Starting a new job means signing up for benefits. In terms of health insurance, this has usually boiled down to choosing either an HMO or PPO plan for us. I still have never been offered the option of a High Deductible Health Plan (HDHP) with a Health Savings Account, even though I think it would be neat to have one.
After reading through all the paperwork and talking to the benefits administrator, talking with my parents (who’ve had lots of different insurance companies), and reading various articles online – here is my limited understanding of the differences, at least in my case. Please add your own thoughts too.
Health Maintenance Organizations (HMOs)
- Usually have the lowest premiums and lower annual deductibles. In return, you must submit to various cost-saving restrictions.
- You must get care from providers in your HMO network. You can’t use a doctor from outside the network unless in some special case it is explicitly approved (unless you pay for it yourself).
- You must find a primary care physician (PCP) who acts as a gatekeeper to other (in-network) specialists. For instance, your PCP decides if you need to see a cardiologist, dermatologist, urologist, whatever. Although this is designed to limit unneeded care, it can also be frustrating if you disagree with your PCP. It also underscores the importance of finding a good PCP.
- Often have less paperwork and forms to fill out.
- You are still covered for emergencies at whatever hospital can best provide care at the time, although they may transfer you shortly afterwards to an in-network hospital.
Preferred Provider Organizations (PPOs)
- Usually have higher premiums and higher annual deductibles than HMOs. In exchange it offers more flexibility.
- You can see any doctor, but the costs for you are lower if you see an in-network provider vs. an out-of-network provider. In-network doctors have agreed to a discounted fee schedule for people in the PPO, essentially providing a bulk discount. This is the PPO method of limiting costs.
- Even if you disagree with your PCP, you can still go to whoever you want (in-network or not).
In the end, I guess one has to balance the details of each HMO and PPO plans carefully with the price differential. How much choice do you give up by going with your specific HMO? Do they have a history of complaints? In looking at cost, it’s important to understand the whole picture beside just premiums – there are also annual deductibles, co-pays, and lifetime maximum benefits.
In our case, the HMO and the PPO are by the same big insurance company, so that simplifies things for us. In addition, our family actually already has an PCP that they’ve been going to for a while, so I’m pretty sure we’re going to go with the HMO over the PPO. The HMO is $200 cheaper per month, has no annual deductible, and has lower co-pays. Otherwise, I think the best bet is to ask co-workers and friends who have the same insurance plan about their experiences and if they know of a good PCP.
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I just watched the movie “John Q” last Saturday. There’s an interesting discussion in it about HMO vs PPO. From what I understand because you pay less for HMO, the insurance company will pay the doctor NOT to check you thoroughly enough to low their cost.
Not sure if it’s true though or anything changed since then, but it definitely sounds scary to me.
Generally HMO’s are evil, but for $200 a month and knowing your preferred doctor is good and already part of the plan I’d go for it… hoping the kidney stones don’t return! All the best….
Had the same dilemma when starting my job… ended up going with the HMO because the cost difference was substantial ($200/month in your case) and I would not have any trouble finding a PCP. Since you live in a big city, if you choose a large HMO company, you shouldn’t have any trouble getting the care you need.
FYI, I did have surgery for my appendix after my PCP recommended a visit to the ER. The HMO paid out without any problems, and I ended up bearing none of the cost (except for the doctor visit co-pay), including even getting my hospital $100 co-pay reimbursed. Looking at the cost that Aetna was responsible for, it was over $12,000 (although the actual amount that they paid looked like it was much less, like you mentioned in a previous article). So, for my one big test of the HMO, it worked perfectly. I have not had any other major medical issues, though (but I am only 27).
Anyway, maybe if you were older and had unique medical issues or had a doctor not covered by your HMO, then a PPO might be a better option. But in your case I would stick with the HMO and invest the $2400/year that you are saving. That is a substantial savings not to be ignored.
Would a specialist (urologist, cardiologist, etc.) even be willing to see you without a referral from a PCP? I imagine that they wouldn’t want to waste their time seeing random people off the street.
I have had good PPOs in the past, bad and good HMOs and currently have a cheap-skate PPO which I dislike immensely. I thought I hated getting referrals, but at least with an HMO if you go to the hospital its one fee, that’s it. When I had an HMO and needed an ER visit (cut my foot), it was $50, that’s it. With my new cheap PPO, one visit to the ER(for my daughter) was the deductible ($250), plus a co-insurance (what the hell is that anyway?), $80, then even though it was a covered hospital, the ER doctor wasn’t and that wasn’t their problem, so ca-ching, another $300. So an emergency room visit (that thankfully turned out fine and required very little treatment), cost more than $600. Echhh!!!
Oh, yeah, and even after the deductible, my PPO wants me to pay 10% of everything up to a yearly family limit of $4000.
But, with that being said, I really feel there are two different types of PPOs, because the ones I had earlier were MUCH better. They would cover everything and I could go to any doctor in the network – without referral. These were generally more expensive than the HMOs, though, so I ended up using the HMO until I got sick of their referrals.
Now I found a PPO that lets me go to any doctor in the network, and then finds ways to make me pay for everything. I wish I had my HMO now.
AGREED. I had bad experiences early in my working career using HMO and switched to PPO after I attained higher income. I pay close to $2000 a year for PPO coverage, only see the dr 2-3 times a year, and I usually get slapped with a bunch of back end fees later. For my annual physical I pay the $20 co-pay and get billed $200 for the blood work tests! MRIs I pay $250 up front.
Missing my old HMO, there weren’t so many back end surprise charges.
Go HMO. For all the horror stories of HMOs, you are just as likely to get screwed through a PPO.
If you ever do get in a bind with a bad condition and they are pulling shenanigans, you are savvy and wealthy enough to quickly determine your options quickly(i.e. get a lawyer), and it looks like you have enough resources to mean that even if a HMO doesn’t cover something, it probably won’t kill you (just cost you money). Most of the Sicko horror stories are perpetrated on folks who really don’t know how to appeal and complain to the right people. If you can talk down your cable bill, you can probably talk through a claim rejection.
It probably depends on the particular HMO and the PPO. I have an HMO and LOVE it. Since I don’t have insurance through my job I have pretty high premiums (though it is actually cheaper than any PPOs I have looked at) but there is usually pretty much nothing out of pocket. I have never seen a bill. IT is just so easy and I like that if I see a bad doctor all I have to do is ask for another. No forms and calling around and trying to figure who the heck is in network. I just find it WAY more convenient. Sure there are some crappy doctors but there are some excellent ones too. Most of the cost cutting measures I have seen are “smart.” For example when I Was pregnant the people I know with PPOs had WAY overkill care and the people in Canada and in US military had really crappy care. I felt the HMO had it right – in the middle. They cut the unnecessary fat but I didn’t feel it cut the quality of the care.
Dan says it VERY well – something else I did not consider. Most of the complaints I hear about my HMO from friends I see as easy enough to work around myself.
Go PPO. Most docs (PCPs) are capitated in HMO practice (they are paid for the number of patients on the HMO, and not the number of patient visits). Hence, scheduling even in a pure HMO practice can be more difficult. Plus, your HMO PCP will have an incentive not to see you; he’s not getting paid directly for it. (This is in addition to the bonus some HMO PCPs get for limiting specialist access.)
This wouldn’t be too bad if your doc has a sole HMO practice, but in many parts of the country this is almost never true. Many providers who are on an HMO plan, also take PPO patients–a major problem.
The PCP in a mixed HMO/PPO practice will get paid to squeeze in (work additional time) for the PPO patient but NOT the HMO patient. Hence, PPO patients can squeeze out access for HMO ones.
Note: Kaiser is probably the only good HMO.
Go with the PPO. You can afford it and it is money well spent. If you get in a situation where you need serious ongoing medical attention — you want to be able to choose your provider.
I have had to go to some sports medicine docs lately. It is important to me and my future ability to enjoy the activities that I love for me to go to the best sports med docs within driving distance to my house. The second question they ask when I made my appt. was HMO or PPO?
I can’t imagine what it takes to go through cancer treatment — but I can only imagine it much worse if at the same time you are going through legal proceedings with your HMO at the same time (as suggested in the above post).
It is sad that we have to worry about health insurance and the costs, I took my wife to get a cortisone shot in her back and they sent a bill for 5,000 dollars!!! This is ridiculous!! I can agree paying 300-400 dollars but 5000 ? Who can afford that ?? sorry we are not rich…
Go with the PPO… you can see who you want and most providers are usually in network
I have a PPO that my work pays for entirely. (a perk given to me when I was considering leaving several years back.)
I would never go back to an HMO.
I watch what my wife goes through (she has an HMO plan from her work) and it is crazy. The whole referral process can even be a nightmare if you require extensive diagnostics or specialist visits. Her primary doc has refused to give her a referral for a diagnostic that her breast specialist said she needed. She had to switch her pcp to one that would give her the referral she needed. Fortunately, she doesn’t have any major issues but like Jake said… I couldn’t imagine dealing with cancer or some other horrid ailment and also have to deal with HMO issues on top of it all.
Jess asked: “Would a specialist (urologist, cardiologist, etc.) even be willing to see you without a referral from a PCP? I imagine that they wouldn?t want to waste their time seeing random people off the street.”
Yes, I just call my cardiologist or any other specialist and make an appt. Almost every doctor and office staff member prefers PPOs as there is no referral process for them to get involved with. Of course my primary doc is still the center point of my medical care. He gets all the reports and tells me who he wants me to see if something requires a specialist that I don’t already have. At this point I have a good team of specialists that I just go to when I know I need to.. cardiologist once a year, etc. The flexibility is great.
By the way my primary doc won’t even take HMOs because they are so hard to deal with he says.
Lastly, like many have said… there are bad and good PPOs and HMOs.. it just depends on what your company negotiated with the underwriter. My copays are $5 for any doctor.. prescriptions are free. My mom has hte same PPO but under a different contract.. she pays 25 to see her primary and 40 for specialists. Same deal with HMOs. So it really depends on what specific plan you are offered. My wife went with the HMO, even though in general we both like PPOs better. The PPO plan offered to her was really bad as far as features and coverage amounts.
PPO have worked well for us and our company, if you haven’t seen it yet you might glance at the current Consumer Reports as the have an article on this very subject.
We just went to a HSA it’s definitely tougher on the lowered paid employees. I think longterm it will be a good plan but change is never simple when you start dealing with people and money.
My wife and I were on a HMO plan that I bought myself. On paper it looked good, but in practice it was a mess. I had to change my PCP twice in 2 years because they stopped accepting my HMO insurance plan. Then the largest Hospital network in my area (Austin, TX) stopped accepting it as well. Then they gave my wife the runaround to get a certain lab test done. There were plenty of labs in town to do it, but none of them accepted our HMO plan. The insurance wanted us to drive an hour or more out of town to get the lab test done.
That’s were I had enough. Now I am on a PPO type plan again, that is accepted by all the large providers and all the doctors we used to go to.
in ur situation, considering the costs…HMO!
In my opinion, your health is something you don’t want to skimp on. Extra dollars on a quality health plan is money well spent. You’ll want the flexibility of a PPO. The scheduling nightmares that are associated with HMOs (both from past experience and seeing what friends/family that have HMOs go through) are reason enough to stay away from them.
If cost was not an issue, I go with PPO.
If you are young and in good health and
someone who does not require frequent
doctor vists, I would go with HMO.
I’ve had a couple of PPOs over the past 10 years, and I can’t compare to HMOs. I generally like my PPO just fine for routine things. I know what my copays are, and I can generally schedule anything I need to easily. My wife has the cardiologist and the physiatrist that she wants, and we like our family doctor.
For things out of ordinary (i.e. expensive) I have found that they all suck. It is in the insurance company’s financial best interest to deny your claims. It’s good for the bottom line, and I found this to be true for all of my insurance companies. I rationalize that evil people have to work somewhere, and there are only so many jobs at collection agencies.
I pride myself on having never lost a claim, and I’ve only needed the help of an attorney one time. But it has been a lot of work. I expect it would be the same with an HMO though. Whichever you choose to get, make sure you get the service you have paid for.
I would go with the PPO. I have seen close family members stricken with a very serious disease. Having PPO coverage at the onset was important because it was the difference between a finding a doctor who thought that the procedure could be done and finding a doctor that was at the top of the field, confident in the course of treatment, and well-versed in the tricky procedure. Now let’s turn that around. Let’s say that my family member only had HMO coverage, learned of the medical condition in February, and was unable to change medical coverage plans until the next open enrollment period, 11 months later. The decision to save $200 per month over that period would have been haunting, if not downright deadly. I certainly believe that health coverage is something you should not attempt to save money on, especially if you have the means to get the best available coverage offered. Given your dual income, I would purchase the better coverage. Even 29-year-olds are susceptible to a life-changing medical diagnosis. The extra $200 a month is worth the piece of mind.
When your wife gets preganant she will need a PPO. Most female care providers will not take HMO insurance.
Otherwise if you have a good PCP, HMO should be okay at your age.
i buy my own medical insurance. it’s an hsa. capitalism does not care if you live or die, so medical insurance can be hard or impossible to buy on the open market. but decoupling medical insurance from my employer has been a wise move.
it is a ppo. the discount on negotiated prices can be substantial. in an hsa context, negotiated prices are basically what you’re buying… a three thousand dollar yearly deductible doesn’t exactly kick in each year. they have a medication discount program that i’m studying now.
i deduct my $100/mo premium, and the contributions to the HSA. i can change employers as much as i want. real freedom if you can get it.
Don’t forget the trump card, the pre-existing conditions exclusion or its cousin the exclusion for conditions developed within X months. It is not uncommon to see HMOs or PPOs exclude pre-existing conditions for a set period of time (say, 6 months). Especially the cheaper plans.
The problem is, you don’t know about these lovely gems until you get the terms for the plan. HR should theoretically have the terms, but you will have to read through the mountains of legalese. Still, if someone has a pre-existing condition, you have no choice.
A close friend & former colleague called me recently to report he had just completed a successful 7-week hospitalization. His cost? Zero. He’s what we would call upper middle class, distinguished in his field & I am pretty sure quite well fixed financially. Even with excellent insurance coverage I hesitate to guess what a 7-week hospital stay plus numerous doctor visits & meds would have cost my friend in, say, New York, where he once worked. Not to mention an inevitable, stressful battle over subsequent insurance claims. My friend is a longtime resident of London, where, if I am not mistaken, adequate health care (generally under a single-payer system) is considered a basic human right. I believe this is the view throughout Western Europe. BTW, according to some authorities as in so much else the French lead the world in health care, with splendid modern hospitals & wonderful doctors and nurses. Freedom fries, anyone?
Hmm… I think I should my prospective PCP about his own opinions regarding HMO and PCP.
I am in the medical field and in reading these comments I find that most of them are correct. For my own health, and that of my family, I have chosen a PPO out of pocket for a number of reasons. The first and foremost is that HMOs can, and do, change the requirements quite often. Second, remember that everyone is in business to make money, and if the insurance company is taking a big cut you can run into a few problems with SOME doctors. Not the majority by any means, but a few. If you can afford it, and I believe that you can, I would not skimp on your health. If you don’t have your health you have nothing, and having treated people in pain I see this everyday. The other problem I have experienced personally is the it can be harder to get an appointment with an HMO than with a PPO. This is for a variety of reasons, but when I was younger and had to deal with this mess, I ran into a couple of doctors who would not see me for a couple of months. Lastly, every doctor that I have been recommended too by physicians whose work I trust have not been in an HMO. The reason is quite simple. Supply and demand. The good doctors do not have to take an HMO for longer than a minute and then they have more patients than they can handle. Now most of them are willing to take 70 cents on the dollar because they want to treat everybody, but none I have meet have been willing to take 30-50 cents on the dollar for very long. Makes sense if you think about it.
Regardless, best of luck in making your decision.
Between 2003 – 2005 I had a PPO (blue cross of California) and since then I have had an HMO (healthnet). I prefer the HMO. The PPO was always charging us money even though we got everything done in network. I think this had to do with the deductible and out of pocket maximums. With our current HMO all we have to pay is co pays and they are very reasonable. You will NOT need a PPO if your wife gets pregnant. I have an HMO and am due in less than 2 weeks and so far everything has been great. In fact, there are not even any copays for pre-natal care. Anytime I request anything, first trimester screening, early FISH results for the amniocentesis, 20 week ultrasound, they have always been approved promptly and competely paid for. In addition, I have access to UCLA doctors through the HMO who are well known and well respected in thier fields.
I have a really great PCP. She takes great care of me. Even then, I differ with her on one thing that I have sought outside treatment for. Luckily I found this outside treatment very inexpensively. Perhaps it’s just being afraid to vary from standard treatment procedures since she has to answer to others in HMO care. The benefit of the HMO is more coverage. Though you might have to rely on referrals, you can petition for things you really think you need. If you have a good relationship with your doctor, you might get your request granted. The $2000 deductible may be worth it if you have a doctor or a specialist you will have a hard time getting to. I felt happy with the PPO when I was seeing an ENT and a speech therapist. But, now I am a little more practical and want to save some dough. If I really need to see someone, I know of docs who will work with you if you see them off the insurance.
I have an “open access HMO” from Aetna. This means that I do not need a referral to see in-network specialists. It’s nice to get the low-cost of an HMO with the freedom of being able to see a specialist without the “permission slip.”
I was enrolled in a PPO for nearly two years when I realized I’d not once gone to the doctor. When rates came up for a rise, I switched to the HMO.
I still haven’t gone.
If you’re young and in good health, the HMO is the way to go.
Following up on SC, I have something similar with United Health Care. I’m on my employer’s group plan, and they gave us options of HMO, PPO, or this “hybrid” that I’m on. (Goes by the name “UHC Choice.”) With this plan, I pay my monthly premium via my check (of course), and then the only other costs I pay are the co-pay. ($15 at PCP, $30 at specialist/urgent care facility, $100 outpatient hospital care, $250 inpatient hospital care.)
I can say that transferring from AR Blue Cross/Blue Shield PPO — this new plan is a godsend. I’m someone who goes to the doctor a lot (allergies and sinus infections), and the costs to me on the PPO plan were absurd. With the new plan, the co-pay greatly limits how much I pay out of pocket. Just as an example, I recently had a CT scan done on my sinuses in consideration of a possible need to do surgery, which probably would have ended up costing me a few grand on a PPO. With my current plan, I paid nothing because it was a covered procedure.
Moreover, I am not required to get a referral to see a specialist, which is very nice.
I live in Los Angeles, so there is no shortage of “in network” providers, and I have not run into an issue yet. I have had some slightly unacceptable wait-times for appointments with my Ear/Nose/Throat specialist, but I have been told he’s “one of the best,” so I’m not sure if that’s because of his reputation, or because he takes HMO patients.
If you have this option, I would tell you to take it. The fact that pretty much everything is covered at 100% is going to limit your costs greatly, especially in a catastrophic health problem.
I have a PPO through my company, with a high-deductible, Health Savings Account. I am going to leave my company soon, and I have been investigating getting a high deductible PPO on my own, and the rates are not too bad, and they will allow me to continue to fund the HSA. You can roll money, only one time ever from an IRA to an HSA, up to the max for the year, for family I think that is around $5800 (there are stipulations, like you have to maintain a high deductible plan for X amount of months after the rollover, so read closely). I already have $4,000 in this account (after next year’s rollover I will have close to $10,000), and it grows in Vanguard funds, tax free, I really think you should look at this option closely. Good luck, it is a tough decision!
If the HMO has your preferred doctor in network, go with it. I have PPO, and have found that in reality, you can’t just see any doctor you want. Many specialists will not take a patient, even PPO, without a referral from your PCP. (I’m not sure why, maybe because they are overbooked already). So PPO is not that advantageous over HMO.
Well, I’m in the medical field as well, so may have be a one-sided opinion. I’m in private practice- my wife is in a HMO. Fwiw, you will have a very difficult time sorting out the “good” providers and “bad” with just vague generalizations. That being said, here are some general observations based on my experiences 🙂
HMOs
-limited formulary, (unless there’s compelling evidence otherwise) will not be getting the latest drugs. This cuts both ways, i.e., the local HMO never approved Bextra, Celebrex, etc. So, their patients never had to deal with those possible side effects. They never got benefited as well (Celebrex is still on the market and has its uses).
-can be difficult to get expensive studies done (MRIs, etc.). This is primarily regarding routine cases. We’ve never seen any urgent case get delayed care, however.
-very efficient (and possibly comprehensive) in their management approach, i.e., use a lot of ancilliary providers as well as technology (electronic records, etc.).
PPOs
-theoretically, much more leeway in testing/prescriptions. This varies a LOT amongst different insurance companies (and even among the different plans from one company).
-somewhat ‘fractured’ care model (i.e, the doc doesn’t necessarily have instant computerized access to those labs/procedures he ordered for you at the last visit, and may have to rely upon the good ol’ fax). Things could get missed.
-easy to shop around, of course, and for major surgeries/decisions, this could offer peace of mind by way of 2nd opinions.
Finally, the old adage of “you can’t get Cadillac care at Ford prices” applies. It is already happening- I’ve seen some pre-authorization requirements that do not pass the common-sense test- they would not meet standard of care criteria, etc.
Anyway, you’re young and relatively healthy, so choose a PCP you’re comfortable with, and stay healthy. It’s the only guaranteed way to beat the system.
kv
In my experience, it is harder to get an appointment with an HMO than with a PPO. There are exceptions though. One time I had to leave work right away for a minor problem because the secretary said the doctor could see me in 30 minutes or 3 days later. And there is an HMO with open access (it does not require that you get referrals).
All I know is that my mother, a Physician Assistant for the last 25 years, and someone who has worked in about 4 different major hospital systems, sees the problem with current healthcare in our country as stemming from HMO’s, and this was before “Sicko” was even conceived of.
It is a really tough call, but if you are young and in relatively good health, I think a PPO is the way to go for the freedom of choice, and especially if you just want to get preventative care and have things checked out.
As you get older and start having real health concerns, where you are assured to be spending money on deductibles and co-pays, then you have to decide if you can take the extra cost of a PPO, yet rest assured that you’re covered. OR, take the lesser cost of the HMO and risk having a serious claim denied.
In either case, America really screwed this one up. Then again, this is what a country founded on principles of Capitalism will do to a healthcare system.
my 2 cents: Most PPO plan will cover you when you/family travel abroad. HMO plan doesn’t.
Good luck in finding proper insurance.
Having had both, I prefer PPO to HMO. HMOs will do everything they can to deny your claims. Everything. They are worse than credit card companies inventing little rules that screw you and charge you more.
I have to add – one thing I didn’t mention why I LOVE my HMO is because it is a non-profit. I have not found most of the negatives with my particular HMO. I think their non-profit status has a lot to do with it. I just don’t agree with any of the negative things I have seen at all with my health plan. BUT like I originally said it really depends on the particular plan – that is for sure. There are some horrid HMOs and PPOS… There are some decent ones as well that have more goals than simply “profit.”
GO WITH THE DOCTOR! If you and your family already know a good PCP in the HMO, that’s definitely your best bet. Also, be sure you understand the referral structure. For instance, if a referral is at first denied, can your Dr. override the denial? Also, it’s important that your Dr. can recommend good specialists w/in the HMO. Good luck.
My Aetna open access HOMO paln is a horror, I have to fight for coverage every step of the way…I HATE it!
Aetna HMO open access sucks too, it is deny, deny, deny, also I am putting out as much if not more than I was on the PPO, $1,500 deductable per year and $3000.00 I put out then they pay everything after that, I can’t get my scripts, they force me to get generic cause I can’t pay between 60-130 for my drugs every month, they actually denied my emergnecy appendix surgery till my wife went nuts and called Dept. of Banking & Insurance to complain, then they paid, this stuff goes on & on with Aetna, they just don’t want to put nay money out & live to deny, deny, deny as many claims as possible…go with PPO!!!!!!!!!!!!!!
Go with the PPO, I also have Aetna hmo and I think it is terrible, you have to get precertified for cat scans and other tests that could save your life cause they deem the test not nessasary??? How dare they do that when my doctor tells them I need that cat scan?????? I had other hmo’s that were better than Aetna but overall they all stink, I had to wait over a week for a referral more than once, if u r in good health it may be ok but over 40…..now way^
we have two hmo’s one is kaiser the other bluecross can we use both for different reasons–thanks steve
Go with PPO, it may mean the difference between life and death. In 2013, during an examination by her doctor for back pain, my mother’s neurologist noticed an anomaly on the very edge of her X-ray. He ordered a CT- scan and then an MRI and located a mass in one of her kidneys. Within 2 weeks, we were able to schedule her with a specialist at the renowned MD Anderson Cancer Center and subsequent removal of the tumor which turn out to be so close to stage 4 that when the tumor was examined post-op they found that it was on the verge to breaking out of the surrounding mass. Her dodged stage 4 by the skin of her teeth. She has PPO. Compare this to my cousin who is about 10 years younger than my mother and had HMO. She is currently dealing with terminal breast cancer that has spread to her spine, liver, hip, and lungs because the doctor within her HMO network gave her the minimal care refusing/denying to do more when she told them she thought something was wrong and wanted to see a specialist. When they finally refer her to a specialist within her HMO network, he botched it and missed the cancer. It was not until 3 years after that when she out of her own pocket visited another specialist and was diagnosed with cancer but by then it had already spread. She is dying and the only thing they can do for her is give her painkillers. All this because under HMO, the overriding concern is minimal care. If my mother had HMO instead of PPO, her doctor would not have had the incentive to go the extra mile and found the cancer. For those of you who do not know this, kidney cancer is rarely diagnosed early because there is no standard exam for it – it is not part of any routine physical and the ONLY way to exam for it is to specifically look for it. No HMO would have done that. Yet, in the case of my cousin where breast cancer prevention is standard and routine, she is the one who is facing a gruesome terrible death.
I know times are tough. I know what it means to have to choose toys for Christmas or food for Christmas. But it seems to me that in this life, you have to consider not just the immediate cost, but the long term cost. HMO are cheap, but you may have to pay dearly in the future.
I’ve had horrible problems with an HMO in the past. Switched to a PPO and never looked back.
The problems is that HMOs have a strong incentive to deny and defer care at every turn of the corner since they are both the insurer and the provider. Under the PPO model, once you establish that you have insurance, the provider (which is a distincly separate entity from the insurer) is incentivised to give you the maximum treatment that your insurer will allow.
With HMOs it is kind of like the fox guarding the henhouse.
Yes, with PPOs you have to deal with more bills and paperwork… small price to pay for the greatly improved quality of care you will receive when you really need it the most.