Never had Kaiser insurance before. How do you like it?

[Scuba]

In studies of expertise, including doctors and surgeons, it takes 10,000 hours of deliberate practice to make an expert. We all may be one car accident or a latent genetic defect from needing specialized major surgery. With our relative's surgery from my previous post, we went to one of a handful of experts in the country for a specialized surgery. We had to pay around $4K extra out of network for the surgeon over what the PPO would pay, but the hospital he operated at was in our PPO so we just had the max out of pocket to pay for hospital costs. I feel like that was a small price to pay to have a real expert with 10,000+ hours of practice for a serious operation, instead of just using someone Kaiser has on staff with maybe 50 hours practice in of the same type of specialized surgery.

Agree 100%.

 

[Scuba]

The difference between Kaiser and PPO available to us, a family of three, is $20k (Kaiser) and $40k (Blue Shield PPO) annually. Tough decision?

One question to ask yourself - if you found yourself in a serious illness situation and you felt you could get better care outside of Kaiser, would you be able to afford to cover that cost yourself? For me, $20K/year difference is a lot but it pales in comparison to having to pay for an expensive treatment, surgery, and/or specialist outside of the Kaiser network. I’m not sure of your age and how long this extra $20K will be a factor, but even if it’s 10+ years, you may want to consider it an investment to give you the option to secure the best specialist available for your future medical needs.

If on the other hand you really can’t stomach the extra $20K/year and you’re willing to make the trade-offs that may be required, there are many good things about Kaiser (cost, convenience for routine procedures, use of technology for administrative aspects).

 

[RetiredAndLovingIt]

My daughter in laws mother has had MS for 20 years and moved to Kaiser a couple of years ago. She's so happy at the care she's receiving, apparently her treatment is totally different from anything she ever had before and it seems to working. She adores her neurologist, they have her in support groups and she gets some heavy duty treatment every so often that makes her very weak and unable to leave the house for a couple of weeks afterwards but the end results are well worth it to her.

 

[cathy63]

... the one Da Vinci surgical robot available in the area (all of Northern California…which was surprising to me). ... So I looked around and found a top doctor in NYC who had done 7000 Da Vinci surgeries.

If you had been on any non-Kaiser ACA plan in Northern California, wouldn't your NYC surgeon have been out of network and on your own dime anyway?

 

[daylatedollarshort]

The difference between Kaiser and PPO available to us, a family of three, is $20k (Kaiser) and $40k (Blue Shield PPO) annually. Tough decision?

That is a big difference. For us, on a Bronze ACA plan, there really wasn't that huge of a difference in premiums, so it was a no brainer to pick Blue Shield over Kaiser with access to a better hospital and doctor network.

 

[Rambler]

If you had been on any non-Kaiser ACA plan in Northern California, wouldn't your NYC surgeon have been out of network and on your own dime anyway?

No. I’m on an ACA plan now that simply doubles the deductible if you go out of network. I still would have paid more than at kaiser, but it would have been a lot less than I actually paid. And, I even appealed their decision to not cover (anything) out of network. They said that because some form of surgery was available (even though the surgeon said it has to happen ASAP and even though the version of surgery offered was not the gold standard) that it was sufficient to stay in network.

Don’t get me wrong. For the everyday sniffle, BP or cholesterol consult, and even an ECG, they were great. But what I experienced when a major problem hit was, in my opinion, unacceptable.

 

[Sue J]

But if someone needs serious medical care--something expensive--it's like the primary care physician is on a budget. He won't be quick to refer you to a specialist if it's going to be costly. It's like his salary is based on what he's not spending on his patients cumulative.

I'm reading this post and nodding my head.

Our example is from an early HMO provider in 1984. This was not Kaiser but very much like their model where you have a primary care gatekeeper doctor and everything happens inside their system.

I was pregnant with our first child. Everything went great for the first 6-7 months. I felt great, all looked normal at all the checkups. Then I got to the third trimester and the uterine growth measurement was slowing down. My doctor would measure at every appt and tell me I was within the accepted range. I asked about an ultrasound. I had many friends who were pregnant at the same time, everyone had at least one ultrasound. He kept telling me that I was just a first time mom and he was the doctor, I shouldn't worry, but there were times when I was in tears, I knew I wasn't getting as big as I should be.

He made a remark about how many ultrasounds he was allowed to order and my pregnancy didn't fall far enough outside the norm. I don't remember how he said it but I got the feeling that it would cost him a bonus or maybe his dept would not meet a goal. Whatever it was, it clouded his judgement on what I, his patient, needed and deserved.

My son was born at full term, just a few days before his due date. He was 4lbs, 1oz. but not premature, just very thin for a full term baby. I had an insufficient placenta, which should have been apparent if the doctor would have looked at me rather than his charts and his guidelines.

So the result of this experience is that I promised I would never do another HMO. I didn't want someone making decisions on my medical care based on their own interests. I followed through on this until we went with ACA insurance 2014-2020 and we had to take what was offered.

And our son turned out fine. He has some issues which may, or may not, be related to just about starving for the last few months before birth. We were just glad that it wasn't worse.

 

[daylatedollarshort]

The hospital network we go to now under our PPO plan clearly makes more money the more specialists we see and the more lab tests we undergo. Our GP, actually a nurse practitioner, hands out referrals like candy. It is okay for DH who is on Medicare. More expensive for me with an ACA plan. It would be nice if there was a plan based on outcomes, not saving money or making the most profit, but we don't have that option. So we're staying with the PPO where we have the highest quality of care and survival rates, even if it costs more.

 

[Kerfuffle]

I think the bottom line is that you never want your insurance company and your doctor to be the same company. I don't even think that should be allowed. I mean, of course they're going to take the lowest cost route every single time and pressure their doctors to doctor by cost savings instead of just doctoring.