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You are here: Home / Anderson On Health Insurance / PPO is not a mark of quality

PPO is not a mark of quality

by David Anderson|  October 12, 20154:17 pm| 16 Comments

This post is in: Anderson On Health Insurance

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Over at ACASignups.net I saw some recent celebration concerning the addition of a PPO plan to the Nevada Exchange.

What I’m puzzled by is this part…which also includes some good news….

This is actually excellent, and unexpected news, as several other insurance companies have decided to drop their PPO offerings…notably BCBS of Texas (both on and off-exchange) and BCBS of Illinois (via the exchange only). Anthem Blue Cross adding PPOs to the exchange is great to hear….

PPOs are not an indicator of whether or not a plan is a good plan.  It is merely an indicator of how out of network expenses are paid and if a primary care provider (PCP) is needed to authorize high end care.  That is it.

As I’ve shown fairly recently, most of the top plans as rated by NCQA are either HMO or Point of Service (POS) plans (yes, please chuckle at the acronym as I do that every day).  Of the bottom twenty rated plans in the country, the majority are PPO plan designs.

This is not too surprising as  PPOs are the easiest plans to build from scratch.  They involve the least infrastructure, the least technical expertise and the simplest build-out.  The rules to adjudicate a claim are simple — is the provider in network?  If yes, send the claim down the red path, if no, send it down the green path (why yes, I’ve been watching a lot of Dora with my son lately).  Any asshole with cash can set up a PPO plan.  Building an HMO or POS takes a lot more effort and that effort deters the swindlers and grifters to some degree.

Furthermore, PPO is not a guarantee that a network is broad. The incentive is for a broad network to be created as the insurer does not want to eat out of network charges, but it is not a guarantee.  In my region, there are several broad network HMOs with 80% of more of the docs, and 85% of the hospitals within 100 miles of Center City in the respective networks.  There is also a PPO plan on Exchange whose base network is 25% of the doctors and 20% of the hospitals.  (Yes, there are HMOs on Exchange with similar super skinny networks).

Keep that in mind when you look at your open enrollment, PPO is not a guarantee of superior insurance, it is just a matter defining the role of the primary care provider and out of network charges.

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Reader Interactions

16Comments

  1. 1.

    benw

    October 12, 2015 at 4:29 pm

    I’ve been watching a lot of Dora with my son lately

    A favorite parenting moment: my son was watching Dora and when Dora said “should we go down the RED path or go down the BLUE path?” my son immediately said, “I don’t want to tell you, Dora.”

  2. 2.

    trollhattan

    October 12, 2015 at 4:40 pm

    @benw: Has Dora stopped shouting? Does the backpack still find the map delicioso? I’ve not had to co-watch for several years now.

  3. 3.

    scav

    October 12, 2015 at 4:41 pm

    @benw: You have reason to be proud.

  4. 4.

    Calouste

    October 12, 2015 at 4:42 pm

    Could you define PPO? We’re not all as well-versed in health insurance TLAs (Three Letter Acronyms) as you are.

  5. 5.

    benw

    October 12, 2015 at 4:51 pm

    @trollhattan: Yeah, me neither. My spawn have graduated from Nick Jr. to Cartoon Network.

  6. 6.

    Auntie Anne

    October 12, 2015 at 4:54 pm

    Richard, I agree that PPO plans (Preferred Provider Organization) are not the be-all, end-all. But I think many people are used to this kind of plan, so find it sort of comforting. Frankly, the name is not as scary as a High Deductible Health Plan, and not as many people have had bad experiences with PPOs as HMOs, when HMOs were touted as the best thing ever 20 years ago. It is all about people’s perceptions, and not about the actual merits of a plan.

    We’re implementing an online decision support tool this year that I hope will spell out the pros and cons of different plans (all on the same network, BTW) so that our folks understand what they’re getting when they make a choice. Setting it up was and is painful; I hope the results are worth it.

  7. 7.

    FlyingToaster

    October 12, 2015 at 6:04 pm

    In our specific case, we wanted the PPO plan because it included every doctor affiliated with [closest hospital redacted], as well as most doctors in Partners hospitals (Mass General, for instance). The HMO plans all excluded some of the specialists we’re likely to need over time.

    We actually don’t see specialists without a PCP referral, because we want ours to know what’s going on. And everyone refers within-hospital if available.

    We haven’t managed to go out-of-network in the past (adding it up) 13 years.

  8. 8.

    Starfish

    October 12, 2015 at 6:36 pm

    The High-Deductible Health Plans scare me. Are the prescription rates for these plans pre-negotiated, or do you eat the cost of prescriptions at retail rates until you hit the deductible?

    Today, we had our last visit with our allergist. He is retiring before we need to see him again in one year. He works with a partner, and his partner will bring in an Unknown New Allergist. There is another allergy group in town, and I know people who go to that group and like it. I would prefer to go ahead and set up an appointment with the doctor that I know people like (as it takes several months to get an appointment with her), but I am not sure if her office is in network for next year’s plan. Our current allergist is preferred by our current network. Some people did not like him because he is not as cheerful and personable, but I do not mind people who are excited about science and do not know what to do with the people.

  9. 9.

    rikyrah

    October 12, 2015 at 6:42 pm

    Thanks for this. It’s open enrollment time, and I don’t know if I should switch from my HMO to PPO. I finally found a medical center where I don’t dread making appointments and going to them. I don’t want to start from scratch again with doctors. ….sigh

  10. 10.

    dr. bloor

    October 12, 2015 at 7:19 pm

    @Starfish:

    The High-Deductible Health Plans scare me. Are the prescription rates for these plans pre-negotiated, or do you eat the cost of prescriptions at retail rates until you hit the deductible?

    You should never take on more of a deductible than you can assume you’ll spend in the course of a year. Folks who either opt for big deductibles or have them foisted on them by their employers for the sake of saving a few bucks on their monthly premium are aching to be victims of the penny-wise-pound-foolish approach to insuring their families.

  11. 11.

    Auntie Anne

    October 12, 2015 at 7:31 pm

    @Starfish: Check with the insurer, but it’s been my experience that prescriptions are at the insurer’s negotiated rate before you hit your deductible. I was on an HDHP last year and never came close to meeting my deductible, but got the insurer’s rate on the prescriptions I needed.

    @Dr. Bloor is right – ideally, you should never choose a plan with a deductible higher than you can afford to pay without resorting to credit cards. Easier said than done, I know, unfortunately.

  12. 12.

    Steve in Sacto

    October 12, 2015 at 8:16 pm

    Richard, agree that breadth of network is important, however the PPO ability to A) Go directly to specialists if desired w/o obtaining PCare/HMO permission and B) Choose any contracted (or not) specialist – as opposed to being funneled to chosen PCare medical group’s specialist – is everything IMO. Respectfully think you do readers a disservice downplaying these critical benefits of PPOs.

  13. 13.

    Mnemosyne

    October 12, 2015 at 9:57 pm

    @Steve in Sacto:

    I think it depends on the area you’re in and your insurance. Here in Los Angeles, my HMO’s network is swarming with specialists. If you get even a little further out into, say, Ventura county, it might be more of an issue to find an in-network specialist.

  14. 14.

    Mnemosyne

    October 12, 2015 at 10:00 pm

    @rikyrah:

    If the medical center you like is in the HMO’s network and you can use their specialists easily, I would stick with the HMO. There’s not much reason to switch to a PPO just in case something changes at your medical center in the next year and you need to change networks again.

  15. 15.

    Nutella

    October 12, 2015 at 11:13 pm

    I know how PPOs and HMOs work, but what is a POS, besides an amusing acronym?

  16. 16.

    Steve in Sacto

    October 12, 2015 at 11:46 pm

    @Mnemosyne:

    HMO networks may be swarming with specialists but insureds will in most cases be limited to those within the medical group of their primary care. In LA there are world class specialists at UCLA, USC, Cedars etc. who may be in network, but getting to them will be problematic to impossible because they aren’t part of the primary care’s medical group.

    …adding, and of course getting to any specialist is at the sufferance of the primary care and HMO gatekeepers.

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