5 ms·

What happened with HMOs?

44 points by luu 3y ago

BugsJustFindMe 3y ago
> Now we all have HMOs Everyone I know (ok, not literally everyone, but more than a few) has a PPO now. Am I in a weird bubble?
- Sebguer 3y ago
  Quick google suggests that while more people use HMOs than PPOs, it's not a majority. My job offers both, but the HMOs are only available in a few states.
- refurb 3y ago
  You're correct. HMO = you have access to one provider PPO = you can't preferred access (lower patient costs) to one provider, but access to all
  - ggm 3y ago
    > PPO = you can't preferred access (lower patient costs) to one provider, but access to all Can you fix the typo in this please? "can't preferred" -I want to understand what you're saying, I can't infer it yet.
    - haldujai 3y ago
      I think the commenter means "you can have preferred access". PPO = Preferred Provider Organization. You have a better deductible/coinsurance/copayment for "in-network" (preferred) providers who have negotiated their rates with the insurer (or accepted the insurance company fee schedule). You typically need pre-authorization for elective surgery and advanced medical imaging. You have the option to see someone "out of network" but with less coverage. HMO = Health Maintenance Organization. Simple version is you don't get to choose your provider, you don't need preauthorizations and you have to go through your designated primary care provider to access specialists. For the most part you can only access providers within the HMO network if you want any coverage.
      - zamfi 3y ago
        > you don't need preauthorizations To be clear, in an HMO you don't need preauthorizations from your insurance but you still need your (not necessarily self-selected) PCP to order care or refer you to a specialist.
        haldujai 3y ago
        Needing a referral (an assessment by a physician that something is medically appropriate) is not the same as needing preauthorization (insurance company agreeing to pay) but in any case hence the following "you have to go through your designated primary care provider". Many PPOs and public systems work in the same way, that's more about judicious and appropriate use of resources than payment authorization.
        zamfi 3y ago
        Yes, I was just clarifying because PPOs often do allow you to seek out a specialist without a referral, and without requiring preauthorization.
    - refurb 3y ago
      To late to edit, I blame my phone's autocorrect. It should read... You're correct. HMO = you have access to one provider PPO = you have preferred access (lower patient costs) to one provider, but access to all
- uxp100 3y ago
  No, not at all. I’m not sure what that line means. We all have (access to) HMOs? Not true, but slightly closer to true. They’ve become much more common? A weird way of saying it, but I guess that is what they must mean. I thought maybe it was something specific to the author, like is the audience for the blog specific to Columbia? But I don’t think so.
  - freddie_mercury 3y ago
    The meaning of the line is pretty clear? It is a rhetorical flourish not to be meant taken literally. The author obviously just means "now they are widespread". "Back in the day HMOs were basically non-existent but promised cost containment, among other benefits. Now they are widespread but they didn't deliver on any of their promises."
- baby 3y ago
  Or you don’t live in California so you can’t get Kaiser? If you in California it’d be crazy to use anything else but Kaiser.
musicale 3y ago
> I guess this arises from the fact that much of the profit for HMOs is coming not from our monthly fees but from those extra charges. At that point it's not an HMO anymore and basically becomes a single-provider PPO with an added subscription fee. > this incentivized insurers to increase dollar margins by growing revenue (and focusing less on costs) and to transfer profits from the regulated insurance side of the business to the unregulated provider side (see UNH and Optum). Pretty much.
stevebmark 3y ago
HMOs are so much better than PPOs, but they're rare these days. They are significantly cheaper than PPOs. Most HMOs don't have deductibles, and all of them have lower premiums than PPOs. The "out of network" coverage of PPOs is an irrelevant scam. Your insurer covering 10% of a $200,000 out of network surgery is still going to bankrupt 99% of people in America. HMOs require you to get a referral from your primary care doctor to see a specialist, which has the added benefit of making sure people actually have a PCP. Primary care is one of the few types of care where the more you apply it, the better a patient's health outcome. No one gets an HMO because they're scared of having less choice of which doctors they can see. They pay more to have a choice that's ultimately irrelevant to their health. Most people choose doctors based on friend/family referrals and Yelp reviews, meaning they don't know how to choose a doctor. Reviews/referrals have no relation to health outcomes. The end of the article refers to the "medical loss ratio" enforced by the ACA, which did indeed incentivize insurance carriers to tolerate higher healthcare bills. This affects PPOs much worse than HMOs. It should all be burnt down. Further reading, one of the best books on the subject: "An American Sickness"
- CobaltFire 3y ago
  Perhaps rare in the general population, but the entire military is functionally an HMO (as are the dependents, unless specifically opted into the PPO option, which is rare). I just swapped to the PPO version after retiring because the cost isn't any different, and I'm no longer in the area of the easy HMO's for them (Military Treatment Facilities). I guess I can't fathom not having a PCP. As far as finding a Primary, what is your actual method for finding a good one if not by people who have experience with them?
- jmspring 3y ago
  I disagree, HMOs can be severely limiting especially as medical practioners (and medical groups) change or cancel insurance groups (HMO providers) they partner with. Further, getting access to specialists can be daunting - in network may be over loaded/over booked (appointment in 6-9 months); out of network providers can take significant hoops to jump through.
  - 3y ago
jmspring 3y ago
Kaiser is primarily a California HMO (they have a few other plans). It has been around for decade. People either hate it or love it because it is quite rigid in how it works (and you have to go specifically to their facilities). For the majority it seems like it's a cheap but very rigid option (especially compared to PPOs). I feel like, at least in California, the majority of HMOs got usurped by HSAs which became popular after Obama-care kicked in. Many many companies used the threat of the never implemented "cadillac plan" tax to rework the benefits they offered. It wasn't unusual to have a couple both have different PPOs and effectively get improved coverage through "double coverage". It's still possible, but not with HSAs.
- haldujai 3y ago
  > It has been around for decade. Assume that's a typo and you mean decades. Kaiser dates back to the interwar period and the modern version of it to the 70s/80s. > For the majority it seems like it's a cheap but very rigid option (especially compared to PPOs). I don't think it's cheaper on the monthly premium level, at least for me it's always listed as the more expensive option to choose from. If you end up using significant healthcare services it's probably cheaper than most PPO plans. > People either hate it or love it because it is quite rigid in how it works (and you have to go specifically to their facilities). I've noticed that too in my friend group. I've heard good things and the rare case that gets sent in to my academic hospital comes with a chart that suggests Kaiser is providing high quality care (in the Bay Area at least). The rigidity is very annoying though, for example I wouldn't be able to get care at the hospital I work at if I went with Kaiser. Conceptually I like the idea of HMOs, seems less wasteful while still good quality.
  - jmspring 3y ago
    Yes, typo. S key acting up.
  - massysett 3y ago
    I’ve been in a Kaiser plan most of my life and the “rigidity” doesn’t bother me, maybe I’m just used to it. I know exactly where I get care. Nearly everything is under one roof: doctor, lab, pharmacy, x-ray, specialists, etc. I almost always know exactly what it will cost. In recent years, I can now book all appointments online and view my medical record online. I guess I understand the appeal of being able to pick any random doctor that takes Blue Cross Blue Shield, but this doesn’t appeal to me. I don’t know squat about picking doctors and might as well throw darts at a board. Most PPO plans I look at have vague pricing: “you pay 15 percent of the plan allowance.” Well, what exactly is “the plan allowance”? Kaiser quotes me an exact copay, like $30. And then I read horror stories about people being unable to get an appointment with a primary care doctor for months, if they can find one at all. Many just go to urgent care or ER for everything. Not a problem with Kaiser. I can look through their primary care doctors and pick one. If I don’t pick, they assign me one. I can get an appointment with my doctor in a few days or a few weeks sometimes. If I need an appointment right away, I can get one with another Kaiser doctor, perhaps at a clinic I never go to. I tried a non-Kaiser HMO for a year or two and hated it, right down to the doctor who answered his cell phone during my appointment. I look at PPOs and the opaque pricing kills it for me. Kaiser has been great.
ThaDood 3y ago
Question for HN - For those not self employed and in the US, does your employer provided health insurance offer a HMO option? I've always heard that some companies do, but I've never seen a company offer one.
- baby 3y ago
  All the companies I’ve worked for have offered an HMO personally
- colanderman 3y ago
  Yes, every company I've worked at has offered both options (HMO and PPO). I live and am employed in Massachusetts.
- ics 3y ago
  Yes however the quality varies wildly. In my two previous jobs, the HMO options were $100/mo and $400/mo respectively for a family (2 adults + unlimited dependents). In my partner's current position, the HMO option is $2000/mo– not a typo. All three plans offering essentially the same benefits but obviously the first two mentioned were carrying a much higher portion of the premiums.
- PrivateButts 3y ago
  In (western) NY it's unheard of now. Everything is some form of PPO.
- piperswe 3y ago
  My company offers Kaiser HMO in California, but elsewhere only a PPO+HRA.
chiefalchemist 3y ago
Listen. No matter how you cut it, the system doesn't want you to be healthy. It starts with the fact that there's no - or at least significantly less - profit in prevention, and then it's all down hill from there. Put another way, health of the masses is down. Yet profits of the "health care" system is up. If you can get your arse up off the sofa...just follow the money. Anything else is a distraction.
- monero-xmr 3y ago
  “Prevention” is such a loaded term because you go to the doctor, they take your blood pressure, weight, temperature, and ask a few questions. If you already know you have pain, you could have simply gone to a doctor about that pain. I switched my family to a virtual PCP, you can text them any time, and they order all the same tests as anywhere else. I guess if you need someone to slap sense into you about being obese and smoking / drinking too much then going to a doctor could make sense. Otherwise there is a standard schedule of tests for age groups. If you have a complex diagnosis you will need a specialist regardless.
  - chiefalchemist 3y ago
    Call what you want then, but the system isn't set up to keep you out - there's no money in that - it's to get you in and keep you there as long as reasonably possible. Sure there's plenty of window dressing to disguise the underlying intent and structure but that doesn't change its core values.
awinter-py 3y ago
related, this is a think tank's history of negotiating power in health care https://www.nihcr.org/wp-content/uploads/2015/03/Congressional_Testimony-_Health_Care_Provider_Market_Power.pdf https://www.nihcr.org/wp-content/uploads/2015/03/Congression... its claim is that there's a shifting balance of power driven by the business cycle. employers expand coverage in random directions in boom times, someone gets squeezed in bust times 'who is the villain' in this mess changes faces from cycle to cycle
Mistletoe 3y ago
I miss my HMO dearly. It was the last time I felt like I got good healthcare. I now have a high deductible healthcare plan with like a $3000 deductible and the plan is “don’t get sick.” It’s disgusting and I work for a major university.
naveen99 3y ago
For Medicare patients, cms is pushing aco’s https://www.cms.gov/priorities/innovation/innovation-models/ACO https://www.cms.gov/priorities/innovation/innovation-models/...
javajosh 3y ago
Years ago I was in a DC bar and struck up a convo with the man next to me. He was a physician and after a few drinks he opened up to me and said, "The main problem with the healthcare system is that we don't let old people die." It was one of those transgressive things you hear and take note of. It does seem like a foolish use of resources to extend the life of someone in their 80's for a few months of more misery for the cost of several million dollars, when that same money spent on younger people could change their whole life for the better. But yeah, "Let old people die" is probably not going to win elections.
Aurornis 3y ago
> The short story as I understand it is that HMOs actually worked early on, but realized people got really really upset when told that their personal doctor sucked and the treatment recommended sucked. They’d bail for whatever insurer covered every damn thing. So insurers realized better to just jack prices rather than control costs. I don't know how true this is for the HMO story, but I do know that many patients absolutely hate being told "no" after they've convinced themselves that they need a certain treatment. We've all heard the stories about the patient who was right about their own diagnosis but was denied care by their doctor, but these are the rare stories. Providers get bombarded daily by demands for antibiotics for colds, for example. If you're well educated about antibiotics you probably wouldn't believe the number of people who think antibiotics treat every infection and doctors are just meanies for refusing to hand them out. Many doctors get tired of fighting these battles and just write prescription after prescription for antibiotics on demand, which creates a loyal customer base of patients who are happy because they get whatever they ask for. The situation is even scarier for controlled substances. The internet and sites like Reddit have a weird way of convincing people that they need Adderall and/or Xanax, and that doctors are evil if they won't prescribe them no questions asked. I've heard too many horror stories from my psychiatrist friends who get patients showing up demanding Adderall, but on closer examination will describe classic depression symptoms (e.g. having trouble focusing after a recent breakup, but no problems for the first 2-3 decades of life). Some of them have been convinced by Reddit (it's always Reddit) that ADHD is the explanation to their mental health problems and a high dose of Adderall will solve all of their problems. Then when they say "no", they get pinged a few weeks later by the psychiatrist down the hall because the patient is back with a different doctor trying the same story. The sad part is that they often continue this rotation until someone shrugs and writes the prescription. A disappointing number of providers don't mind having a lot of controlled substance patients because it's a steady stream of easy appointments to write new prescriptions every few months.
dragonwriter 3y ago
FTFA: > But something happened between 1978 and today. Now we all have HMOs No, we don’t. “Forty-nine percent of covered workers are enrolled in PPOs, followed by HDHP/SOs (29%), HMOs (12%), POS plans (9%), and conventional plans (1%)” [0] And part of this is government policy actively promoting the HDHP/SO, and starting before that private market blowback of the provider choice issue in public healthcare policy debates as far back as the debates over the Clinton healthcare plan effecting marketplace decisions. [0] https://www.kff.org/report-section/ehbs-2022-section-5-market-shares-of-health-plans https://www.kff.org/report-section/ehbs-2022-section-5-marke...
hakfoo 3y ago
At my last job, we never had employer-supplied care; it was too small a firm to get into anything unless he bought into a cooperative, which I think was a word with about three too many syllables for the CEO to grasp. I ended up buying marketplace plans, and the first two or three years, you had a choice between HMO and PPO plans; after that, it's obvious the local insurers (who also dwindled to one or two) decided all the market wanted was "it's the minimum that counts as coverage" Silver-tier HMO plans, all with the exact same (highest legal) copay/out-of-pocket limits, and either removed anything else or priced it stratospherically. I guess the health-care marketplace ended up much like the airlines after Expedia; they had to jettison anything appealing to look good on a price-comparison engine. Once we had a guy visit the office trying to sell a HSA/HDHP plan; after three minutes discussing it after his visit, we all decoded that the basic premise of the plan was that it disincentivizes you from getting the care you actually need. It's sold on the concept of "you're an above average driver" (you won't ever be sick enough to actually need to tap the HSA) and promises of being able to stick the IRS with a tax-exempt savings scheme. My current position offers a PPO or HSA/HDHP scheme and pays like 90% of the costs for your choice. I wouldn't touch the HSA option with a 10-metre pole.

44 points by luu 3y ago

> Now we all have HMOs Everyone I know (ok, not literally everyone, but more than a few) has a PPO now. Am I in a weird bubble?

Sebguer 3y ago
Quick google suggests that while more people use HMOs than PPOs, it's not a majority. My job offers both, but the HMOs are only available in a few states.
refurb 3y ago
You're correct. HMO = you have access to one provider PPO = you can't preferred access (lower patient costs) to one provider, but access to all
- ggm 3y ago
  > PPO = you can't preferred access (lower patient costs) to one provider, but access to all Can you fix the typo in this please? "can't preferred" -I want to understand what you're saying, I can't infer it yet.
  - haldujai 3y ago
    I think the commenter means "you can have preferred access". PPO = Preferred Provider Organization. You have a better deductible/coinsurance/copayment for "in-network" (preferred) providers who have negotiated their rates with the insurer (or accepted the insurance company fee schedule). You typically need pre-authorization for elective surgery and advanced medical imaging. You have the option to see someone "out of network" but with less coverage. HMO = Health Maintenance Organization. Simple version is you don't get to choose your provider, you don't need preauthorizations and you have to go through your designated primary care provider to access specialists. For the most part you can only access providers within the HMO network if you want any coverage.
    - zamfi 3y ago
      > you don't need preauthorizations To be clear, in an HMO you don't need preauthorizations from your insurance but you still need your (not necessarily self-selected) PCP to order care or refer you to a specialist.
      - haldujai 3y ago
        Needing a referral (an assessment by a physician that something is medically appropriate) is not the same as needing preauthorization (insurance company agreeing to pay) but in any case hence the following "you have to go through your designated primary care provider". Many PPOs and public systems work in the same way, that's more about judicious and appropriate use of resources than payment authorization.
        zamfi 3y ago
        Yes, I was just clarifying because PPOs often do allow you to seek out a specialist without a referral, and without requiring preauthorization.
  - refurb 3y ago
    To late to edit, I blame my phone's autocorrect. It should read... You're correct. HMO = you have access to one provider PPO = you have preferred access (lower patient costs) to one provider, but access to all
uxp100 3y ago
No, not at all. I’m not sure what that line means. We all have (access to) HMOs? Not true, but slightly closer to true. They’ve become much more common? A weird way of saying it, but I guess that is what they must mean. I thought maybe it was something specific to the author, like is the audience for the blog specific to Columbia? But I don’t think so.
- freddie_mercury 3y ago
  The meaning of the line is pretty clear? It is a rhetorical flourish not to be meant taken literally. The author obviously just means "now they are widespread". "Back in the day HMOs were basically non-existent but promised cost containment, among other benefits. Now they are widespread but they didn't deliver on any of their promises."
baby 3y ago
Or you don’t live in California so you can’t get Kaiser? If you in California it’d be crazy to use anything else but Kaiser.

musicale 3y ago

> I guess this arises from the fact that much of the profit for HMOs is coming not from our monthly fees but from those extra charges. At that point it's not an HMO anymore and basically becomes a single-provider PPO with an added subscription fee. > this incentivized insurers to increase dollar margins by growing revenue (and focusing less on costs) and to transfer profits from the regulated insurance side of the business to the unregulated provider side (see UNH and Optum). Pretty much.

stevebmark 3y ago

HMOs are so much better than PPOs, but they're rare these days. They are significantly cheaper than PPOs. Most HMOs don't have deductibles, and all of them have lower premiums than PPOs. The "out of network" coverage of PPOs is an irrelevant scam. Your insurer covering 10% of a $200,000 out of network surgery is still going to bankrupt 99% of people in America. HMOs require you to get a referral from your primary care doctor to see a specialist, which has the added benefit of making sure people actually have a PCP. Primary care is one of the few types of care where the more you apply it, the better a patient's health outcome. No one gets an HMO because they're scared of having less choice of which doctors they can see. They pay more to have a choice that's ultimately irrelevant to their health. Most people choose doctors based on friend/family referrals and Yelp reviews, meaning they don't know how to choose a doctor. Reviews/referrals have no relation to health outcomes. The end of the article refers to the "medical loss ratio" enforced by the ACA, which did indeed incentivize insurance carriers to tolerate higher healthcare bills. This affects PPOs much worse than HMOs. It should all be burnt down. Further reading, one of the best books on the subject: "An American Sickness"

CobaltFire 3y ago
Perhaps rare in the general population, but the entire military is functionally an HMO (as are the dependents, unless specifically opted into the PPO option, which is rare). I just swapped to the PPO version after retiring because the cost isn't any different, and I'm no longer in the area of the easy HMO's for them (Military Treatment Facilities). I guess I can't fathom not having a PCP. As far as finding a Primary, what is your actual method for finding a good one if not by people who have experience with them?
jmspring 3y ago
I disagree, HMOs can be severely limiting especially as medical practioners (and medical groups) change or cancel insurance groups (HMO providers) they partner with. Further, getting access to specialists can be daunting - in network may be over loaded/over booked (appointment in 6-9 months); out of network providers can take significant hoops to jump through.
- 3y ago

jmspring 3y ago

Kaiser is primarily a California HMO (they have a few other plans). It has been around for decade. People either hate it or love it because it is quite rigid in how it works (and you have to go specifically to their facilities). For the majority it seems like it's a cheap but very rigid option (especially compared to PPOs). I feel like, at least in California, the majority of HMOs got usurped by HSAs which became popular after Obama-care kicked in. Many many companies used the threat of the never implemented "cadillac plan" tax to rework the benefits they offered. It wasn't unusual to have a couple both have different PPOs and effectively get improved coverage through "double coverage". It's still possible, but not with HSAs.

haldujai 3y ago
> It has been around for decade. Assume that's a typo and you mean decades. Kaiser dates back to the interwar period and the modern version of it to the 70s/80s. > For the majority it seems like it's a cheap but very rigid option (especially compared to PPOs). I don't think it's cheaper on the monthly premium level, at least for me it's always listed as the more expensive option to choose from. If you end up using significant healthcare services it's probably cheaper than most PPO plans. > People either hate it or love it because it is quite rigid in how it works (and you have to go specifically to their facilities). I've noticed that too in my friend group. I've heard good things and the rare case that gets sent in to my academic hospital comes with a chart that suggests Kaiser is providing high quality care (in the Bay Area at least). The rigidity is very annoying though, for example I wouldn't be able to get care at the hospital I work at if I went with Kaiser. Conceptually I like the idea of HMOs, seems less wasteful while still good quality.
- jmspring 3y ago
  Yes, typo. S key acting up.
- massysett 3y ago
  I’ve been in a Kaiser plan most of my life and the “rigidity” doesn’t bother me, maybe I’m just used to it. I know exactly where I get care. Nearly everything is under one roof: doctor, lab, pharmacy, x-ray, specialists, etc. I almost always know exactly what it will cost. In recent years, I can now book all appointments online and view my medical record online. I guess I understand the appeal of being able to pick any random doctor that takes Blue Cross Blue Shield, but this doesn’t appeal to me. I don’t know squat about picking doctors and might as well throw darts at a board. Most PPO plans I look at have vague pricing: “you pay 15 percent of the plan allowance.” Well, what exactly is “the plan allowance”? Kaiser quotes me an exact copay, like $30. And then I read horror stories about people being unable to get an appointment with a primary care doctor for months, if they can find one at all. Many just go to urgent care or ER for everything. Not a problem with Kaiser. I can look through their primary care doctors and pick one. If I don’t pick, they assign me one. I can get an appointment with my doctor in a few days or a few weeks sometimes. If I need an appointment right away, I can get one with another Kaiser doctor, perhaps at a clinic I never go to. I tried a non-Kaiser HMO for a year or two and hated it, right down to the doctor who answered his cell phone during my appointment. I look at PPOs and the opaque pricing kills it for me. Kaiser has been great.

ThaDood 3y ago

Question for HN - For those not self employed and in the US, does your employer provided health insurance offer a HMO option? I've always heard that some companies do, but I've never seen a company offer one.

baby 3y ago
All the companies I’ve worked for have offered an HMO personally
colanderman 3y ago
Yes, every company I've worked at has offered both options (HMO and PPO). I live and am employed in Massachusetts.
ics 3y ago
Yes however the quality varies wildly. In my two previous jobs, the HMO options were $100/mo and $400/mo respectively for a family (2 adults + unlimited dependents). In my partner's current position, the HMO option is $2000/mo– not a typo. All three plans offering essentially the same benefits but obviously the first two mentioned were carrying a much higher portion of the premiums.
PrivateButts 3y ago
In (western) NY it's unheard of now. Everything is some form of PPO.
piperswe 3y ago
My company offers Kaiser HMO in California, but elsewhere only a PPO+HRA.

chiefalchemist 3y ago

Listen. No matter how you cut it, the system doesn't want you to be healthy. It starts with the fact that there's no - or at least significantly less - profit in prevention, and then it's all down hill from there. Put another way, health of the masses is down. Yet profits of the "health care" system is up. If you can get your arse up off the sofa...just follow the money. Anything else is a distraction.

monero-xmr 3y ago
“Prevention” is such a loaded term because you go to the doctor, they take your blood pressure, weight, temperature, and ask a few questions. If you already know you have pain, you could have simply gone to a doctor about that pain. I switched my family to a virtual PCP, you can text them any time, and they order all the same tests as anywhere else. I guess if you need someone to slap sense into you about being obese and smoking / drinking too much then going to a doctor could make sense. Otherwise there is a standard schedule of tests for age groups. If you have a complex diagnosis you will need a specialist regardless.
- chiefalchemist 3y ago
  Call what you want then, but the system isn't set up to keep you out - there's no money in that - it's to get you in and keep you there as long as reasonably possible. Sure there's plenty of window dressing to disguise the underlying intent and structure but that doesn't change its core values.

awinter-py 3y ago

related, this is a think tank's history of negotiating power in health care https://www.nihcr.org/wp-content/uploads/2015/03/Congressional_Testimony-_Health_Care_Provider_Market_Power.pdf https://www.nihcr.org/wp-content/uploads/2015/03/Congression... its claim is that there's a shifting balance of power driven by the business cycle. employers expand coverage in random directions in boom times, someone gets squeezed in bust times 'who is the villain' in this mess changes faces from cycle to cycle

Mistletoe 3y ago

I miss my HMO dearly. It was the last time I felt like I got good healthcare. I now have a high deductible healthcare plan with like a $3000 deductible and the plan is “don’t get sick.” It’s disgusting and I work for a major university.

naveen99 3y ago

For Medicare patients, cms is pushing aco’s https://www.cms.gov/priorities/innovation/innovation-models/ACO https://www.cms.gov/priorities/innovation/innovation-models/...

javajosh 3y ago

Years ago I was in a DC bar and struck up a convo with the man next to me. He was a physician and after a few drinks he opened up to me and said, "The main problem with the healthcare system is that we don't let old people die." It was one of those transgressive things you hear and take note of. It does seem like a foolish use of resources to extend the life of someone in their 80's for a few months of more misery for the cost of several million dollars, when that same money spent on younger people could change their whole life for the better. But yeah, "Let old people die" is probably not going to win elections.

Aurornis 3y ago

> The short story as I understand it is that HMOs actually worked early on, but realized people got really really upset when told that their personal doctor sucked and the treatment recommended sucked. They’d bail for whatever insurer covered every damn thing. So insurers realized better to just jack prices rather than control costs. I don't know how true this is for the HMO story, but I do know that many patients absolutely hate being told "no" after they've convinced themselves that they need a certain treatment. We've all heard the stories about the patient who was right about their own diagnosis but was denied care by their doctor, but these are the rare stories. Providers get bombarded daily by demands for antibiotics for colds, for example. If you're well educated about antibiotics you probably wouldn't believe the number of people who think antibiotics treat every infection and doctors are just meanies for refusing to hand them out. Many doctors get tired of fighting these battles and just write prescription after prescription for antibiotics on demand, which creates a loyal customer base of patients who are happy because they get whatever they ask for. The situation is even scarier for controlled substances. The internet and sites like Reddit have a weird way of convincing people that they need Adderall and/or Xanax, and that doctors are evil if they won't prescribe them no questions asked. I've heard too many horror stories from my psychiatrist friends who get patients showing up demanding Adderall, but on closer examination will describe classic depression symptoms (e.g. having trouble focusing after a recent breakup, but no problems for the first 2-3 decades of life). Some of them have been convinced by Reddit (it's always Reddit) that ADHD is the explanation to their mental health problems and a high dose of Adderall will solve all of their problems. Then when they say "no", they get pinged a few weeks later by the psychiatrist down the hall because the patient is back with a different doctor trying the same story. The sad part is that they often continue this rotation until someone shrugs and writes the prescription. A disappointing number of providers don't mind having a lot of controlled substance patients because it's a steady stream of easy appointments to write new prescriptions every few months.

dragonwriter 3y ago

FTFA: > But something happened between 1978 and today. Now we all have HMOs No, we don’t. “Forty-nine percent of covered workers are enrolled in PPOs, followed by HDHP/SOs (29%), HMOs (12%), POS plans (9%), and conventional plans (1%)” [0] And part of this is government policy actively promoting the HDHP/SO, and starting before that private market blowback of the provider choice issue in public healthcare policy debates as far back as the debates over the Clinton healthcare plan effecting marketplace decisions. [0] https://www.kff.org/report-section/ehbs-2022-section-5-market-shares-of-health-plans https://www.kff.org/report-section/ehbs-2022-section-5-marke...

hakfoo 3y ago

At my last job, we never had employer-supplied care; it was too small a firm to get into anything unless he bought into a cooperative, which I think was a word with about three too many syllables for the CEO to grasp. I ended up buying marketplace plans, and the first two or three years, you had a choice between HMO and PPO plans; after that, it's obvious the local insurers (who also dwindled to one or two) decided all the market wanted was "it's the minimum that counts as coverage" Silver-tier HMO plans, all with the exact same (highest legal) copay/out-of-pocket limits, and either removed anything else or priced it stratospherically. I guess the health-care marketplace ended up much like the airlines after Expedia; they had to jettison anything appealing to look good on a price-comparison engine. Once we had a guy visit the office trying to sell a HSA/HDHP plan; after three minutes discussing it after his visit, we all decoded that the basic premise of the plan was that it disincentivizes you from getting the care you actually need. It's sold on the concept of "you're an above average driver" (you won't ever be sick enough to actually need to tap the HSA) and promises of being able to stick the IRS with a tax-exempt savings scheme. My current position offers a PPO or HSA/HDHP scheme and pays like 90% of the costs for your choice. I wouldn't touch the HSA option with a 10-metre pole.