Obamacare and you

[crazy canuck]

The point is I wouldnt have to go to Seattle....

And I wouldn't have to go out of Chicago.

On the one hand I have American posters stating that all but the expensive HMOs are restrictive and then I have you and Berkut making the case that all HMOs provide exactly the same quality of choice and care as I have.  One of those versions of the American system is incorrect.

But assuming that all HMOs are as good as what I enjoy.  What is the downside of creating a system that ensures that quality for all?

[Malthus]

Pretty much everything that you could do with an HMO.

I thought someone said that you need to go through some kind of approval process to change a primary care physician in an HMO?

In any event, even if you had complete freedom of choice in an HMO similar to what we have you are still restricted to the doctors employeed in the HMO.  What if the doctor who is the best fit is employeed elsewhere?

The Canadian system allows for all doctors because it's a national program, and all doctors agree to a set charge. An HMO limits it to the doctors who sign a contract with them, agreeing to charge a specific charge.

Yes, we are in agreement that I have a wider range to choose from.

Would your Canadian system cover a doctor in the US?

It doesnt.  I have no idea what point you are making here.  Why would a Canadian tax payor subsidize an American doctor who is not part of the cost controls I have been talking about?

Her point is that you are making a distinction without a practical difference.

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

If in fact the Canadian system then creates a pool of less qualified doctors to begin with, the "greater choice" could actually be even less meaningful (I don't know if that is the case or not, of course).

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

I thought the issue was 'My HMO prevents me from seeing Dr. Blogs, my favorite guy, whom I would otherwise want to see'.

This issue doesn't arise in a nationally-based system, because other than with certain specialists for very severe conditions like Cancer, a patient doesn't usually travel outside of a major Western nation just to go to visit their favorite doctor. In fact, if you live in a major city like Toronto or Vancouver, you are unlikely to travel out of your city.

[Berkut]

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

By definition "the bulk" of local doctors does not mean all local doctors. I can choose all local doctors and you cant.   No big mystery.

I think I covered this. Distinction without a practical difference, at least, there is no reason to simply assume that there is a difference.

I would much rather choose from 20 great doctors than 40 crappy ones.

Or more to the point, my list of doctors for my HMO includes pretty much every single doctor I would consider anyway without such a list, and since I have no ability to distinguish qualitatively between them at a enough of a granular enough level that it matters, your extra "choice" is not useful to me.

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

Do all HMOs have such a large pool to choose from?
[/quote]

I don't know - do you?

I do know that whenever I've need to see a doctor, I've had zero trouble finding an excellent one in the variety of different HMOs I've been part of so far.

  If so why do I read posts complaining about lack of choice within HMOs?

If not, why are you right now reading posts not complaining about the lack of choice in HMOs? Anecdotal evidence is not really all that useful. For exactly that reason.

Why is it that there is a distinction between well run HMOs that give good choice and those that do not?

Is there such a distinction? I suppose there could be - sound to me like the answer would be to get a different HMO. Of course, the real problem is never lack of choice, it is "I don't like my doctor". And the answer to that problem is "Find another one in your HMO - they almost certainly have a huge array of choices".

The real difference in my experience between well run HMOs and the shit ones are generally administrative. Crappy ones it seems we spend a ridiculous amount of time arguing with them about who pays for what, when, and how.
But that is just my experience, of course. Others may differ.

[Malthus]

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

By definition "the bulk" of local doctors does not mean all local doctors. I can choose all local doctors and you cant.   No big mystery.

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

Do all HMOs have such a large pool to choose from?  If so why do I read posts complaining about lack of choice within HMOs?  Why is it that there is a distinction between well run HMOs that give good choice and those that do not?

It really seems like you're struggling to find some major flaw in the HMO system that just isn't a big deal, because you've found out that the Canadian system is the same thing.

The issue is that we in Canada hear people in the US complain that if they go with certain HMOs, they can only use approved doctors, and so they can't use (say) their favorite guy, Dr. Blogs.

This complaint can of course be totally incorrect. I really have no idea.

[Berkut]

The point is I wouldnt have to go to Seattle....

And I wouldn't have to go out of Chicago.

On the one hand I have American posters stating that all but the expensive HMOs are restrictive and then I have you and Berkut making the case that all HMOs provide exactly the same quality of choice and care as I have.  One of those versions of the American system is incorrect.

My suspicion is that it is the strawman version.

But assuming that all HMOs are as good as what I enjoy.  What is the downside of creating a system that ensures that quality for all?

I am not arguing that our system is great, far from it. Just pointing out that your caricature of our system is rather bizarrely out of whack with the actual system.

[crazy canuck]

Is there such a distinction? I suppose there could be - sound to me like the answer would be to get a different HMO. Of course, the real problem is never lack of choice, it is "I don't like my doctor". And the answer to that problem is "Find another one in your HMO - they almost certainly have a huge array of choices".

The real difference in my experience between well run HMOs and the shit ones are generally administrative. Crappy ones it seems we spend a ridiculous amount of time arguing with them about who pays for what, when, and how.
But that is just my experience, of course. Others may differ.

I am just going by what I am learning from what Americans are posting in this thread.  If you are asserting that all HMOs are created equal that runs contrary to what others have said and frankly seems rather unlikely.  I find the position put forward earlier that the more expensive HMOs are run similar to the Canadian system while others can be a bit of a nightmare more pursuasive because  I find it highly unlikely that the cheaper HMOs provide the same level of care as the expensive HMOs.

[Berkut]

Pretty much everything that you could do with an HMO.

I thought someone said that you need to go through some kind of approval process to change a primary care physician in an HMO?

In any event, even if you had complete freedom of choice in an HMO similar to what we have you are still restricted to the doctors employeed in the HMO.  What if the doctor who is the best fit is employeed elsewhere?

The Canadian system allows for all doctors because it's a national program, and all doctors agree to a set charge. An HMO limits it to the doctors who sign a contract with them, agreeing to charge a specific charge.

Yes, we are in agreement that I have a wider range to choose from.

Would your Canadian system cover a doctor in the US?

It doesnt.  I have no idea what point you are making here.  Why would a Canadian tax payor subsidize an American doctor who is not part of the cost controls I have been talking about?

Her point is that you are making a distinction without a practical difference.

You don't really know if you have a wider range to choose from, since your choices are limited by more than simply what is available within the system. Factors like timing and geography enter into it as well, and if in the US the set of choices for a typical HMO encompass the bulk of the doctors in a particular area, then in fact the distinction becomes largely meaningless.

If in fact the Canadian system then creates a pool of less qualified doctors to begin with, the "greater choice" could actually be even less meaningful (I don't know if that is the case or not, of course).

Does it matter if I can choose between 1000 specialists and 2000? I don't think it really does, as long as there are excellent choices within each pool.

I thought the issue was 'My HMO prevents me from seeing Dr. Blogs, my favorite guy, whom I would otherwise want to see'.

This issue doesn't arise in a nationally-based system, because other than with certain specialists for very severe conditions like Cancer, a patient doesn't usually travel outside of a major Western nation just to go to visit their favorite doctor. In fact, if you live in a major city like Toronto or Vancouver, you are unlikely to travel out of your city.

Yeah, but since I've lived in Rochester, I've had 5-6 different HMOs.

And the same doctor the entire time. Because it is in her interest to be signed up with all the local major HMOs, and it is in their interest to have her signed up, so in reality, most of the doctors are members of most of the HMOs. Hell, this is probably part of the problem with the system, is that everyone pretty much signs on for all the major providers, and there isn't any actual competition based on price or anything like that. I suspect most of the HMOs provide payment to the doctors based on some generic schedule as well, so there isn't even pressure on the doctors to not be part of any particular HMO.

Maybe it is different elsewhere, but in my experience the "choice" issue just isn't an issue at all.

[Berkut]

The real difference in my experience between well run HMOs and the shit ones...

If you are asserting that all HMOs are created equal

<boggle>

[crazy canuck]

I am not arguing that our system is great, far from it. Just pointing out that your caricature of our system is rather bizarrely out of whack with the actual system.

Its not mine.  If you have a beef with the way OVB characterized it take it up with him.

The "bad" HMOs, which is most of them, don't actually have everyone employed by the same organization. Instead there is a "virtual network" of providers who accept the HMO's coverage, and it tends to be a patchwork quilt of varying quality and painful restrictions and paper work to get anything covered.

[grumbler]

Do all HMOs have such a large pool to choose from?  If so why do I read posts complaining about lack of choice within HMOs?  Why is it that there is a distinction between well run HMOs that give good choice and those that do not?

The distinction, I believe, is that you don't get to choose whether or not you have a good HMO.  Your employer chooses your HMO, and the good ones are likely to be more expensive.

As a note, I don't have an HMO, so I might not understand the issues as fully as those who do.

[OttoVonBismarck]

Interesting.  Under our system your first visit would be to your family doctor who would then assess what further treatment you require.  If the doctor determines you need a specialist then you will be referred directly to that specialist and your doctors office will help make that appointment.  Also the doctor would likely order some tests so that the specialist has the results for your visit.  Sounds like our system is very much like a well run HMO.

But I am curious.  What do you see as the downside to a single payor system?

My perception at least is there is a speed differential in receiving services and in terms of having to wait a long time in between your doctor deciding you need a procedure and when a time slot opens for you to receive said procedure. Kaiser Permanente (KP) is a well oiled machine in this regard. Within the 9m member KP network I think probably the single greatest negative compared to single payer or "Government Payer" is simply that it would not work for the entire country since a large portion have preexisting conditions, a large portion could not afford the coverage, a large portion are old and wouldn't be wanted in the system (if Medicare didn't already exist.) I think SP/GP is superior from a societal perspective because it is "almost as good" in every other area as a well run HMO like KP, and it provides universal access--which is a substantial positive.

I should mention even in terms of access, where KP is available it is often more affordable than other HMOs or traditional health insurance because their "complete control" model gives them extremely strong cost controls. It's almost like a SP/GP system even with outside suppliers because as a huge organization with almost 9m patients they have significant bargaining power over suppliers. Part of how KP achieves this is their "tripod" system, they have a "Health Plan" division, a "Medical Group" division, and a "hospital" division. The health plan division basically does traditional insurance type activities, they provide access to the KP system and set rates, coverage rules etc. Most HMOs don't have the deductible model of insurance, but they do have copays and obviously have monthly premiums. The health plan is almost exclusively where the revenue for the Medical Group and Hospital division comes from.

When you're a KP customer, if you need to get services from a GP you go to a doctor that works for one of the Medical Groups. The Medical Group employs GPs and lots of other specialists who hold regular office hours. If you need surgery or hospitalization, you ideally go to a KP hospital. (There is coverage for emergencies, which obviously don't as easily go through a KP hospital based on where you are when the emergency happens.) The interesting thing about all of this is, every physician working for the medical group or the hospitals is salaried. Their pay is the same whether they have you take 10 tests or 2, or whether they see 25 patients or 5 patients in a day. It removes a lot of the bad incentives that doctors have under traditional insurance to push through as many patients a day as possible.

But yes, in a sense I think the few well run managed care organizations are very similar to SP/GP systems in terms of results and even cost savings. However since the ultimate revenue stream comes from individual consumers, it misses out on the universal access benefits of true SP/GP.

[crazy canuck]

The real difference in my experience between well run HMOs and the shit ones...

If you are asserting that all HMOs are created equal

<boggle>

Ok, you werent the one that said care was the same its just the paperwork that separates them?

[crazy canuck]

Do all HMOs have such a large pool to choose from?  If so why do I read posts complaining about lack of choice within HMOs?  Why is it that there is a distinction between well run HMOs that give good choice and those that do not?

The distinction, I believe, is that you don't get to choose whether or not you have a good HMO.  Your employer chooses your HMO, and the good ones are likely to be more expensive.

As a note, I don't have an HMO, so I might not understand the issues as fully as those who do.

Yeah, that is a good point and is consistent with OVB's observation of good vs not so good HMOs.

[crazy canuck]

Interesting.  Under our system your first visit would be to your family doctor who would then assess what further treatment you require.  If the doctor determines you need a specialist then you will be referred directly to that specialist and your doctors office will help make that appointment.  Also the doctor would likely order some tests so that the specialist has the results for your visit.  Sounds like our system is very much like a well run HMO.

But I am curious.  What do you see as the downside to a single payor system?

My perception at least is there is a speed differential in receiving services and in terms of having to wait a long time in between your doctor deciding you need a procedure and when a time slot opens for you to receive said procedure. Kaiser Permanente (KP) is a well oiled machine in this regard. Within the 9m member KP network I think probably the single greatest negative compared to single payer or "Government Payer" is simply that it would not work for the entire country since a large portion have preexisting conditions, a large portion could not afford the coverage, a large portion are old and wouldn't be wanted in the system (if Medicare didn't already exist.) I think SP/GP is superior from a societal perspective because it is "almost as good" in every other area as a well run HMO like KP, and it provides universal access--which is a substantial positive.

I should mention even in terms of access, where KP is available it is often more affordable than other HMOs or traditional health insurance because their "complete control" model gives them extremely strong cost controls. It's almost like a SP/GP system even with outside suppliers because as a huge organization with almost 9m patients they have significant bargaining power over suppliers. Part of how KP achieves this is their "tripod" system, they have a "Health Plan" division, a "Medical Group" division, and a "hospital" division. The health plan division basically does traditional insurance type activities, they provide access to the KP system and set rates, coverage rules etc. Most HMOs don't have the deductible model of insurance, but they do have copays and obviously have monthly premiums. The health plan is almost exclusively where the revenue for the Medical Group and Hospital division comes from.

When you're a KP customer, if you need to get services from a GP you go to a doctor that works for one of the Medical Groups. The Medical Group employs GPs and lots of other specialists who hold regular office hours. If you need surgery or hospitalization, you ideally go to a KP hospital. (There is coverage for emergencies, which obviously don't as easily go through a KP hospital based on where you are when the emergency happens.) The interesting thing about all of this is, every physician working for the medical group or the hospitals is salaried. Their pay is the same whether they have you take 10 tests or 2, or whether they see 25 patients or 5 patients in a day. It removes a lot of the bad incentives that doctors have under traditional insurance to push through as many patients a day as possible.

But yes, in a sense I think the few well run managed care organizations are very similar to SP/GP systems in terms of results and even cost savings. However since the ultimate revenue stream comes from individual consumers, it misses out on the universal access benefits of true SP/GP.

Yeah, I agree with that criticism of the Canadian system.  We attempt to move toward the kinds of efficiency your HMO has but with a system this size it is hard to achieve.  The upside is our system is provided to all at a lesser cost.  So there are definitely tradeoffs involved.

[OttoVonBismarck]

I would say the number one issue people have with HMOs by far is "I can't visit the doctor I want." As a Federal employee we have a wide range of options, KP is not the only HMO, and each year during open enrollment we got bombarded with advertising from many other HMOs available to Federal employees. Probably the #1 advertising point all of them like to tout is "all of the doctors in our network."

However KP is the only true managed care organization in the list. The rest may be structured as an HMO, but they do not actually directly employ doctors. Instead they operate a "network" of physicians that accept the HMO rate for specific services. Really it's very, very similar to traditional insurance. Which means it's fine in terms of coverage as long as your employer is subsidizing the premium, but it's bad in terms of cost control because unless you have all the actors on salary and all/most of the services within the same organization you lose much of the ability to control cost that comes with true managed care.

A genuine managed care organization does not have an expansive selection of doctors, so if you are part of such an organization and it doesn't have your region very well covered, it's bad for you if the doctors they do have are not to your liking. The more "virtual" HMO model, where the practitioners are still in business for themselves, typically have the same options locally as "regular" health insurance. The only difference is that instead of the doctor billing your insurance "full price" and then "accepting" the "pre-approved negotiated price", with an HMO the doctor just bills the HMO for "one unit" of x service at "x rate." A virtual HMO so to speak is really just a different type of billing from the physician's perspective. Real managed care the doctors work for the managed care organization itself, and when those sort of organizations are poorly run or maybe just poorly staffed in the area you live, they don't provide great care and they provide very poor coverage outside of the network.