Many employers now give employees a choice between health insurance or membership in health maintenance organizations, or HMOs. While the
availability of a choice is welcome, it is not always clear which type of health coverage should be chosen.
What should people keep in mind when selecting health plans?
One starting point might be a careful look at the monthly premium for each option, said Michael Rooney, director of projects at the People`s Medical Society, a nonprofit consumer education and information organization in Emmaus, Pa. ”Consumers should look at the amount of coverage provided by both the insurance and the HMO,” Rooney recommended. ”How complete is each? What physicians` services are covered? What is the hospital coverage and the coverage for catastrophic illnesses?”
He also advised looking at what out-of-pocket expenses are likely to be incurred with each option. He said that most insurance plans have deductibles (an amount paid by the patient before insurance begins) and co-payments (a provision for sharing the expense of a medical service with the insurance company at a pre-ordained rate). ”HMOs usually have fewer deductibles and co- payments than insurance plans.”
”A patient never runs out of benefits in the case of catastrophic illness when the patient belongs to an HMO,” said Carron Maxwell, vice president of administrative services and government at Anchor HMO in Chicago. ”The out-of-pocket expenses are also minimal.”
”The absence of deductibles and out-of-pocket expenses may be attractive to people who need lots of medical attention,” said Frank Nicholson, vice president for health service programs at Blue Cross of Chicago.
Nicholson suggested that people with special needs thoroughly check the specialists available through each HMO option. ”Although HMOs usually have rich benefit packages, with a health insurance plan you are able to go directly to a specialist without waiting for a primary-care physician to refer you, as is the case with HMOs. With insurance you retain unlimited access to specialists. It`s a question of tradeoffs.
”I would not say HMOs are for everybody. It`s a very personal decision.”
Other elements of this decision, Nicholson said, include weighing your choice of doctors, the location of services and your family`s medical needs:
— ”Find out whether any of the doctors you and your family see happen to be affiliated with any of the plans your employer is offering,” Nicholson said. ”If they are, talk to them about it. If they`re not, decide if you want to change. If you don`t mind the change, study the lists of doctors available through each plan, and ask people about the doctors.”
People who join an HMO, however, shouldn`t feel they are stuck with whatever doctor they choose, Maxwell said. ”You are free to change your primary-care physician for any reason. Those reasons can range from wanting either a male or female physician to simply not liking the doctor you have been seeing. The only requirement is calling and saying you want a different doctor. Some people find that difficult. With insurance plans, people can just walk away.”
— ”Location is important,” said Michael Cashman, vice president for corporate resources, Bethany Methodist Corp., Chicago. Cashman said doctors and other medical services should be easy to reach.
”Many consumers need the convenience of one-stop shopping,” Maxwell said. ”They should check where they would have to go for X-rays, for lab work, for gynecological services. Nobody has everything, but larger facilities generally have more things.”
— The needs of each family member must be kept in mind because, Cashman said, ”health needs are primarily a practical consideration, but there are psychological considerations, too. For example, some people may find it difficult to break a relationship with a private physician.”
Cashman said he faced this quandary, but reached a compromise that works well for him. He and his family joined an HMO because it offered the kind of coverage he wanted for his young children, but he chose to maintain a longstanding relationship with an allergist in private practice. ”This way I don`t have to go through all the tests again,” he said. ”But more important, the doctor knows me and my particular case. I use the HMO for my other health needs, but continue seeing my allergist on a fee-for-service basis when I need to.”
People who can afford to see private physicians who know them may wish to continue doing so. ”With certain kinds of chronic illnesses, a patient may be better off with the consistency of care offered by a doctor who knows them well,” said Dr. F.M. Adamji, an internist at the Corporate Health Center of Rush-Presbyterian-St. Luke`s Medical Center, Chicago.
”From my own point of view,” Adamji said, ”the better I know a patient, the better care I can give. Someone with a private physician who can afford the deductibles that go with an insurance policy may do well to stay with that doctor. But that is not to say that relationships cannot be formed with doctors at HMOs.”
People engaged in or in need of long-term psychological counseling should carefully study the coverage offered by all the options open to them. ”It is generally true that HMOs focus on short-term crisis counseling rather than long-term therapy,” Cashman said. ”Many HMOs limit psychotherapy to 20 sessions, with a deductible to be paid for each visit, while insurance plans offer varying options, from 50-50 coverage after a deductible, to full coverage after a deductible, with lifetime and yearly maximums prescribed.”
Cashman also suggested that consumers check the kind of coverage available for substance abuse and alcoholism treatment, if those issues are a family concern.
Consumers should study all options carefully, particularly because health-care plans are constantly changing, said Sandy Moulton, who gathers information on HMOs for the Metropolitan and Chicago Health Care Council. (The council provides services to hospitals and other health-care facilities.)
”People used to say, `When you`ve seen one HMO, you`ve seen them all,`
” Moulton said. ”Now they say, `When you`ve seen one HMO, you`ve seen one HMO.` HMOs follow several different models, and people are always looking around to see what sells the best.”
Maxwell said that insurance plans also have changed in recent years.
”Everybody is concerned with cost containment,” she said.
Although choosing between insurance and an HMO plan may be complicated, those making the choice need not feel they must go it alone. ”Most employers offer side-by-side descriptions of each plan they offer,” Cashman said. ”And marketing directors for each plan will be available for questions” during the yearly open-enrollment period.
”Ask questions. Go to the facility you`re interested in to get a good perspective on what is available,” Nicholson suggested.
