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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

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.
  - haldujai 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 should have said it can be* very annoying, the rigidity isn't an issue for everyone and it really depends on your situation/healthcare needs and what your alternatives are. The rigidity is mostly annoying when you want to see a specialist without having to go through a PCP (although this may not be a bad thing from a health systems perspective) or need advanced care (like cancer) that may be better outside of Kaiser (although again noting that they're still very good from what I've seen) and you want to choose where you get treatment. Or if, like in my situation, you know exactly where you want to get your care and it's not part of Kaiser.
- hedora 3y ago
  The rigidity and cost savings come from the fact that they don’t have to spend money negotiating with themselves about whether to pay a bill. On average, 33 cents of every insurance dollar in the US goes to paperwork and paid negotiators on the doctor or insurance company side. If hospitals and insurance companies established a standardized (regional) fixed price list for all procedures, auto-approved everything and asked patients to occasionally spot check bills for care they received (for anti-fraud), then all that could be automated, and the balance could go to increasing quality of care without increasing prices. That would make them cost-competitive and roughly as convenient as Kaiser, but also less rigid than Kaiser.
  - haldujai 3y ago
    > On average, 33 cents of every insurance dollar in the US goes to paperwork and paid negotiators on the doctor or insurance company side. That's misleading, this is the percentage quoted for overall non-clinical costs. The better number you should be mentioning is billing and insurance related (BIR) expenditures which ranges from 3-15% depending on the setting you're talking about. Note that a fixed fee schedule does not eliminate BIR expenditures, Medicare which works like what you're proposing is ~3.5% for BIR. Canadian provinces are in the 5-10% range. > If hospitals and insurance companies established a standardized (regional) fixed price list for all procedures Should procedures cost the same wherever you go? The quality of care is certainly not the same although everyone meets the minimum standard. e.g. cancer care at Stanford is higher quality than at a neighboring community hospital, should they not be allowed to charge more for it? In any case that's the point of PPOs, the hospital/provider has pre-negotiated/accepted the insurer's fee schedule for the year. It's not negotiated on every visit. > auto-approved everything Does anywhere do this? How do you control for unnecessary/wasteful use of resources? Neither HMOs nor the public Canadian health system auto-approve everything. HMOs like Kaiser appear to "auto-approve" but they control the referral and keep a check on their PCP resource utilization and referral rates. You can't just walk in and demand a spine MRI because you've had back pain for 2 days, if the PCP imaging rates deviate from what is expected they will be audited and/or disciplined by Kaiser.
wrayjustin 3y ago
Not just California, it's common in a few other states and operates in eight states (HI, WA, OR, CA, CO, MD, VA, GA) plus DC.
alex_young 3y ago
Kaiser is great. It really is a comprehensive system that rewards providers based on outcomes. When you have a medical emergency, you’re covered. It’s pretty simple. In PPO systems, you’re always fighting to understand when you are covered, at which hospital, by which doctor, using what machine. Sure there is choice, but how often do you actually have an informed opinion on what expert can best help you with whatever is happening to you in the moment? With an HMO you either go into any hospital in an emergency and it’s covered for emergency care, or you go to one of their hospitals if it’s not an emergency. Very simple. In my experience the level of care is great and everyone is actually trying to make sure you have the best outcome.
- ak217 3y ago
  I've had some pretty awful experiences at Kaiser (including major professionalism issues among staff at a major op) and their facilities in my area are old and overcrowded. Many of their specialists are overbooked and PCPs routinely refuse to provide referrals based on that fact. Their insurance billing is supposed to be a breath of fresh air, and it usually is, but they've managed to screw that up too (in my case, by duplicating a patient record and billing to the inactive one). They are not the worst, but Kaiser has a lot of work to do.
  - alex_young 3y ago
    I’m sure there are issues and areas for improvement, but allow me to explain my experience. I’ve experienced positive results with their child birth system and have had a successful shoulder surgery. The care I and my family have had has been much better than my experience has been in the PPO system. Obviously experiences differ.
  - hedora 3y ago
    Note that Kaiser has many (independent?) divisions. Kaiser Northern California was the highest rated HMO in the US the last time I checked, but that experience doesn’t necessarily extend to other regions.
- mjhay 3y ago
baby 3y ago
My only worry about moving to new york is not having access to Kaiser. It is such an amazing platform honestly. Anyone knows if new york has equivalents?
winrid 3y ago
Kaiser took me in an ambulance for a four hour ride when I broke my ankle and got surgery that night. I paid $250 out of pocket, total. But they wouldn't give me an MRI for my knee pain from the same injury. So I switched to PPO (best plan I could get, anthem 250) which also denied my MRI. Then I went to the ER for a back spasm, got muscle relaxants, $10k bill. Negotiated to $1k. Healthcare in general in the US is a nightmare.
- what-no-tests 3y ago
  Yes - and if you choose not to pay for health insurance, you get fined on your income taxes. Don't pay your income taxes? Go to prison.
  - freddie_mercury 3y ago
    You don't get fined on your income taxes. That hasn't been the case since 2018, which was half a decade ago. What punishment do you think is appropriate for someone who engages in willful tax fraud or evasion?
    - buzer 3y ago
      I guess that depends on state. https://www.coveredca.com/learning-center/tax-penalty-details-and-exemptions/penalty/ https://www.coveredca.com/learning-center/tax-penalty-detail...
      - dragonwriter 3y ago
        The tax enforcement of the federal mandate has not existed since 2018. Four states (and the District of Columbia) have mandates with financial penalties, though.
    - what-no-tests 3y ago
      Rather than tax us, just print the money to pay the medical providers. Failing that, nationalize the "healthcare" industry.
hn_throwaway_99 3y ago
What do you mean by "the majority of HMOs got usurped by HSAs"? I'm only familiar with HSA as a Health Savings Account, and it doesn't make sense to compare it with an HMO in that context. Is there another acronym? Or are you instead referring to an HDHP, a High Deductible Health Plan?
dragonwriter 3y ago
> Kaiser is primarily a California HMO Kaiser is unusual among HMOs, in that it is both an HMO and a provider organization where, for most covered services, Kaiser (as the provider organization) is the only in-network provider for Kaiser (as the HMO).

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.
- haldujai 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 should have said it can be* very annoying, the rigidity isn't an issue for everyone and it really depends on your situation/healthcare needs and what your alternatives are. The rigidity is mostly annoying when you want to see a specialist without having to go through a PCP (although this may not be a bad thing from a health systems perspective) or need advanced care (like cancer) that may be better outside of Kaiser (although again noting that they're still very good from what I've seen) and you want to choose where you get treatment. Or if, like in my situation, you know exactly where you want to get your care and it's not part of Kaiser.
hedora 3y ago
The rigidity and cost savings come from the fact that they don’t have to spend money negotiating with themselves about whether to pay a bill. On average, 33 cents of every insurance dollar in the US goes to paperwork and paid negotiators on the doctor or insurance company side. If hospitals and insurance companies established a standardized (regional) fixed price list for all procedures, auto-approved everything and asked patients to occasionally spot check bills for care they received (for anti-fraud), then all that could be automated, and the balance could go to increasing quality of care without increasing prices. That would make them cost-competitive and roughly as convenient as Kaiser, but also less rigid than Kaiser.
- haldujai 3y ago
  > On average, 33 cents of every insurance dollar in the US goes to paperwork and paid negotiators on the doctor or insurance company side. That's misleading, this is the percentage quoted for overall non-clinical costs. The better number you should be mentioning is billing and insurance related (BIR) expenditures which ranges from 3-15% depending on the setting you're talking about. Note that a fixed fee schedule does not eliminate BIR expenditures, Medicare which works like what you're proposing is ~3.5% for BIR. Canadian provinces are in the 5-10% range. > If hospitals and insurance companies established a standardized (regional) fixed price list for all procedures Should procedures cost the same wherever you go? The quality of care is certainly not the same although everyone meets the minimum standard. e.g. cancer care at Stanford is higher quality than at a neighboring community hospital, should they not be allowed to charge more for it? In any case that's the point of PPOs, the hospital/provider has pre-negotiated/accepted the insurer's fee schedule for the year. It's not negotiated on every visit. > auto-approved everything Does anywhere do this? How do you control for unnecessary/wasteful use of resources? Neither HMOs nor the public Canadian health system auto-approve everything. HMOs like Kaiser appear to "auto-approve" but they control the referral and keep a check on their PCP resource utilization and referral rates. You can't just walk in and demand a spine MRI because you've had back pain for 2 days, if the PCP imaging rates deviate from what is expected they will be audited and/or disciplined by Kaiser.

wrayjustin 3y ago

Not just California, it's common in a few other states and operates in eight states (HI, WA, OR, CA, CO, MD, VA, GA) plus DC.

alex_young 3y ago

Kaiser is great. It really is a comprehensive system that rewards providers based on outcomes. When you have a medical emergency, you’re covered. It’s pretty simple. In PPO systems, you’re always fighting to understand when you are covered, at which hospital, by which doctor, using what machine. Sure there is choice, but how often do you actually have an informed opinion on what expert can best help you with whatever is happening to you in the moment? With an HMO you either go into any hospital in an emergency and it’s covered for emergency care, or you go to one of their hospitals if it’s not an emergency. Very simple. In my experience the level of care is great and everyone is actually trying to make sure you have the best outcome.

ak217 3y ago
I've had some pretty awful experiences at Kaiser (including major professionalism issues among staff at a major op) and their facilities in my area are old and overcrowded. Many of their specialists are overbooked and PCPs routinely refuse to provide referrals based on that fact. Their insurance billing is supposed to be a breath of fresh air, and it usually is, but they've managed to screw that up too (in my case, by duplicating a patient record and billing to the inactive one). They are not the worst, but Kaiser has a lot of work to do.
- alex_young 3y ago
  I’m sure there are issues and areas for improvement, but allow me to explain my experience. I’ve experienced positive results with their child birth system and have had a successful shoulder surgery. The care I and my family have had has been much better than my experience has been in the PPO system. Obviously experiences differ.
- hedora 3y ago
  Note that Kaiser has many (independent?) divisions. Kaiser Northern California was the highest rated HMO in the US the last time I checked, but that experience doesn’t necessarily extend to other regions.
mjhay 3y ago

baby 3y ago

My only worry about moving to new york is not having access to Kaiser. It is such an amazing platform honestly. Anyone knows if new york has equivalents?

winrid 3y ago

Kaiser took me in an ambulance for a four hour ride when I broke my ankle and got surgery that night. I paid $250 out of pocket, total. But they wouldn't give me an MRI for my knee pain from the same injury. So I switched to PPO (best plan I could get, anthem 250) which also denied my MRI. Then I went to the ER for a back spasm, got muscle relaxants, $10k bill. Negotiated to $1k. Healthcare in general in the US is a nightmare.

what-no-tests 3y ago
Yes - and if you choose not to pay for health insurance, you get fined on your income taxes. Don't pay your income taxes? Go to prison.
- freddie_mercury 3y ago
  You don't get fined on your income taxes. That hasn't been the case since 2018, which was half a decade ago. What punishment do you think is appropriate for someone who engages in willful tax fraud or evasion?
  - buzer 3y ago
    I guess that depends on state. https://www.coveredca.com/learning-center/tax-penalty-details-and-exemptions/penalty/ https://www.coveredca.com/learning-center/tax-penalty-detail...
    - dragonwriter 3y ago
      The tax enforcement of the federal mandate has not existed since 2018. Four states (and the District of Columbia) have mandates with financial penalties, though.
  - what-no-tests 3y ago
    Rather than tax us, just print the money to pay the medical providers. Failing that, nationalize the "healthcare" industry.

hn_throwaway_99 3y ago

What do you mean by "the majority of HMOs got usurped by HSAs"? I'm only familiar with HSA as a Health Savings Account, and it doesn't make sense to compare it with an HMO in that context. Is there another acronym? Or are you instead referring to an HDHP, a High Deductible Health Plan?

dragonwriter 3y ago

> Kaiser is primarily a California HMO Kaiser is unusual among HMOs, in that it is both an HMO and a provider organization where, for most covered services, Kaiser (as the provider organization) is the only in-network provider for Kaiser (as the HMO).