Come for the politics, stay for the snark.

Prediction: the gop will rethink its strategy of boycotting future committees.

Hey Washington Post, “Democracy Dies in Darkness” was supposed to be a warning, not a mission statement.

Stand up, dammit!

Sometimes the world just tells you your cat is here.

The “burn-it-down” people are good with that until they become part of the kindling.

Rupert, come get your orange boy, you petrified old dinosaur turd.

Republicans are the party of chaos and catastrophe.

Too often we hand the biggest microphones to the cynics and the critics who delight in declaring failure.

The National Guard is not Batman.

Every reporter and pundit should have to declare if they ever vacationed with a billionaire.

The most dangerous place for a black man in America is in a white man’s imagination.

We are builders in a constant struggle with destroyers. keep building.

The republican caucus is covering themselves with something, and it is not glory.

The willow is too close to the house.

It’s easy to sit in safety and prescribe what other people should be doing.

I see no possible difficulties whatsoever with this fool-proof plan.

Fight them, without becoming them!

She burned that motherfucker down, and I am so here for it. Thank you, Caroline Kennedy.

They are lying in pursuit of an agenda.

I like political parties that aren’t owned by foreign adversaries.

We still have time to mess this up!

The republican speaker is a slippery little devil.

“In this country American means white. everybody else has to hyphenate.”

Disappointing to see gov. newsom with his finger to the wind.

You are here: Home / Anderson On Health Insurance / Texas PPO to HMO conversion

Texas PPO to HMO conversion

by | 61 Comments

This post is in: 

From Charles Gaba:

we won’t be offering our Blue Choice PPO insurance plans for our under 65 block of business going forward…..
Currently, we have about 367,000 individual Texas members who will have their PPO plan discontinued in 2016….
Our Blue Advantage® HMO network will remain. We are working to expand the numbers and reach of providers participating in that network.
We only had the first full year of ACA claims data for analysis this year, for 2014 claims. In the individual market segment in 2014, BCBSTX paid out more than $400 million more in claims than it collected in premiums. Losses that high are unsustainable, and we have adjusted our offerings – as many insurers have – to be sustainable in the new market reality.
Why is BCBSTX discontinuing the Blue Choice PPO?
For the past two years, BCBSTX has been the only health insurer offering an individual PPO plan in all Texas markets. BCBSTX found that the PPO is not sustainable at an affordable price due to anti-selection. BCBSTX will continue to offer other plan options in all 254 counties, on and off the Marketplace.

Charles asks a good question

The highlighted question above is the one which I had the most trouble understanding: If HMO enrollees were profitable but PPO enrollees weren’t, why not simply raise the rates on the PPO crowd? I mean, they obviously wouldn’t be happy about it and many might move elsewhere anyway, but wouldn’t that make more sense than dropping the whole PPO line completely.

There are a few things going on here from an insurance strategy side. The first is that total claims expense is the product of the number of services billed and the average price per particular service. This the key claims equation and insurers try to do quite a lot of things to minimize one or both components of the equation.

HMO’s, all else being equal, have lower utilization than PPOs.  HMOs use the primary care physician as a a gatekeeper and care manager so for anything expensive, the patient has to go through the primary care physician first.  The PCP will divert some proposed care from high cost centers to lower cost centers, as well as discouraging low value/pointless procedures.  PPOs have no requirements for pre-approval.  On average, two identically healthy populations will see more care in a PPO plan.

Secondly, HMOs will have lower cost per service than a PPO plan, all else being equal.  HMOs only pay claims to in-network providers that have a discounted rate contract with the insurer.  PPOs pay claims to any and all providers.  The PPO pays a much higher percentage of the claim for an in-network provider than for an out of network provider.  For instance a PPO might have a $1,250 in network deductible but a $3,000 out of network deductible.  The PPO might pay 80% of the next $5,000 of an in-network claim and then 100% after that while the PPO would pay 50% of the next $14,000 for the out of network claim before paying usual and customary.

PPO plans will see people who have common conditions go out of network to high cost providers when there was no good medical need to do so.  BCBS of Texas switching to an HMO model is looking to reduce both the cost per service and the number of services billed by switching away from the PPO.  These are common considerations for plan design and these are common trade-offs.

The wider business strategy is a simpler one.  All else being equal, a less restrictive plan will have a slightly sicker population than a more restrictive plan.  PPOs are the least restrictive common plan design (the peanut gallery can stop chiming in about indeminity plans) while HMOs are very restrictive.  If BCBS is offering the least restrictive, broad network plan that is also the only PPO on the market, it is highly likely to self select a fairly sick population compared to the other insurers.

Reinsurance and risk corridors can help mitigate these problems in the short term, but in the long term, being the only offered of a desirable to sicker than average people product means eating a lot of losses as the subsidy pricing design is optimized to chase after fairly healthy people who are monthly premium sensisitive and able/willing to switch plans for $5 per month.

Reader Interactions

61Comments

  1. 1.

    Raven Onthehill

    If I had been in an HMO when I was sickest in my life, I would probably be severely disabled or dead.

    I can’t stress enough how dangerous the “gatekeeper” function in health care is. One woman who spent months in pain because her gatekeeper refused to authorize an X-ray comes to mind. Turned out she had a broken ankle, which has probably healed poorly because of delayed treatment. I know others. This is typical, this is common.

    But that’s all right, the insurance companies make money anyway.

  2. 2.

    feral1

    Richard,

    A member of a Houston Rockets BBS that I frequent posted about this yesterday before it hit the news. From his posting history I know that this guy works in the insurance field and his early info came from some kind of internal memo. He’s that very rare bird, a conservative, who’s not a wingnut, and lives in the reality-based world. I’d be very interested in your thoughts his take on this development. I’ll post his comments below. Text in italics are questions/comments he is responding to.

    In their first full year’s worth of claims data, Blue Cross will report a $400 million loss on the individual marketplace. As a result they are pulling the product completely off the marketplace in order to remain competitive. They will terminate nearly 400k policies in this state alone, offering a transition strategy to put people on a new product offering.

    Right now it looks like that will be on their Blue Advantage HMO plan, which has about 30% of the network access that the PPO plan provided.

    This is an absolute disaster for Texas consumers.

    The market in Texas is going to collapse. The numbers I’ve been told are just absolutely staggering in terms of loss. The Blue Cross HMO that will be offered is so incredibly small that it’s a joke. You can’t even use Memorial or any of the other name brand hospitals!

    All of the worst nightmare scenarios talked about by Republicans are coming true.

    Humana sold out to Aetna…
    Aetna is shrinking network access anyway and reduced service…
    The most solvent carrier in the state is pulling up stakes on their #1 product because of the risk pool being so horrible…
    CIGNA is nearly non-existent in the state now…

    Why would they not just raise their prices to market-clearing rates? It’s not like they requested one of those 100% type rate hikes – they requested 20%. They have 400k customers – why throw that all away? Just raise rates and/or make the network a bit smaller – if you end up with fewer customers, they are likely to be the wealthier (and thus healthier) of the bunch, so their risk pool improves. They already have all the infrastructure (claims processing, etc) in place and that all will remain for other plans anyway, so it’s not like they wouldn’t be able to function with 300k customers.

    The way the law requires them to file pricing is as a single block, meaning all HMO and PPO plans together.

    Also keep in mind that Texas frequently rejects major rate hikes.

    $400 million in losses JUST on the PPO is a hard pill to swallow. Everyone throws a fit when they increase rates, but in order to make up $400 million in claims they would need to raise the rates $1000 per member per year. Not per policy mind you, per member. So a family of 5 would see a $5000 a year rate increase. (These are all rough averages of course.)

    That would then push off the healthy and the young which would further exacerbate the problem. The only long term viable option (in their mind) is to break the cost problem. How do you do that? You create a dirt cheap network and try to force as much participation onto that as you can. The HMO.

    Their long term goal (I believe) is to release an EPO (works like a PPO but no out of network) built off of their HMO Blue Advantage network. That network is terrible right now of course.

    Texas is a broken insurance marketplace as a whole. The exchange wasn’t going to fix that.

    Rates are going up here where I live but its nothing like Texas. Even with the final rate increases, Minnesota most likely will end up with the lowest premiums in the US for the third year in a row.

    The general population here is far healthier and the government has a lot more support for low income families that pushes them into expanded Medicaid and a separate state run program called MinnesotaCare that targets families above the Medicaid threshold. So the insurance pool here tends to be much more sustainable than Texas which basically pushed the burden of coverage solely on insurance companies.

    Bottom line, how your government chooses to approach health care makes a gigantic difference. Texas as a whole is a disaster. I can’t say I’m shocked that the marketplace is struggling as a result. You have a government that will do everything it can to sabotage the health care law and a population that is below average in terms of health and health outcomes.

    This is all true. I blasted Perry when the law was passed for his disastrous handling of implementation in this state. Medicaid expansion would have helped, but it would not have solved the problem of course.

  3. 3.

    Another Holocene Human

    @Raven Onthehill: I agree, plus you have all the expenses from having to cycle back into the PCP to get more referrals, and the churning. Given a choice, the vast majority of patients will not be party to churning because it’s a fucking pain in the ass! (Unless it’s a chiro or a provider like that. Insurance should not be paying for chiropraxy. Too much risk for same pain relief as massage. Pay for licensed massage and call it a day. Some masseur/se/s are into woo but it’s not nearly as pervasive as the chiropractor vitamin and other crap scams.

  4. 4.

    Another Holocene Human

    gah, Texas sounds more dysfunctional than Florida, and that’s saying something.

  8. 8.

    Roger Moore

    If HMO enrollees were profitable but PPO enrollees weren’t, why not simply raise the rates on the PPO crowd?

    I assume there’s an adverse selection cost spiral problem with that. When you raise rates, the customers who want to be in a PPO just in case they need to access an out-of-network provider will shift to the HMO. That leaves people who know they’re going to need to go out of network, who are going to be more expensive. The more you raise rates to try to cover your costs, the more you’ll be stuck with people who know they’ll have lots of costs to cover.

  9. 9.

    John

    Same thing happened in New York. It is now impossible, or virtually impossible, to get a PPO plan, at least for the self-employed.

    Since we’ve been slammed into a HMO, the quality of our healthcare, not to mention the time commitment and hassle, has increased dramatically. Have a rash? Go see the idiot PCP, pay for that visit, he fails to recognize the rash and prescribes the wrong medication, which you have to pay for. One month later, still suffering from a rash? Go see the idiot PCP, and pay for that visit. Then get a referral to a dermatologist, and wait 3 months more for an appointment and pay for that visit. And of course as someone who is self-employed, all of this time wasting has a very defined cost attached to it.

    I’m speaking from the perspective of someone who trains physicians–in fact I’ve written their board reviews in many therapeutic areas. HMOs are a nightmare. The net result is that if there is something wrong, I wait until the situation is desperate before I bother going through the gatekeeper. For the aforementioned rash, I even used a veterinary medication to avoid having to deal with all of this.

    I could also bitch about the additional taxes–we’re well into the 1%. But I’m happy that everyone finally gets healthcare. It’s just frustrating that I’m the one of those who are truly paying for it, and I’m stealing my dog’s medication so that I don’t have to spend the time dealing with the gatekeepers and arguing over what medications are needed.

  10. 10.

    ? Martin

    @Raven Onthehill:

    I can’t stress enough how dangerous the “gatekeeper” function in health care is. One woman who spent months in pain because her gatekeeper refused to authorize an X-ray comes to mind.

    You’re proposing contradictory things without realizing it. The gatekeeper is necessary to keep costs in line because without the gatekeeper, everyone with any kind of issue whatsoever would be running off for MRIs. That incredible pain in my knee a few weeks ago after running – turned out to be my IT band, which was fine with ice and advil, but it hurt as much as the fractured ankle I had years back. Running for an x-ray might have seen perfectly reasonable given the pain level.

    But if the consumer feels they know better, there’s not a fucking thing in the world stopping them from getting the x-ray. There’s a place 2 blocks from my house that will gladly do that x-ray, and there’s 3 other places within a block of them willing to do it. You’ve characterized your objection that the doctor prevented the x-ray from being taken, which is incorrect. The doctor simply prevented it for being paid for by the insurer. That’s not nothing, but that’s also not what you are claiming. Bypassing the gatekeeper and going to the specialist isn’t necessarily going to result in a better outcome as the specialist is equally empowered to refuse to authorize the x-ray. So you have a trade-off – save money, which is what the gatekeeper does, or do what you want, which you’ve always been able to do but you’re going to pay more.

    Also keep in mind that the quality of HMOs varies widely. One of the top rated care plans in the nation in terms of patient outcomes is an HMO. It’s a big fucking HMO, mind you, with loads of specialists and hospitals and all that.

  11. 11.

    Another Holocene Human

    @raven: Making people come back every 3 mos or 1 mo for a scrip that should be able to be done on a 12 mo basis, just for $$$ or specifically to HMOs where you’re forced to keep returning to the PCP for a referral for ongoing service from a specialist (allergy shots, mental health care, anything where you legitimately have to keep going back outpatient for service), thus ringing up an additional $110 or $120 or $130 for nothing but “you’re still alive, here’s your referrals”.

  12. 12.

    Another Holocene Human

    @? Martin: I don’t get what you’re saying. If I can’t afford it, I’ve been denied. Even if I’ve suffered major physical trauma and I’m still in horrible pain. Sorry, this happened to two people I know. It was a worker’s comp issue (and kind of complicated) but it was also BULLSHIT. I don’t know how the people who kept refusing to image those injuries sleep at night.

  14. 14.

    ? Martin

    @Another Holocene Human: But you aren’t proposing an alternative that necessarily solves the problem. You still can be denied by the specialist, which also happens, and may have happened in these cases. And the PPO is more expensive for all the reasons that Richard has documented, which leaves it unaffordable for many people, leaving them with no care. You need to tighten up the process, which is what a good HMO can do, eliminating a lot of unnecessary costs so that care can be delivered more affordably.

    I know a number of people that have gotten far worse service from their PPO than I’ve received from my HMO. I think you’re ascribing a problem to a business process which is actually only a problem of implementation. Problems of implementation can happen to any process, and I don’t doubt that a lot of HMOs are bad, particularly a lot of small HMOs. But that doesn’t mean that HMOs are inherently bad – it just means that there are some bad implementations out there. I think scale is a big problem – HMOs benefit from a certain amount of scale, and there are quite few large HMOs.

  16. 16.

    A guy

    How bout everybody pay for their own stuff and quit relying on the government to do it for u

  17. 17.

    ? Martin

    @Another Holocene Human: I’ve been in an HMO for 21 years and that’s never happened to my family – and my wife and both kids are all regularly seeing specialists and we have 4 prescriptions going through the house at any given time. We get prescriptions extended via phone call and usually only need a 6mo or 12mo visit (depending). We’ve never had to go back to the PCP to continue treatment from a specialist.

    These are not inherent qualities of an HMO, just poor implementations of one.

  18. 18.

    BillinGlendaleCA

    @A guy: Sure, you were never forced to change plans or doctors and rates never increased pre-ACA? Everything was crystallized in amber. Can was have better trolls?

  19. 19.

    Howard Beale IV

    @feral1: MinnCare I could rip them a new areshole. I have now gotten mail for a person who claims to live at my mailing address four times, and each time through returned mail, they have not corrected it. Next piece of mail I get from them I’m shredding it.

  20. 20.

    A guy

    17 percent increase in the group coverage I pay for my employees. I have been forced to accept coverages I don’t want or need. The carriers I had for 15 years prior to Obamacare got out of the business. I liked them and never had a problem. Premiums increased but never so much for so little. And all this bullshit for less than 3 percent of the country, most of whom for a little effort could qualify for a card. Hell it would have been simpler to just pass a law that the could be no denial of coverage for pre existing conditions and be done with it.

  21. 21.

    BillinGlendaleCA

    @A guy: Do you have insurance? If you do, you are either paying for someone else’s healthcare or they are paying for yours. What to folk do who cannot afford healthcare? Don’t get sick, die quickly? Got it.

  23. 23.

    Patrick

    @BillinGlendaleCA:

    Sure, you were never forced to change plans or doctors and rates never increased pre-ACA? Everything was crystallized in amber. Can was have better trolls?

    I wish we did. Prior to ACA, my company’s health insurance plan had big raises every fricking year. Not only did the premiums go up, the deductibles would skyrocket as well. It is funny, FoxNews or people like our troll would not complain one bit about that. Why are they choosing to complain now???

  25. 25.

    Richard mayhew

    @A guy: so you want a law that lets the sick get coverage at any point , so the only ones with insurance are the chronically ill and the people who just got an oh shit you have cancer conversation that morning.

    Brilliant way to destroy the insurance function of the insurance market

  28. 28.

    Fred Fnord

    @? Martin:

    I know a number of people that have gotten far worse service from their PPO than I’ve received from my HMO.

    People don’t receive (medical, anyway) service from their PPO. And unless they are on a specific model of HMO (say Kaiser) they don’t receive service from it, either. They receive service from their doctor. In the HMO model, they are limited to one specific doctor that they can receive service from, period, until that doctor refers them to someone else. And since changing your PCP is a hassle and requires hunting for a new PCP in a market that, if it’s anything like the markets I’ve been in, contains 20 GPs who are not taking new patients for every one that can give you an appointment ‘in a month or two’, if you get turned down for a referral and given pain meds for your (say) dental abscess that is rotting your jawbone away from the inside, your next chance at fixing the problem is in a month or two, after a large amount of work on your part.

    Perhaps, if there is an urgent care facility in your area that is in-network, and you can plausibly claim that what’s happening is urgent, then you might be able to be seen there, albeit by another generalist. If you can afford to take the several hours off work in order to wait in line for an appointment. Mind you, I live in a good-sized and wealthy city and had a broad-network PPO two years ago and there were no in-network urgent care facilities within an hour’s drive. So maybe not. (Fun story from said PPO: I once called their ‘advice nurse’ hotline and spoke to someone, who advised me to go to an emergency room immediately. I did. Later, they told me they would not pay for the ER visit because it turned out not to be an emergency.)

    Or, of course, if you can afford to pay out-of-pocket for your specialist, and all the tests they might order, you can go to one. Which is from the HMO’s perspective the best of all possible worlds.

    I do wonder what happens when you go to a specialist, get a bunch of tests done, pay your $2000 or $5000 or $10,000 out of pocket, and get a result back that says you need lots of expensive treatment. Can you then take these results back to your PCP and say, ‘hey, uh, look, I have some test results that say I should see a specialist’ and expect to see one? I would assume so, but I also never underestimate the ability of some corporations to find ways to completely screw you.

  32. 32.

    Davebo

    Any idea what ec-cdn.stitcher.com is and why I get an invalid certificate warning about it every time I visit BJ?

    Anyone else experiencing this?

  33. 33.

    A guy

    Because it’s part of the employment package I must provide to keep the incredible people I have. Free market thing I’m sure you don’t understand

  34. 34.

    BillinGlendaleCA

    @A guy: You could have paid them more money and let them choose to buy or not buy insurance on the individual market. That’s how the free market works.

  35. 35.

    Patrick

    @Fred Fnord:

    He says he doesn’t want insurance for anybody. So I am assuming he is for universal health care then. Surely he doesn’t propose that we all have to pay for cancer treatment or MS drugs with our own pockets. Can you imagine an 18 year old kid coming up with $100k or whatever it takes for cancer treatment, or 3k per month for MS drugs?

  36. 36.

    BillinGlendaleCA

    @Patrick: No, he is suggesting just that. Pay for medical care out of your own pocket or with chickens.

    ETA: His solution, such as it is, would make medical care a much, much smaller sector of the economy. Think of all the surplus trained medical personnel.

  37. 37.

    Roger Moore

    @Davebo:

    Any idea what ec-cdn.stitcher.com is and why I get an invalid certificate warning about it every time I visit BJ?

    Stitcher.com is a podcast site, AFAIK the one Elon James White uses to distribute TWIB. I think they’ve been responsible for a lot of the technical problems on Balloon-Juice.

  38. 38.

    Patrick

    @BillinGlendaleCA:

    I guess the bankruptcy rates in this country would skyrocket if the troll had his way. And it will be the rest of us that will have to help pay for the bankruptcies.

  39. 39.

    A guy

    Billin— lol at your stupidity. The fact my assistant has been with me for 20 years proves the free markets works. Or that she has a high tolerance for my insanity

  41. 41.

    BillinGlendaleCA

    @A guy: I’m leaning towards the later as an explanation. But you never responded to my question, you could just pay your assistant more and forgo the provision of ANY benefits. Health insurance as a benefit only started during WWII when the government enacted wage controls, so employers started offering insurance to attract employees.

  42. 42.

    Mandalay

    @BillinGlendaleCA:

    You could have paid them more money and let them choose to buy or not buy insurance on the individual market. That’s how the free market works.

    That’s a good zinger, but I am not sure that it is accurate because the costs for medical insurance are not based on free market principles.

    I think the overall cost increases for an employer if they stop providing medical insurance because the pay raises necessary to fairly compensate employees for the loss of that insurance are greater than the costs of providing insurance.

    So A guy is probably minimizing his/her costs right now by providing health insurance as a benefit.

  43. 43.

    shell

    @A guy: Snort! Sure, if youre ever unlucky enough to need heart bypass surgery, Im sure you can just break into your piggy bank to pay for it. Or mayve your family can have a bake sale.

  46. 46.

    Roger Moore

    @Mandalay:

    I think overall costs increase for an employer if they stop providing medical insurance because the pay increases necessary to fairly compensate the employees for the loss of that insurance are greater than the costs of providing insurance.

    This certainly used to be true, but I’m not sure it is today. As I understand it, the small group market doesn’t have the same protections that the exchanges do, so a small company with an unfavorable risk profile can have truly exorbitant premiums. It may very well be cheaper these days for a small employer to give employees a big enough raise to afford to buy on the exchange than to try to cover their employees themselves. That’s especially true because a lot of employees will be eligible for subsidies if they stop being eligible for employment-based insurance.

  48. 48.

    BillinGlendaleCA

    @Roger Moore: That’s true, he did say that his premiums were going up 17%. But I doubt that he would take advantage of any program that came from “the liar in chief”.

  50. 50.

    GHayduke (formerly lojasmo)

    @A guy:

    So you used to provide worthless insurance to your employees? Let me guess….bare minimum wage too?

  51. 51.

    ? Martin

    @Fred Fnord:

    People don’t receive (medical, anyway) service from their PPO

    But the issue isn’t the service – the issue is what will be paid for, as that was the original assertion against the HMO, and ‘what will be paid for’ was then used as a proxy for the service itself. The same mechanism exists in a PPO, but the gatekeeper is weaker in the PPO which is why the costs are higher.

    In the HMO model, they are limited to one specific doctor that they can receive service from, period, until that doctor refers them to someone else.

    I am not limited to one specific doctor. I have a PCP, who I can request, but most of the time I just ask for first available which gets me an appointment within a few hours. In 21 years I’ve never waited more than a day for a PCP appointment. If it’s after hours, that’s when I go to urgent care.

    And since changing your PCP is a hassle and requires hunting for a new PCP in a market that, if it’s anything like the markets I’ve been in, contains 20 GPs who are not taking new patients…

    My former PCP retired, so I requested a new one. I could have requested a specific one but I’m not qualified to pick among them, so I just had them assign one to me from my local office. No hassle, no hunting. They offered the same PCP as my wife, but I asked if a different one was available. We like having different doctors so that we can sort of compare. If I didn’t like my new one I could ask to switch to hers. If I just raved over my new one she might ask to switch to mine.

    if you get turned down for a referral and given pain meds for your (say) dental abscess that is rotting your jawbone away from the inside, your next chance at fixing the problem is in a month or two, after a large amount of work on your part.

    Worst case I’d just request an appointment for the next day, but I can always ask for a 2nd opinion from the department head, which I’ve done twice and each time was done while I was still in the office.

    Perhaps, if there is an urgent care facility in your area that is in-network, and you can plausibly claim that what’s happening is urgent, then you might be able to be seen there, albeit by another generalist. If you can afford to take the several hours off work in order to wait in line for an appointment. Mind you, I live in a good-sized and wealthy city and had a broad-network PPO two years ago and there were no in-network urgent care facilities within an hour’s drive

    There are 3 HMO-run urgent cares within half an hour of my house, and 2 full hospitals. I’ve never had to wait even an hour to be seen at the urgent care or the hospital. We are in a pretty high density area, though.

    I do wonder what happens when you go to a specialist, get a bunch of tests done, pay your $2000 or $5000 or $10,000 out of pocket, and get a result back that says you need lots of expensive treatment.

    Can’t speak to that since none of the horror stories described above have happened to me or any one I know who has my HMO (which is most of my coworkers for the last 20 years). That include everything from two premature children, an emergency appendicitis, all the way to several rounds of stitches, a fingertip removed in a kitchen accident, down to mental health treatment and even a remarkably frustrating run with a child who needed minor surgery and who has a proper needle phobia requiring 4 cancelled in-patient procedures and 3 cancelled surgical center ones, all in a span of a few weeks – interleaved with said mental health treatment to address the phobia, and all that.

    I should also note that I’ve never once seen a medical bill, never had a treatment denied, and never faced a copay higher than $100 – which was for an elective procedure. Nothing else on the list above cost more than $50 including the cancelled surgical treatments, which were all cancelled after prep when we determined we could not administer the sedative. And my other child with the emergency appendectomy wasn’t a standard case – she didn’t present with the typical symptoms, so they brought in a total of 4 doctors – the receiving, the attending, and two pediatric specialists to diagnose her – between midnight and 2AM. For the premature kids we had more equipment at home than I can count for monitoring contractions, etc. including a nurse who visited the house 3x a week, 20 emergency L&D visits, 3 weeks in the hospital, and 2+ weeks of kids in NICU and no copays, no bills, no paperwork.

    And you can buy this plan off of Covered California.

  56. 56.

    TEL

    @Roger Moore: That was my guess. I’ve been with Kaiser in the past, and they were pretty good. They get the highest favorability numbers for Silver plans in Northern California (where I live). I’m thinking of signing up with them again next year.

  57. 57.

    Adam Lang

    @? Martin: Kaiser is fine. (That’s who you’re with, I’d lay roughly 90% odds)

    It’s literally the only HMO in the country that is run that way. So universalizing your experience seems a bit… overenthusiastic.

  58. 58.

    ? Martin

    @Adam Lang: I wasn’t universalizing it. I was knocking down the universalization that HMOs cannot work.

    Look, with the exception of Kaiser, HMOs are quite often the bolt-on product to the PPO (as you see in Texas) and suffer both from being too small to work properly and not being the core product and therefore mismanaged. Just the SoCal division of KP has 3.5M members – that’s 10x the size of Blue Choice – and that scale gets you much better in-network services.

    I don’t have much faith in anything in Texas not fucking over the population, but concentrating their efforts on the HMO might actually work out. HMOs can work.

  59. 59.

    Kent

    I live in Texas and I have a PPO plan through Aetna. So I’m not exactly sure what is going on here. Although mine is through my school district employer not the exchange. Just got notice that the price is going up very slightly for the upcoming school year but otherwise no changes. So some PPO plans still exist here.

  60. 60.

    Adam Lang

    @? Martin:

    I don’t have much faith in anything in Texas not fucking over the population, but concentrating their efforts on the HMO might actually work out.

    If your model is Kaiser, then no, there isn’t even that theoretical possibility. They already have their HMO. It does not follow the Kaiser model, it follows the model of more or less every other HMO out there. Absent some evidence that they plan to spend tens of billions of dollars buying hospitals and employing physicians all over Texas, your argument that their HMO could end up looking anything like Kaiser is incorrect.

Comments are closed.