[itsmyparty]

I posted this first on the 'health' forum, but realized that firstly its really a $$ issue...so hope to get some of your thoughts/experiences. Thanks!

Just received my open enrollment forms for next year's coverage under the retiree plan...and saw they have doubled the monthly premium for the ppo plan I've always been on. (new rate about $3900 yr for 2 of us) I'm sure to try to convince us to switch to an HMO. If we choose the HMO there would be no monthly premium. I'm tempted...and would like to hear from anyone who has used HMO's and what your thoughts are. Luckily no major problems for my DH or myself at this time...so we don't go to dr. alot..but of course one never knows! Co-pays and prescription costs same on both plans...and I've noticed that even though some costs on HMO are covered at 100%..there are restrictions - ie skilled nursing limited to 30 days per year vs PPO of 80% of unlimited. After next year I'll be on medicare, but my DH will have another 2 yrs until he is (he's retiring end of this year...but no health care coverage so lucky we have mine). Neither of us like the idea of having to go to one doctor first just to ask him/her to refer us to another .. but wondered perhaps its not as bad as we think. Also we need to check to see if our doctors on covered under this plan. Would really appreciate any info/advice/experiences you have!! Thanks all!

 

[dgoldenz]

For free I'd take the HMO unless you travel a lot or the network sucks. If it's a network like BCBS or United Healthcare there are probably plenty of providers around. You can always change the selection next year if you don't like it.

 

[Sue J]

We were in an HMO in the early 1980's. I think they were fairly new then. While I loved having a big all-in-one facility to go to and no co-pays the business model has it's problems. Maybe the business model is fine, the medical care model has flaws.

Our experience is that when I needed something that was outside of their idea of the basics, it would have impacted the bottom dollar of the business and it was denied.

This was during my first pregnancy and my OB changed twice, I was shuffled around and when I had growth issues in the pregnancy I was not allowed to have an ultrasound. In 1984 ultrasounds were not standard like they are now. Other private physicians were using them frequently but my HMO needed a reason for them. My reason was that my baby's growth had slowed and almost stopped after about 6.5 -7 months. I could tell the growth had slowed, people around me could tell I was not progressing like I should at the end but my Dr insisted that I was just a first time mom and he was the Dr and he said I did not need an ultrasound.

He did the weekly measurements but he kept telling me that I was within normal ranges. I was in tears, telling him that I just wasn't feeling like I was expanding like I expected. That just made me an emotional first time mom.

I went into labor the week that I was due and as soon as they put monitors on the baby showed poor signs. With every contraction his heart rate would drop very low and not recover. I ended up with a C-section and our son was full term but only 4 lbs, 1 oz which is very underweight for a full term baby. He was limp and gray and scored very low on the Apgar scores. After giving him oxygen he perked up and pinked up and was bright and alert, but very small and skinny for a baby. His Apgars improved, too.

It turns out I had an insufficient placenta and our son had intrauterine growth retardation. He grew up just fine intellectually, was always very bright and a great learner. At about age 3 he was diagnosed with very mild cerebral palsy, possibly from lack of nutrients in the womb or lack of oxygen during the birth. Most people would not notice this in him, but when he's tired we can see it in his gait. His teachers noticed it in some physical tasks. He is VERY LUCKY in how mild this is.

Certainly, the HMO did not cause these problems in my pregnancy. But I knew something wasn't right and because a business was making decisions about what my medical care should be we didn't know that my baby was in danger.

I have NO DOUBT that my Dr denying me an ultrasound was based on HMO policy to keep costs low. Maybe it saved him brownie points or a bonus, I'll never know.

After that, we said we would never use an HMO again.

Of course, now we have a "basic" PPO with high deductibles where we are paying for a good deal of our medical care. But I don't feel our doctors are making decisions based on their business's profit.

 

[Emeritus]

We had Kaiser permanente for 24 years, and then for reasons of the state plan had Aetna for 6 months. Compared to Kaiser Aetna was a disaster. We live within a mile of NIH in one of the top concentrations of both doctors and lawyers in the world, so people here have high expectations. .

Kaiser knows their "business". Thy are not perfect and have quirks and undoubtedly the squeaky wheel gets the grease. But we have been very happy with the care.

 

[GregLee]

Most university people in Hawaii choose between the Kaiser HMO plan and HMSA, a non-HMO (though I guess HMSA now also has an gateway type system). I chose the non-HMO plan, because I could hardly imagine not being able to choose my own doctors. But I've compared notes with a colleague who was on the HMO plan for many years. I gather from him that the Kaiser specialists are top-notch, if you can get to see them, but that is often not easy. He decided to switch to the non-HMO plan, a couple of years ago.

 

[Rambler]

My folks have Kaiser, and love not having to drive all over town for different tests and soca etc. It's all in one place. See the doc, get referred for a test, get the test, get the results...all in one place. I'm thinking about going with them when we repatriate.

R

 

[itsmyparty]

Thank you everyone for your replies and sharing your experiences. They reflect many of my concerns. Sue J. I'm so glad your son is doing well.
Unfortunately our insurance coverage is through Aetna...and I'm not surprised to read in a reply that they don't come close to Kaiser. From my experience, their only concern is how not to provide coverage. I still have a short amount of time to consider my decision...but right now am leaning to keeping the ppo. Strangely this is the first year the company I retired from has offered the choice of even having an hmo....and it looks like they are committed through premium costs, etc. to getting us there.
Thanks again everyone.