[ocrenter]

The congresswoman talked about the Palin Crosshairs at 2:00 during the election.

here’s the map:

[img_assist|nid=14445|title=targets across the US of A|desc=|link=node|align=center|width=426|height=310]

[ocrenter]

The congresswoman talked about the Palin Crosshairs at 2:00 during the election.

here’s the map:

[img_assist|nid=14445|title=targets across the US of A|desc=|link=node|align=center|width=426|height=310]

[ocrenter]

[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!!
[/quote]

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.

[ocrenter]

[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!!
[/quote]

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.

[ocrenter]

[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!!
[/quote]

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.

[ocrenter]

[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!!
[/quote]

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.

[ocrenter]

[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!!
[/quote]

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.

[ocrenter]

[quote=bearishgurl]

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.

[ocrenter]

[quote=bearishgurl]

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.

[ocrenter]

[quote=bearishgurl]

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.

[ocrenter]

[quote=bearishgurl]

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.

[ocrenter]

[quote=bearishgurl]

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.

[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.

[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.

[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.

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