[quote=bearishgurl]
First of all, the monthly premiums for low-deductible PPO’s (=<$500) are 30-50% HIGHER than HMO premiums. Second of all, nearly half of "PPO policyholders" have (more-affordable) high-deductible health plans (HDHP's) which have a $3000 - $8000 annual deductible (avg $5000). How much do you think an HDHP is going to pay out-of-pocket for your "chest-pain odyssey??" Do you actually think a person with a deductible of say, $5000, is going to check into an emergency room complaining of "phantom" chest-pain?? No, they may pay a $50 co-pay to see a cardiologist. But the party stops at that first “specialist-office call,” ocrenter!!
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you don’t even know the half of it.
reality is every PPO patient that walks into a physician’s door is viewed as a cash cow. like it or not, this is the reality. this is especially true in regard to the low deductible plans, which one will immediately switch to if there’s ever a chronic disease diagnosed. as for the high deductible plans, yes it does prevent someone from going in to seek care, and this may also cause a real chest pain guy to wait until a heart attack, forcing a 911 call to the ER.
The young and healthy are going to pick the HDHP. That much is true. But their utilization under the HMO system is not high either.
The real juice comes with the population with chronic conditions. Those will not be picking the HDHP. So if 50% of PPO are HDHP, I guarantee you the other 50% picking are chronic disease folks picking low deductible plans.
Let’s take a PPO guy with diabetes, cholesterol problems, and hypertension. This guy is going to be given Lipitor at $140/mo, Januvia at $220/mo, and Benicar/HTZ at $110/mo. True cost for this guy is $470/mo, or $1410/3mo. His copay for the drugs will be $150. So it doesn’t even begin to cover for the meds. His guy will have a cardiologist for his blood pressure, an endocrinologist for his diabetes and cholesterol. Both of which will charge specialist billing to the health plan. (btw, the cardiologist and the endocrinologist will be routinely visited by their prospective double D enhanced drug rep couple of times a week to re-enforce the need to prescribe these meds.)
In the meantime, the same guy at a HMO will get a metformin at $18/mo, a lisinopril/HCTZ at $22/mo, and simvastatin at $28/mo. He will see a HMO internist who will manage all of his medications. $204/3 mo is the total cost of meds, of which this guy pays $90 on his copay, about half of the drugs’ cost. His HMO internist will not be visited by the double D enhanced drug rep at all because he simply will not go to those medications until he tried all other available medications.
The cost spillover from the PPO guy will be adsorbed by everyone else on the PPO plan, and that is why everyone pays.
