huge topic:Americans keep getting fatter

[ocrenter]

[quote=bearishgurl]
Another hint: I’ve had co-workers and friends who have died due to misdiagnosis and/or too many hoops to jump through for care and not enough time on (or off) the books to play the waiting game. All were with “Kaiser” HMO.[/quote]

While I value your anecdotal comments, we have to put things into context.

One big issue is PPOs do not have direct control over their physicians. So if there is a bad outcome, or if there is a problem such as misdiagnosis, the word on the street would be “Dr. So-and-so did this to me! Dr. So-and-so is a bad doctor.” The word on the street would not be Anetna is a BAD insurance because it contracted with Dr. So-and-so.

But Kaiser is a HMO that hire their physicians. Therefore, if there is a bad outcome, then we have “Kaiser did this to me! Kaiser is a BAD HMO.”

So let’s think this through in real numbers.

Now Kaiser is the 800 lb gorilla in southern Cal, so out of say 12 million souls in SoCal, 1/4 are Kaiser members.

So that’s about 3 million.

Say Kaiser does a good job 95% of the time. That still leaves 150,000 anecdotal complaints out there. And these 150,000 will repeat that bad experience time and time again. And when these 150,000 report the events, they will not name this specific doctor that errored, it would be a blanket Kaiser problem.

Now let’s go back to Aetna. Let’s say in SoCal it has 1 million members. And its contracted providers does a good job also 95% of the time. Just by the numbers, we are now looking at 50,000 people going around complainting about their mistreatment. But because of the nature of the PPO structure, that 50,000 will likely blame the specific doctors that errored, not Aetna in general. Because there is no such thing as an “Aetna physician.”

There is always a personal story behind each and every anecdotal story. And they are important in their own ways. But we need to be careful when we try to apply anecdotal stories into the context of good vs bad care.

Overall, by numbers, per the US News and World Report, Kaiser SoCal scored a 84.1 out of 100, landing it #71 out of 239 health plans ranked.

But Aetna, and remember this is the same insurance giant that tried to raise rate by over 30% last year in Cali, scored 77.8 and landed #208 out of 239 health plans ranked.

[UCGal]

Closed network systems like Kaiser and open networks systems like Aetna, Pacificare, etc are all limited by the primary care doctor you choose.

Kaiser lets you change your primary doctor. If you think your doctor is misdiagnosing you or a family member or not pursuing an appropriate course, change doctors, go to urgent care (if appropriate) etc. Most people are sheep when it comes to medical care… and doctor’s are human.

You have to advocate for your care with ANY doctor or insurance. For example, I have a paranoia about my cancer risks. (I’ve mentioned previously – 3 of 4 grandparents had cancer, dad had 2 separate malignancies, mom had ovarian, my brother had 2 separate malignancies, I have 3 cousins and 2 have had cancer). But I have a small family so I don’t meet the statistical requirements to fall into high risk. (Not enough aunts/cousins to sample from.) But – I talked Kaiser into increasing my mammograms, doing annual u/s’s to look for ovarian cancer, and doing ca125 tests to see if it ever goes up. These are all fairly low cost, but not typical. I had to ask for them, but when I laid out my case, it was agreed to immediately.

ocr’s point about people blaming a private practice doctor vs a system is accurate. I’ve heard similar complaints about the VA system. My father in law gets his care at the VA and I have to say – it’s a LOT better than the care he was getting through a doctor under blue cross/blue shield. But he’s got people advocating for him here. My husband and I go with them to his appointments, ask questions, do research.

[UCGal]

Closed network systems like Kaiser and open networks systems like Aetna, Pacificare, etc are all limited by the primary care doctor you choose.

Kaiser lets you change your primary doctor. If you think your doctor is misdiagnosing you or a family member or not pursuing an appropriate course, change doctors, go to urgent care (if appropriate) etc. Most people are sheep when it comes to medical care… and doctor’s are human.

You have to advocate for your care with ANY doctor or insurance. For example, I have a paranoia about my cancer risks. (I’ve mentioned previously – 3 of 4 grandparents had cancer, dad had 2 separate malignancies, mom had ovarian, my brother had 2 separate malignancies, I have 3 cousins and 2 have had cancer). But I have a small family so I don’t meet the statistical requirements to fall into high risk. (Not enough aunts/cousins to sample from.) But – I talked Kaiser into increasing my mammograms, doing annual u/s’s to look for ovarian cancer, and doing ca125 tests to see if it ever goes up. These are all fairly low cost, but not typical. I had to ask for them, but when I laid out my case, it was agreed to immediately.

ocr’s point about people blaming a private practice doctor vs a system is accurate. I’ve heard similar complaints about the VA system. My father in law gets his care at the VA and I have to say – it’s a LOT better than the care he was getting through a doctor under blue cross/blue shield. But he’s got people advocating for him here. My husband and I go with them to his appointments, ask questions, do research.

[UCGal]

Closed network systems like Kaiser and open networks systems like Aetna, Pacificare, etc are all limited by the primary care doctor you choose.

Kaiser lets you change your primary doctor. If you think your doctor is misdiagnosing you or a family member or not pursuing an appropriate course, change doctors, go to urgent care (if appropriate) etc. Most people are sheep when it comes to medical care… and doctor’s are human.

You have to advocate for your care with ANY doctor or insurance. For example, I have a paranoia about my cancer risks. (I’ve mentioned previously – 3 of 4 grandparents had cancer, dad had 2 separate malignancies, mom had ovarian, my brother had 2 separate malignancies, I have 3 cousins and 2 have had cancer). But I have a small family so I don’t meet the statistical requirements to fall into high risk. (Not enough aunts/cousins to sample from.) But – I talked Kaiser into increasing my mammograms, doing annual u/s’s to look for ovarian cancer, and doing ca125 tests to see if it ever goes up. These are all fairly low cost, but not typical. I had to ask for them, but when I laid out my case, it was agreed to immediately.

ocr’s point about people blaming a private practice doctor vs a system is accurate. I’ve heard similar complaints about the VA system. My father in law gets his care at the VA and I have to say – it’s a LOT better than the care he was getting through a doctor under blue cross/blue shield. But he’s got people advocating for him here. My husband and I go with them to his appointments, ask questions, do research.

[UCGal]

Closed network systems like Kaiser and open networks systems like Aetna, Pacificare, etc are all limited by the primary care doctor you choose.

Kaiser lets you change your primary doctor. If you think your doctor is misdiagnosing you or a family member or not pursuing an appropriate course, change doctors, go to urgent care (if appropriate) etc. Most people are sheep when it comes to medical care… and doctor’s are human.

You have to advocate for your care with ANY doctor or insurance. For example, I have a paranoia about my cancer risks. (I’ve mentioned previously – 3 of 4 grandparents had cancer, dad had 2 separate malignancies, mom had ovarian, my brother had 2 separate malignancies, I have 3 cousins and 2 have had cancer). But I have a small family so I don’t meet the statistical requirements to fall into high risk. (Not enough aunts/cousins to sample from.) But – I talked Kaiser into increasing my mammograms, doing annual u/s’s to look for ovarian cancer, and doing ca125 tests to see if it ever goes up. These are all fairly low cost, but not typical. I had to ask for them, but when I laid out my case, it was agreed to immediately.

ocr’s point about people blaming a private practice doctor vs a system is accurate. I’ve heard similar complaints about the VA system. My father in law gets his care at the VA and I have to say – it’s a LOT better than the care he was getting through a doctor under blue cross/blue shield. But he’s got people advocating for him here. My husband and I go with them to his appointments, ask questions, do research.

[UCGal]

Closed network systems like Kaiser and open networks systems like Aetna, Pacificare, etc are all limited by the primary care doctor you choose.

Kaiser lets you change your primary doctor. If you think your doctor is misdiagnosing you or a family member or not pursuing an appropriate course, change doctors, go to urgent care (if appropriate) etc. Most people are sheep when it comes to medical care… and doctor’s are human.

You have to advocate for your care with ANY doctor or insurance. For example, I have a paranoia about my cancer risks. (I’ve mentioned previously – 3 of 4 grandparents had cancer, dad had 2 separate malignancies, mom had ovarian, my brother had 2 separate malignancies, I have 3 cousins and 2 have had cancer). But I have a small family so I don’t meet the statistical requirements to fall into high risk. (Not enough aunts/cousins to sample from.) But – I talked Kaiser into increasing my mammograms, doing annual u/s’s to look for ovarian cancer, and doing ca125 tests to see if it ever goes up. These are all fairly low cost, but not typical. I had to ask for them, but when I laid out my case, it was agreed to immediately.

ocr’s point about people blaming a private practice doctor vs a system is accurate. I’ve heard similar complaints about the VA system. My father in law gets his care at the VA and I have to say – it’s a LOT better than the care he was getting through a doctor under blue cross/blue shield. But he’s got people advocating for him here. My husband and I go with them to his appointments, ask questions, do research.

[bearishgurl]

[quote=ocrenter] . . . But Kaiser is a HMO that hire their physicians. Therefore, if there is a bad outcome, then we have “Kaiser did this to me! Kaiser is a BAD HMO.” . . . [/quote]

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.

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.

I have never had an HMO (even when given a choice thru an employer, I chose the PPO or HDHP) because I don’t want to be held back from care by an HMO “gatekeeper.” It is TOTALLY WORTH IT to have a PPO or indemnity plan, even if it costs more out-of-pocket, IMO.

[bearishgurl]

[quote=ocrenter] . . . But Kaiser is a HMO that hire their physicians. Therefore, if there is a bad outcome, then we have “Kaiser did this to me! Kaiser is a BAD HMO.” . . . [/quote]

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.

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.

I have never had an HMO (even when given a choice thru an employer, I chose the PPO or HDHP) because I don’t want to be held back from care by an HMO “gatekeeper.” It is TOTALLY WORTH IT to have a PPO or indemnity plan, even if it costs more out-of-pocket, IMO.

[bearishgurl]

[quote=ocrenter] . . . But Kaiser is a HMO that hire their physicians. Therefore, if there is a bad outcome, then we have “Kaiser did this to me! Kaiser is a BAD HMO.” . . . [/quote]

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.

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.

I have never had an HMO (even when given a choice thru an employer, I chose the PPO or HDHP) because I don’t want to be held back from care by an HMO “gatekeeper.” It is TOTALLY WORTH IT to have a PPO or indemnity plan, even if it costs more out-of-pocket, IMO.

[bearishgurl]

[quote=ocrenter] . . . But Kaiser is a HMO that hire their physicians. Therefore, if there is a bad outcome, then we have “Kaiser did this to me! Kaiser is a BAD HMO.” . . . [/quote]

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.

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.

I have never had an HMO (even when given a choice thru an employer, I chose the PPO or HDHP) because I don’t want to be held back from care by an HMO “gatekeeper.” It is TOTALLY WORTH IT to have a PPO or indemnity plan, even if it costs more out-of-pocket, IMO.

[bearishgurl]

[quote=ocrenter] . . . But Kaiser is a HMO that hire their physicians. Therefore, if there is a bad outcome, then we have “Kaiser did this to me! Kaiser is a BAD HMO.” . . . [/quote]

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.

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.

I have never had an HMO (even when given a choice thru an employer, I chose the PPO or HDHP) because I don’t want to be held back from care by an HMO “gatekeeper.” It is TOTALLY WORTH IT to have a PPO or indemnity plan, even if it costs more out-of-pocket, IMO.

[all]

[quote=sdrealtor]
My friend hasnt worked in the US for over a decade and his perspective is not to think our model is best. He is in the trenches and sees what goes on. Hope you enjoyed the Thai information also. He said they do a number of things very well there. The biggest difference he emphasized about US physicians over the Thai (and many other countries) physicians is the ability to think outside the box to find solutions when things arent exactly as they were taught. In Thailand if they dont see something fitting exactly in their frame of reference they refer you to someone else and this can go on and on. His point was that the concept of American ingenuity is very real.[/quote]

This might add some context. Where I went to school medical schools were not attracting the top talent. The most prestigious were electrical engineering and mathematics and almost all of the top achievers were aiming at those. Mechanical and civil engineering and medical schools were seen as kind of a second tier schools for hard working students who lacked the creativity and problem solving skills of the top performers.

Law, economics and political sciences were the bottom. You go there if you fail at everything else.

Consequently, most of the physicians were not outside the box thinkers. Here you get more of that, but they float up and unless you are a professional athlete or have access to top hospitals you won’t be treated by a top performer.

[all]

[quote=sdrealtor]
My friend hasnt worked in the US for over a decade and his perspective is not to think our model is best. He is in the trenches and sees what goes on. Hope you enjoyed the Thai information also. He said they do a number of things very well there. The biggest difference he emphasized about US physicians over the Thai (and many other countries) physicians is the ability to think outside the box to find solutions when things arent exactly as they were taught. In Thailand if they dont see something fitting exactly in their frame of reference they refer you to someone else and this can go on and on. His point was that the concept of American ingenuity is very real.[/quote]

This might add some context. Where I went to school medical schools were not attracting the top talent. The most prestigious were electrical engineering and mathematics and almost all of the top achievers were aiming at those. Mechanical and civil engineering and medical schools were seen as kind of a second tier schools for hard working students who lacked the creativity and problem solving skills of the top performers.

Law, economics and political sciences were the bottom. You go there if you fail at everything else.

Consequently, most of the physicians were not outside the box thinkers. Here you get more of that, but they float up and unless you are a professional athlete or have access to top hospitals you won’t be treated by a top performer.

[all]

[quote=sdrealtor]
My friend hasnt worked in the US for over a decade and his perspective is not to think our model is best. He is in the trenches and sees what goes on. Hope you enjoyed the Thai information also. He said they do a number of things very well there. The biggest difference he emphasized about US physicians over the Thai (and many other countries) physicians is the ability to think outside the box to find solutions when things arent exactly as they were taught. In Thailand if they dont see something fitting exactly in their frame of reference they refer you to someone else and this can go on and on. His point was that the concept of American ingenuity is very real.[/quote]

This might add some context. Where I went to school medical schools were not attracting the top talent. The most prestigious were electrical engineering and mathematics and almost all of the top achievers were aiming at those. Mechanical and civil engineering and medical schools were seen as kind of a second tier schools for hard working students who lacked the creativity and problem solving skills of the top performers.

Law, economics and political sciences were the bottom. You go there if you fail at everything else.

Consequently, most of the physicians were not outside the box thinkers. Here you get more of that, but they float up and unless you are a professional athlete or have access to top hospitals you won’t be treated by a top performer.

[all]

[quote=sdrealtor]
My friend hasnt worked in the US for over a decade and his perspective is not to think our model is best. He is in the trenches and sees what goes on. Hope you enjoyed the Thai information also. He said they do a number of things very well there. The biggest difference he emphasized about US physicians over the Thai (and many other countries) physicians is the ability to think outside the box to find solutions when things arent exactly as they were taught. In Thailand if they dont see something fitting exactly in their frame of reference they refer you to someone else and this can go on and on. His point was that the concept of American ingenuity is very real.[/quote]

This might add some context. Where I went to school medical schools were not attracting the top talent. The most prestigious were electrical engineering and mathematics and almost all of the top achievers were aiming at those. Mechanical and civil engineering and medical schools were seen as kind of a second tier schools for hard working students who lacked the creativity and problem solving skills of the top performers.

Law, economics and political sciences were the bottom. You go there if you fail at everything else.

Consequently, most of the physicians were not outside the box thinkers. Here you get more of that, but they float up and unless you are a professional athlete or have access to top hospitals you won’t be treated by a top performer.

[Author]

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