Obamacare and you

[Malthus]

In Ontario at least there is the theoretical "safety valve" for speed, that if the Ontario medical system can't provide a treatment in a reasonable time to prevent death or injury, you can go elsewhere - such as the US - and get that treatment, and the Ontario public insurer will pay for it.

However, getting the government to pay up may be a major task.

[OttoVonBismarck]

Also, I believe the reason many plans that are really just traditional U.S. style health insurance are "organized" as HMOs is because of the tax code. I think traditional health insurance plans have to operate or typically do operate as for-profit companies which has tax implications. Organized as an HMO you're tax exempt, so a lot of plans that aren't really managed care but just regular health insurance, are organized as HMOs.

[Malthus]

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.

Berkut and Meri just told us quite forcefully that physician choice isn't a problem in the US at all.

Colour me confused. Is physician choice a problem in the US, or is it not?

[Berkut]

Berkut said in his experience this wasn't the problem that CC says it is, and that CC may not have good information.
Berkut also said several times that he was relating HIS PERSONAL EXPERIENCE.

[merithyn]

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.

That's true of any insurance plan down here, to an extent. Even Medicare is limiting in which doctors that they can go to. We don't have an HMO, and yet we cannot see the doctor of our choice, since he's not contracted with our insurance company.

In our case, it's a pretty small pool because I work for a health insurance company that's owned by a hospital and physicians' services group. Ergo, I'm required to go to one of the doctors from that group and/or the hospital to see the full payment of benefits. That's a problem.

Also, my big issue with the whole HMO system is that I dislike having to go pay a $20 co-pay when I'm having issues with my asthma before I can go to the specialist, who will then charge me another $40 co-pay. Then, of course, I have to pay for my prescription, too. I have asthma. I've had asthma for 20+ years. I know when I need to see the specialist, and I don't see a need to go to my PCP first. It's a waste of everyone's time and my money.

I think that would grate against me if I lived in Canada, too.

[Eddie Teach]

Berkut and Meri just told us quite forcefully that physician choice isn't a problem in the US at all.

Colour me confused. Is physician choice a problem in the US, or is it not?

Sounds like a matter of having enough doctors to choose from vs having every doctor to choose from. There's always gonna be someone who opts out.

[Jacob]

Berkut said in his experience this wasn't the problem that CC says it is, and that CC may not have good information.
Berkut also said several times that he was relating HIS PERSONAL EXPERIENCE.

That Berkut guy. Always saying things.

[OttoVonBismarck]

Physician choice can be a problem for people who are in real managed care organizations that have bad service coverage, people who have Medicaid, or people who have "sub prime" insurance.

Medicaid is hated by physicians because the reimbursement rates are horrible and the patients themselves are usually not great to deal with and anything they end up owing on their end has a high chance of going to collections, so many physicians refuse to accept Medicaid. Sub prime plans, are basically "bad" health insurance plans that many employers offer in very low income/low skill industries to their employees. Many have described these plans as "not insurance at all" but just a relatively meager fixed benefit costs quite a lot for doing very little. Those plans have bad reimbursement schedules and many doctors will not accept them.

Finally, I tried to distinguish between "genuine managed care" and "health insurance organized as an HMO", genuine managed care has cost savings and other benefits, but if it's a small HMO you have a very limited selection of doctors. True managed care organizations simply will not cover services you get at a doctor outside the organization, meaning you don't visit that physician or you pay the full price. With say KP, that doesn't matter because the organization has 9m patients and like 14,000 physicians, it's basically like a Scandinavian country in scope, and where it offers membership it has more than enough service facilities. With smaller plans, for example I knew awhile back that employees of the State of WV had an option to be in a true managed care local to WV and the Ohio Valley region of Ohio. I think in the capital of the State, it had like 4 family doctors that worked for it, so if you were in that plan you probably waited a 1-3 months to get an appointment and if you didn't like that doctor you only had a few others to choose from.

If you have traditional insurance, through a PPO network or one of the "pseudo-HMOs" you basically will be served by any doctor around. Most doctors accept all the decent insurance plans as it is to their benefit to accept as many as possible (if they aren't Medicaid/some garbage bin insurance plan.)

[OttoVonBismarck]

That's true of any insurance plan down here, to an extent. Even Medicare is limiting in which doctors that they can go to. We don't have an HMO, and yet we cannot see the doctor of our choice, since he's not contracted with our insurance company.

In our case, it's a pretty small pool because I work for a health insurance company that's owned by a hospital and physicians' services group. Ergo, I'm required to go to one of the doctors from that group and/or the hospital to see the full payment of benefits. That's a problem.

Also, my big issue with the whole HMO system is that I dislike having to go pay a $20 co-pay when I'm having issues with my asthma before I can go to the specialist, who will then charge me another $40 co-pay. Then, of course, I have to pay for my prescription, too. I have asthma. I've had asthma for 20+ years. I know when I need to see the specialist, and I don't see a need to go to my PCP first. It's a waste of everyone's time and my money.

I think that would grate against me if I lived in Canada, too.

It's not really that onerous with KP, because everyone works for the same company so when you get schedule for a specialist KP does it for you. They basically say "okay, your GP has said you need to go here, this is your appointment date/time at this facility and you'll be seen by this doctor that day." You do have to pay various copays, but that's the tradeoff with many HMOs, you pay (IMO) small copays here and there but there isn't the deductible scheme like with traditional insurance. You don't have to worry about paying a deductible or out of pocket maximum before your full benefits come in.

[merithyn]

I would say the number one issue people have with HMOs privatized insurance in the US by far is "I can't visit the doctor I want."

FYP

[DGuller]

Berkut said in his experience this wasn't the problem that CC says it is, and that CC may not have good information.
Berkut also said several times that he was relating HIS PERSONAL EXPERIENCE.

Stop putting words in Berkut's mouth.

[Admiral Yi]

How much is Kaiser paying you to shill for them Biscuit?

[Malthus]

Berkut said in his experience this wasn't the problem that CC says it is, and that CC may not have good information.
Berkut also said several times that he was relating HIS PERSONAL EXPERIENCE.

Aside from whatever CC has or hasn't said, is it fair to say that under the US system physician choice issue is an issue for some, while physician choice isn't an issue in Canada for any? 

[Eddie Teach]

How much is Kaiser paying you to shill for them Biscuit?

Isn't his wife an MD? 

[garbon]

I would say the number one issue people have with HMOs privatized insurance in the US by far is "I can't visit the doctor I want."

FYP

Under a PPO, is that as big an issue?