ocrenter, you hit upon the problem right there. I guess I should have intimated that the business model of the typical HMO (such as Kaiser) was to blame for patient-runaround.[/quote]
but the PPO business model will bankrupt us.
[quote=bearishgurl]
If I want to see a particular specialist, I can just make an appt with him/her (in or out of “network”). If I am a cancer patient and want to participate in a clinical trial at the MD Anderson Cancer Center in TX or a specialized treatment program that is only being offered at the Mayo Clinic in MN, I can do that and Aetna will cooperate acc to the terms of my coverage, no problem. If the providers happen to be “out of network,” I’ll just have more co-insurance responsibility. HOWEVER, there are many thousands of Aetna providers across the nation. [/quote]
The freedom of choice CREATES a huge cost burden for the society at large.
For example, let’s assume someone is having chest pain. In an HMO world that someone is seen by the primary. The primary physician makes the determination whether this is cardiac chest pain that requires further evaluation or whether this is say… heart burn. Let’s say 10 people that show up with chest pain all go to the primary, perhaps only 3 really sound likely to be heart, and perhaps only 1 really has a heart condition. But point is 3 gets referred to cardiology and work up is focused on the 3 that have symptoms and family history and risk factors that warrant further evaluation.
But in a PPO world the 10 people with chest pain will ALL go to the cardiologist. And because the cardiologist owns a treadmill and he can bill for it, ALL 10 will get the stress treadmill. And because the stress treadmill creates a lot of false positives, now we got 5 positive treadmill studies that the cardiologist will REFER to his buddy who owns a nuclear medicine suite who will then get to do 5 nuclear medicine stress test, of the 1 really has the heart issue, that person then gets the angiogram.
So now we all end up paying for 10 cardiologist bills, 10 treadmills, and 5 nuc med stress tests plus the one angiogram under the PPO system. But in the HMO plan we pay for 3 treadmills and one angiogram.
So granted you get what you think you want, but ultimately everyone loses.
