Making Sense of the Health Insurance Debate – Part III

Today we continue our discussion of health insurance and its effects on health care in our country. If you missed parts one and two, please go back and read them in order to help make more sense out of today’s blog.

Last week we talked about how managed care crept into the healthcare equation and some of the damage and potential damage resulting from that. The next stage in this evolutionary process was the introduction of HMOs and PPOs. Although by now most of us know what those two entities are, we’ll start with a layman’s definition.

An HMO (Health Maintenance Organization) is a network of medical providers—doctors, hospitals, labs, etc.—either set up by or approved by an insurance company. Because of the financial strength of the insurance company, particularly if it’s a large one, in its dealings with this network it can negotiate relatively favorable prices for the services provided.

Prices are further held down by having a gatekeeper in the form of a primary care physician. This doctor becomes our personal family doctor. Not necessarily the doctor we’ve been seeing through the years, but one either appointed by the insurance company or else selected by us from a list the insurance company provides us with.

The term gatekeeper has come into use because we have to “go through the gate” to get anywhere. We must see this primary care physician first, regardless of the nature of our problem, and get a referral from him before we can see a specialist, get a test done or anything else involving our health.

Remember, this doctor has been appointed by our insurance company to hold down on costs by not allowing us access to medical care unless he thinks it’s really necessary. There are laws and regulations designed to protect us against undue influence from the insurance company to keep us from care, but just think about it for a moment. If this doctor’s bread is buttered by our insurance company, won’t there be at least some level of temptation for him or her to deny us a referral if there is any room for doubt.

The PPO (Preferred Provider Organization) is less restrictive than the HMO, at least in theory. With a PPO, we’re given a list of network-approved providers, but we’re free to go outside the network if we prefer.

Trouble is, when we do, the benefits aren’t nearly so good. We have bigger copays, usually a coinsurance percentage and frequently dollar limits on what the insurance company will pay. Usually the extra cost out of our pockets is enough that we decide to stay in the network anyhow. At least we don’t have to go to a gatekeeper to get a referral before we can seek further treatment.

The most obvious disadvantage to these HMOs and PPOs is that every time the list of providers changes, we have to change doctors. It’s rare nowadays to find someone who has been able to remain with the same doctor for 20 or 30 years. Many people I’ve talked to have been forced to change doctors every few years—and sometimes every year.

The problems of dealing with these networks are in addition to the problems of managed care discussed last week. We’ve still got an insurance company sticking its nose into our relationships with our doctors and saying what treatment they can and can’t give.

The change from health insurance as it was originally designed and what we have today has encouraged higher prices as the patient’s responsibility for the bills has become a smaller and smaller percentage. Why do we care what the cost is? Some insurance company is going to pay for it.

At the same time, it has caused real problems in many doctors’ attitudes about their patients as well as lowered patient confidence in the doctors, because the doctor-patient relationship has been cratered by intrusion from the insurance companies.

Next week, we’ll discuss the government’s answer to the problem.

Ø How good do you think your medical treatment is if you never have time to get to know your doctor and for him or her to get to know you if you have to change evry two ro three years?

Ø When are you most concerned about holding down costs by refraining from excessive use of the system—when you’re paying the bills, or a substantial part of them, out of your own pocket, or when some third party is paying the freight?


About David N. Walker

David N. Walker is a Christian husband, father and grandfather, a grounded pilot and a near-scratch golfer who had to give up the game because of shoulder problems. A graduate of Duke University, he spent 42 years in the health insurance industry, during which time he traveled much of the United States. He started writing about 20 years ago and has been a member and leader in several writers' groups. Christianity 101: The Simplified Christian Life, the devotional Heaven Sent and the novella series, Fancy, are now available in paperback and in Kindle and Nook formats, as well as through Smashwords and Kobo. See information about both of these by clicking "Books" above.
This entry was posted in Archives. Bookmark the permalink.