This is a continuation of the quasi-series of open-enrollment advice posts. A valued commenter and reader e-mailed me with a very interesting question:
I’m changing jobs, and have a choice between a PPO, an HMO, and Kaiser. (Kaiser is listed separately, and one has to ask about it; for whatever reason, it is discouraged by HR.) the cost difference between the PPO and the HMO are nominal – the difference in my cost is about $6/mo for just me.
Thanks to your blogging, I’m trying to pay attention to the depth of the networks, but it is hard to tell what is going on. The online directory they have (this is UnitedHealthCare) lists a bunch of doctors. Is there any reasonable way a mostly clueless-about-this-stuff person can get an idea of how sizable their network is?
This is a two layered process. The first layer is to make sure that if you value to keep seeing your doctors and facility services is to make sure that they are in the directory. If you want Dr. Brown to continue to treat you, you should be checking to see if Dr. Brown is in network. If he appears in the directory, then you’re good on this stage.
The second check is a cheat for narrow networks and gives you a good sense of the net that was cast.
Most narrow networks are primarily concerned about controlling what hospitals are being used as hospitals have high costs and more importantly, high variance in costs. There will be exceptions as some networks will actively seek to exclude specific doctors but most narrow networks are premised on controlling hospital costs.
There are two basic flavors of narrow networks. The first flavor is the simple version of cost control. An insurer will offer X, and any hospital that will accept X or less is in network, while everyone else is out. A good check here is to see if the major academic medical centers in the central urban area of the region is in the network. If it is, the network is probably fairly broad.
If the major academic medical center has a split hospital structure where there are a few high end specialty hospitals (pediatrics, ob/gyn, trauma etc) and also general purpose hospitals, look at the general purpose hospitals.
The other type of narrow network is a business buggering thy competitors strategy. This is more common when a region has an integrated payer provider system (like Geissenger, Steward, Sutter, Meridian etc) . If you are buying insurance through an integrated payer-provider, see if major hospital chains not owned by the insurance company are in the network. Outlying community hospitals that are independent or part of small local chains will probably be included in modestly narrow networks solely to give coverage, but chains have negoatiating power. If the non-owned chain is in, the network is probably fairly broad.
These are not perfect cheats, but they are 20 second checks as doctors usually follow hospitals when narrow networks are created.
Flanders Other Neighbor
Once Kaiser is on the table, I’m done with the decision-making process. Not for everybody I’m guessing, but I’ve had good experiences and when you have kids it makes life so much easier.
Roger Moore
@Flanders Other Neighbor:
I’m right there with you. I had a health scare earlier this year and wound up going in for a whole battery of tests: CT, EKG, EEG (x2), echocardiogram, brain MRI, cardiac MRI, month-long cardiac monitoring, a bunch of lab tests, and consultations with a neurologist and cardiologist to make sense of the test results. The whole thing, including a trip to urgent care that got the whole thing started, cost me $80 out of pocket. Once a doctor decided I needed a test, I got the test with no arguments, no second guessing from some insurance company bean counter, and no copays. Kaiser is a machine that will sometimes deny care that the patient asks for because the machine says it isn’t medically indicated, but once a doctor says you need a treatment, you get it with a minimum of fuss.
pamelabrown53
Richard Mayhew. You are a treasure. Seems to me you’ve written enough posts and answered enough questions to have an easy book, at minimum, out lined.
Thank you so much for your intrepid focus on the nuts and bolts of our healthcare system. No one, IMHO, from any singular source has offered so much education for little in return.
Thank you, thank you, thank you.
P.S. Love hearing about your soccer coaching.
Yatsuno
@pamelabrown53:
Fixed that fer ya. :)
raven
So I have BCBS HMO and there are two hospitals in town. One is public (I guess that’s what you call it) and the other is Mackerel snappers. It seems like my doc has admitting rights at both and I keep telling her I want to go too the public that is about 100 yards from my house. When I sliced my ulnar nerve in May I went to the Ortho Clinic that is across the street from the one I want but I ended having the surgery with the annoying catholics. (Some old biddy came in my stall and asked if I wanted to pray with her and I said “I’m good”. She walked away saying “I’m going to pray for you anyway”! This stuff doesn’t matter to me except if I get hospitalized for any overnight or more because I want my wife to be able to walk right there.
Jamie
Thanks so much Richard – that’s awesome information, something a mere mortal like me can actually figure out.
Also, I believe this is the first time I’ve ever been called a valued commenter. I think I need to get that engraved somewhere before you sober up.
Ruckus
@raven:
I noticed this years ago that in some hospitals there is visiting 24 hrs a day and at some nurse rachet will come by and nag you out of the room. Never understood why, the 24 hr a day ones will chase you out of the room if they need to do something “delicate” or scrub the floor. Seems to do much better for patient morale. Patients do tend to not sleep on on the hospital schedule.
Fred Fnord
BTW, I might be able to shed a bit of light on the Kaiser thing, or at least a little darkness that has more of a shape to it.
There are at least four HR-providing companies that I know of who small-to-medium businesses in the SF Bay Area contract with to handle all the benefit stuff for them. Of those, two have semi-exclusive contracts with Blue Cross. One of them I don’t know much about. The other, they CAN provide Kaiser if they are specifically requested to do so but they very heavily discourage people from taking them up on it. When a company I worked for switched over to one of these providers, the CEO (a big Kaiser fan) specifically requested Kaiser, and so they offered it. And I immediately started evangelizing to everyone about Kaiser.
HR cornered me and explained that no, I wasn’t allowed to do that. If I wanted Kaiser I could sign up for it, but encouraging others to do so was against the rules, and in fact they’d prefer I refrained from even mentioning Kaiser out loud. Implied was that it didn’t cost OUR company extra money, but that there was perhaps some unsaid limit to the number of people who could get Kaiser, or that if too many people chose Kaiser then the company would refuse to do business with us the next year, or something like that. My speculation is that this HR contracting firm has a contract that requires them to pay BC at least some amount for every employee of every company they cover, whether or not that employee is actually covered by BC.
The Raven on the Hill
“this is UnitedHealthCare”
That alone ought to raise Kaiser in your considerations; UHC has a well-deserved bad reputation.
Jamie
Thanks, Raven and Fred. UHC’s directory has actually been down since I sent that note to Richard, and I haven’t been able to do much research since then.
But I am going to ask a bout Kaiser and see what the deal is.
I’m now waiting for an opportunity to tell someone that I get my trusted insurance advice from foul-mouthed political bloggers and commenters.