HMO versus PPO (which should I choose?)

[ApatheticNoMore]

I don't expect an answer just some advice making the decision. I have always gone with the PPO because the price of it was never that much more than the HMO. I have no experience whatever dealing with HMOs (only PPOs). When the price of the PPO was $70 a month more than the cheapest HMO, choosing it seemed a no brainer and the difference has never been more than that.

Now I seem to be working in a company that heavily heavily biases toward the HMO choice. The HMO is free, the PPO is $280 a month! The price of health insurance of course went up this year. The company ate the entire of the HMO price increase, but not for the PPO. And $280 a month is really IMO a ripoff. I think there is probably a good chance I could get as good a rate as an individual buying insurance with no employer subsidy at all (mid 30s, no preexistings). It really is that bad. I don't really care about a higher deductable in such a case. I'm more than willing to take my chance with a somewhat higher deductable, I can afford it in an emergency. Ok but I probably am going to take employer provided insurance even though it's a rip off. So do I finally make the shift to the HMO? Something I have always resisted. Because $280 a month! I could try to get a HMO provider who is part of a medical group so that it would be less trouble getting a referral if I needed one. Or should I just bite the bullet with the $280? I won't starve due to medical preimiums :). I can afford it if I have to.

All my decisions on medical insurance have always been driven by what would happen if I really needed it. I have barely cost anything to my medical insurance ever. I don't go around seeing specialists for the fun of it (though I have seen them ocassionally). But I know sickness can happen to anyone and so if I came down with a horrible disease I wanted to make sure I had good insurance. Can I really trust an HMO for that? Or should I just do the safer PPO, as I have always done?

[sweetana3]

With us it was always a year by year decision. I loved my local HMO. No paperwork, no copays, and so easy to deal with. But, since it was smaller, it had difficulty qualifying to belong to the federal program. I would be the first one in line for something like Kaiser in California. But I dont necessarily need my own personal family doctor. I am well aware of my own issues and keep myself knowledgable. I dont take antibiotics or go to the doctor all the time.

If you have the option, try the HMO for one year.

[Rosemary]

My worst health care experiences were with an HMO in Arizona in 1994. BUT that was a long time ago and all HMOs are different. I had excellent experiences with an HMO here in Minnesota in 2004.
I think the best thing to do would be to talk to people who have that HMO, or go see the clinic in action.

[herisf]

If I could use my primary care provider, I would use my company's HMO in a heartbeat. It's way cheaper than the PPO that I do choose and I know the providers are decent. But since all of the HMO providers are over an hour away, I choose to have my primary care provider in town and utilize as many docs close by as I can (2 of my specialists are an hour away in separate directions, but I go to see them just once a year). I just found out that the HMO dental plan has a provider with Saturday hours once a month, so I'll probably switch next year. Since I only go once or twice a year to the dentist, traveling an hour away is OK.

If you can find a primary care provider who you are happy with, and your specialist providers are in the network, personally I would switch. But for me it all comes down to the primary provider - mine is a PA (physician's assistant) who works under the licensure of a physician. My PA is fabulous and I really trust her (and I'm an RN), so your primary doesn't have to be an MD or DO. I've also had a Nurse Pracititioner as my primary care - I find that PAs and NPs listen to the patient better.

[Bastelmutti]

We had a PPO for years and paid a premium for it because of a fear of HMOs due to bad experiences in the family. In retrospect, we should have gone with the HMO, which is what we have now. Sure, you do have to get referrals, but it's not that bad. The caveats in our case are that we have an excellent network here - if you don't you may end up driving very long distances for specialists - & the PPO option is much more expensive, which was the main reason we switched. But we've been happy with it so far (this is our 4th year). BTW, this is BCBS.

[Jemima]

I've always stuck with PPO's, largely because my personal doctor is thirteen miles away and the hospital with which she is affiliated is even farther. I much prefer the local hospital, less than five miles away, which has staff who appear to be caring and the hospital itself seems to be well-managed overall. The hospital where my doctor is affiliated is old and beat up, and the corridors are a maze. The few times I went there it left a bad impression. They also send bills that are impossible to understand and are quick to sic a collection agency on late payers. I was really insulted to receive a letter from a collection agency recently. I didn't pay it because I thought they had misposted my co-pay, which has happened before. The bill was unintelligible. Oh, wait, I'm getting off into a rant....

[HumboldtGurl]

I've always used PPOs, but my parents have always been members of a huge HMO so my experience comes from watching them deal with their doctors. Take it for what it's worth.

When my Dad was very, very sick, the HMO came through and despite a month in the hospital, the illness didn't bankrupt him. However, we had to fight like crazy to get the tests and overall level of care we wanted him to have.

It seems like every time my elderly Mom or Dad has an illness, we really have to be vocal about getting good care for them. I think that's the biggest difference between the two: With my PPO insurance, doctors will order tests at the drop of a hat. With my parent's HMO care, you won't get really good care unless you know how to be a good advocate.

[ApatheticNoMore]

HumboltGurl: was the HMO Kaiser? I don't know whether or not other HMOs are really better or not, I just know Kaiser has a horrible reputation among just about everyone. My plan is NOT through Kaiser though. (I have however been warned about maybe having to advocate to see specialist, which since I'm not naturally good at, I'm pretty sure I wouldn't be good at if I was sick).

[Wildflower]

So far I have been happy with my HMO. Of course, I haven't experienced any serious illness or surgeries. Something like that might change my positive opinion. So far being in an HMO has saved me alot of money though...

[Bastelmutti]

For what it's worth, it must matter greatly, which particular HMO you are in because our docs don't hesitate to recommend blood tests and other tests, specialists, etc. when necessary.

[HumboldtGurl]

HumboltGurl: was the HMO Kaiser?

Hah! How did you guess?

Yes, they've been members for years. I have to say I have see some changes for the better now for example, doctors are prescribing physical therapy and rehab over prescription drugs when my parents complain about aches and pains.

But, I also know that they gave my Mom a total runaround last year when she really needed a MRI for some awful back pain, and the docs did all they could to avoid it, while meanwhile my Mom was in agony.

[treehugger]

Everyone seems to have really different experiences between different PPO and HMOs, and even within the same organizations, which is why it's hard to give advice to someone else about which plan to choose. Too many variables.

Take Kaiser, for instance. Mine and my husband's lifetime personal experiences with Kaiser are very positive. Kaiser absolutely saved my husband's life (and saved us tons of money and hassle) when dealing with kidney disease, dialysis, transplant, and aftermath. It's a non-profit, and there is a genuine focus on prevention and treating the whole patient, rather than just medicating symptoms.

But again, I realize that this depends greatly on local services and individual doctors. For us personally, being able to stay on Kaiser influences a lot of our decisions, like jobs and where to live.

Good luck finding the right plan for you!

Kara

[ApatheticNoMore]

Beginning to seem more like a dice toss (as in it's a non-rational decision - just pick heads or tails), only with lots of money and health involved. :|(

[Spartana]

My sister has Kaiser HMO and is having a huge problem getting them to do anything. Back in Oct. she had bad pain, swelling, etc.. in her knee. She's an uber athlete so figured she just needed to rest it. She did and it didn't get any better. Went to her Dr. and he basicly gave her the run around. Wouldn't do an x-Ray, then finally did - which she had to wait weeks for. Showed nothing. Then they wouldn't do an MRI but, after my sister's endless badgering, finally scheduled one but she had to wait 6 weeks for it. the MRI came back showing an "undetermined lesion" saying she needed a contrast MRI. She had to wait another 6 plus weeks to get that. That came back saying it was either this very rare vein thing (synovial hemangioma) or a rare type of cancer (synovial sarcoma) and that she should be seen by a specialist. So her Dr. put in for her to see a specialist (orthopedic oncologist). He is 75 miles away and the only one that Kaiser has for the entire southwestern portion of the USA - ONLY ONE!! So now, she's had to wait several more weeks before she can see him and then, depending on what he deterimes to it is, maybe several more weeks or even months before she can get surgury (needs it in either case). So besides living for months now with extreme pain and possible cancer, she has to continue living like that because Kaiser is soooooo $#&^*#@ slow, understaffed, and denies patients services when they clearly need it. So had she kept with a PPO (what she had before she changed to a cheaper HMO when she knew she'd be getting laid off) she would have been able to have everything taken care of back in Oct. Unfortunately, now that she has a pre-existing condition and is unemployed, she will not be able to change health insurers even if she wanted to.

So, fwiw, I don't like HMO's except for the fact that you know 100% that you will never have to pay for anything other than your co-payments. When I had a PPO, same with sis, and I went to the Dr. or had things done, I ALWAYS received bills for that treatment even though my insurer was suppose to pay for it. Sometimes it takes months - even years - to get those bill paid for my the insurance co. and even then you still receive bills from the places you had your treatment. Can go to collections, etc... even if you don't really own anything. So it's that trade-off: good service with lots of providers with a PPO but a headache payment-wise, vs. terrible service for anything other then basic stuff at an HMO (at least Kaiser) but no hassle with billing. I use the VA Healthcare System which is structured like an HMO with a primary care provider who has to approve any treatment. But my experience has been great and I have always been seen pretty quickly by a specialist after my primary care provider puts in for it. If the VA doesn't have the man power or resources to take you fairly quickly, they will send you to a private Dr. for treatment/testing and pay for it. heck, they even pay your gas mileage to the place!

[HumboldtGurl]

Is Kaiser in multiple states? If so I wonder if there's a difference in the treatment one gets in CA versus another location? Does someone in another state get better treatment because costs are lower there? Hmmm.

My Mom is in CA. Where is your sister, Spartana?

[Spartana]

Is Kaiser in multiple states? If so I wonder if there's a difference in the treatment one gets in CA versus another location? Does someone in another state get better treatment because costs are lower there? Hmmm.

My Mom is in CA. Where is your sister, Spartana?

My sister is also in Calif - southern Calif in "The O.C.". I don't know if Kaiser is elsewhere or not but I know she said even in Calif they are fragmented and that if she's in a certain part of the county (she's in coastal South O.C.) she can't just use another Kaiser in another part of the county (like inland). But she's very unhappy with them. After months of the run around she had an appointment scheduled for next week. Yesterday they cancelled it and put it for mid-March instead. This seesm to be par for the course for Kaiser. Not sure if that's other people's experience with other HMO's though. Maybe they have had better experiences.

My own personal PPO story for the OP is this: After I quit my job I carried my old work health insurance (a PPO) via Cobra for awhile. I hurt my knee playing volleyball. Looked in the book to find an orthopedic sports med person, called and got an appt for a few days later. He looked at my knee, and that day I got both an x-ray and MRI. He scheduled my surgury for 5 days later in the hospital. Before getting anything done I called my PPO to make sure he was still in their network and that all my costs - surgury, hospital stay, aftercare, etc... - would be covered. They said yes to everything and told me how much my co=pays would be (not much). So got everything done and then the bills started to arrive. From the hospital, the anestigiologist, the physical therapist, and even a second sports medicine surgueon who assisted and it was over $25K just for him. I spent months dealing with my insurance Co. and the various medical entities to have them pay the bills and get off my back. Eventually everything worked out except the 2nd surgeon. Because he wasn't pre-approved by the insurance co., they refused to pay and I was liable for that $25K plus. I didn't even know he would be there. I never met him, spoke to him and was never told that he would be part of the surgury team. But even though I was totally unaware of him being there, the insurance co still refused to pay. I spent many more months getting that taken out and it was only resolved because the surgeons decided to split their fees.

This is apparently common with PPO's. I once had to pay $1500 for something I had done that they denied even though they had first said it was approved. It's crazy! So if I had an HMO, this kind of stuff never happens because no one will see you unles you are pre-approved. However, as seems to be the case with HMOs, you may be waiting for Kingdom Come before you are even seen, let alone treated. So I guess it's a "Your Money Or Your Life" question - would you rather possibly lose your money, or your life.

[frugalone]

Gee, I never had any issues with the HMO we had for years. I have heard these kinds of horror stories before, but maybe we were just lucky it never happened to us?