Conference 7.286::digital

This would be a rather strange decision.

Not only was John Hancock insurance discontinued quite some time ago and
replaced with the Digital Employee Health Plan (not insurance, and JH is
only the administrator), but the industry is discovering that HMOs are
raising their prices and becoming less and less of a bargain for companies
as the HMO membership population ages.

But it wouldn't be the first wrong decision made...

I'm also not sure it would be legal in all states -- some states require
that a plan be available which allows employees to choose their own healt
care providers.

It seems extremely unlikely that Digital would require employees to leave
their family doctors.

/john

    re .0
    
    How 'bout elevating the "rumor" to Personnel and/or John Murphy and
    validate it?
    

    <applause>

	RE: Taking the issue to someone who should know.

	Sounds like a good idea. Try it. It may work. But I doubt it. People
	who know the real answers are generally not going to confirm or
	deny anything until it's officially true or known never ever to
	be going to be true. 

			Alfred

    I agree with .0 - I'll never join an HMO. (besides, none are offered
    here on the sunny Alabama Gulf Coast...)

    There are some, who because of divorce decrees, are required to provide
    medical INSURANCE (coverage or equivalent) for dependent children.
    
    In the case where the non-custodial parent is living in a different
    geographic area than the child, how could the parent being 'forced' to
    join a local HMO for his/her coverage, provide medical coverage for the
    child, unless two HMOs were involved?
    
    	-Barry-
    

    Why not call the Boston Globe and ask them ?  They have not been
    too far off the track so far on "what is going to happen at DEC
    next".
    
    If the Globe conferms the rumor and DEC denies the rumor than the
    rumor must be true.
    
        gene

    I recently spoke with somebody from Harvard Community Health Plan
    and was told that HCHP has been engaged in discussions with DEC
    to develop an "industry leading" health plan centered around the
    HMO model. Health benefit costs under the JH administered programs
    have been increasing at an alarming rate; Digital is looking to
    an HMO model as a means to better "manage" costs. 
    
    There presumably will be an option whereby the employee can opt
    to see a specialist or receive hospital care from outside the HMO
    referral network, however the employee will incurr deductible
    & copayments.  These additional "surcharges" are intended to
    discourage employees from going outside the plan, but still allows
    for individual choice.                           

    re: .8
    
    >There presumably will be an option whereby the employee can opt
    >to see a specialist or receive hospital care from outside the HMO
    >referral network, however the employee will incurr deductible
    >& copayments.  These additional "surcharges" are intended to
    >discourage employees from going outside the plan, but still allows
    >for individual choice.                           
    
    This is known as "Point Of Service" (POS) in the health-care industry.
    
    Bob

    If in fact the cost of the JH administered plan is becoming prohibitive
    the corporation may be looking at alternatives for our health care
    needs.
    
    I have confidence that we will not be left without options.
    
    Not to derail the subject, but it is my feeling that the consumer is
    paying for inefficient practices by our health care professionals.
    It is unfortunate that the burden of health care costs are always
    the responsibility of the consumer.

>    It is unfortunate that the burden of health care costs are always
>    the responsibility of the consumer.
    
    Perhaps we should just get rid of the consumers.
    
      John (had the same doctor for 15 years, not about to switch)

    The service from JH must be a bit better for you people in New England.
    As far as I'm concerned.... they can't get rid of ol' JH to fast.
    JH cost me $500 out-of-pocket expenses when they wouldn't pay for some
    of the cost from our last child... something about "expenses out of the
    ordinary".  You try to complain to them, and it's like talking to a
    brick wall.
    
    I hope its all true... and YES I now belong to an HMO.
    
    BTW... not all alternative health plans mean an HMO.  Before I joined
    DEC I worked for a University who belonged to a "Health Plan" that
    included about half the doctors in Albuquerque.  Our DR was already
    a member of this Organization, so we didn't have to change.
    
    GaryB
    

One of the things we have to pay for (because such a large proportion of
our employees live in Massachusetts) is the idiotic Massachusetts Blue
Cross law.

The law specifies that _if_ a doctor accepts Blue Cross, they must accept
the 80% Blue Cross pays and eat the rest.

Of course, this doesn't apply to the DEC plan.

This means that doctors set their prices 25% higher than they would otherwise
be.  DEC pays 80% of the inflated prices, and then we pay the extra money out
of our own pockets, subsidizing the Blue Cross participants.

Lousy.

/john

    RE: .12
    
    Gary, you're right.  Health plans are different there.  I even found
    I LIKED HMO's better in Albuquerque.  In New England, its' a totally
    different story.  So, PLEASE don't hope its "...all true."  Being in
    an HMO where they (have been known) to cut costs at the expense of 
    patients is not only stressful, but could prove bad for ones' health! 
    (pun intended)
    
    And, folks - its' not only family doctors at stake, there are some 
    patients who use a specialist as their primary physician.  For example,
    if one of my family was being treated by a leading cancer specialist, 
    known and trusted by the patient for years - would it make sense to 
    start/continue treatment with another doctor?

    re:  Point of Service 
    
    One possibility I wondered about for a long time was the establishment
    of "company doctors" who would eventually replace company medical
    insurance.  You would either go to them, or do without.  Then someone
    pointed out to me that it would open a company up to direct involvement
    in malpractice insurance.  So the Point of Service system seems to be
    one of the dodges to avoid liability problems.  To me, it just sounds
    like contracting with the low-cost bidder.
    
    Health-care costs keep spiralling because everybody takes advantage of
    the current system.  The medical profession has little or no direct
    control of itself, and is violently opposed to any monitoring from the
    outside.  The insurance industry is not so much interested in keeping
    *costs* down as they are in keeping *claims* losses down.  And finally,
    the consumer has no direct incentive to seek cost-effective medical
    care.  In fact, the current system seems designed to prevent consumers
    from making any sort of intelligent decision about purchasing services.
    
    If the HMO-only plan is truly in the works (or the POS plan) I hope
    two things happen:
    
    Digital spends the time and effort to secure competent healthcare
    providers.  This means doing research like digging through obscure
    and misleading AMA disciplinary reviews.
    
    Digital rejects the low-bid approach.  If employees are really the
    "most important assets of the company" then they deserve better than
    minimal healthcare.  I also believe that healthcare plans will be the
    third most important factor (behind job duties and salary) in making
    career decisions in the coming years.
    
    Geoff
    

    Sounds like a pay cut to me - maybe an incentive for a few more people
    to leave - cheaper than buyouts...
    

    I have been with an HMO for the entire 10+ years I've been with DEC.
    Comparing cost/vs benefits of JH & HMO I would never switch to JH.
    
    I realise the HMO's are different in each state so I cannot comment on
    what they are like in Mass.  As far as I am concerned the Colorado
    HMO's are far superior to JH. Even when my wife was hospitalized out of
    state I never saw a bill.  In fact I have never seen a bill for any
    hospital stay that I or my family has had, and with a diabetic son that
    is a BIG plus
    
    Ray 

    I WILL NOT USE AN HMO!!!!!!!  Those who speak in favor of HMOs in this
    file are noting costs - the least important of the factors to be 
    considered in evaluating health care.  When you face a lifelong 
    impairment, or the loss of life, cost is of no importance. 
    Unfortunately, I have faced both situations, with wife and self in both
    HMO and individual provider.  Fifteen years ago, with two individual
    providers (both my wife's and mine), my personal liability after her
    death was over $25,000, which is one of the easist bills I ever paid.
    I have had both plans and repeat, I WILL NOT USE AN HMO!!!!!!

    RE:            <<< Note 1128.18 by LABC::MCCLUSKY >>>
    
         That applies to your HMO in your state.  That kind of situation
    may not apply to all HMOs.  Generalization of this sort is almost
    always misleading.
    
                                        Greg

    	The latest thing I heard was that instead of removing the "choice"
    the price of JH will be jacked up so high as to not be a viable choice
    at all. Maybe if the company is having such a difficult time providing
    decent benefits to employees, they should look into a flexible benefit
    package like some companies provide. The employee can choose one of the
    company benefit packages or choose cash instead. In the latter case,
    the employee must secure his/her own benefits. This needn't be "all or
    nothing" but can apply to particular benefits.
    	And don't get me started on SAVE! I'm still ticked off that the
    company doesn't contribute to the SAVE program and has not addressed
    the "discrimination" problem that forces them to shut off SAVE
    contributions every year for a few months.

         Be fair, now.  SAVE is only shut off for employees over a certain
    pay level for certain times of the year.  As for Ditital not
    contributing to SAVE, that has baffled me too.
    
                                         Greg

    RE: .22
    
         That is PRECISELY why the SAVE contributions are frozen each year
    for people who earn above a certain level of salary.
    
                                       Greg

    re: .19
    It applies to three HMOs in two different states and a program
    of socialized medicine in another country.  In addition, it includes
    at least ten opinions from ten other states and their HMOs.  It is
    not a great big generalization.  When you have experience with
    serious medical situations you meet and share with others in similar
    circumstances.  Your knowledge base expands rapidly if you listen.
    
    Daryl

    Its sounds to me like the HMO's are being beaten up here.
    
    What medical coverage depends on the lifestyle and history of the
    individual or family.
    
    I live in Ma. and belong to a HMO.  I didn't have to change doctors
    (same doctor I've had since age 4 he delivered both of my kids).  Actually I
    left JH after being in the plan for 4 years and never having enough
    bills to pay of the minimum surcharge.  Thank God we are a healthy
    family.   
    
    BUT when my son almost cut his index finger off from the knuckle I found
    no problem with the HMO.  A specialist was called in to operate joining
    togeher once again the nuckle, muscle, and tendoins all for the $10 
    emergency room fee.  Three months of physical therapy twice a week at
    no charge.  At first they estimated 50% recovery and he is today at
    full use of his finger.
    
    So as I said before each persons needs as with each health plan is
    different.  That probably why there are so many different health plans.
    
    Janet

    I am currently using an HMO and find, in most cases, the service
    adequate.   BUT  I have heard, with the one I am currently in and
    others, that there can be problems with out of state treatment (If it's
    not life threatening, take two aspirin and jump the next plane).
    
    I guess I have a question about whether this is true (I have not had to
    test it either out of state or out of country which I hear can be even
    tougher)?  And if so, is it just a few HMO's or is it more widespread.
    

    My son was ill in PA a year or two ago, high fever (estimated by hand
    on forehead).  We called our HMO (Harvard Community Health Plan) and
    took him to a local emergency room.  They paid without a squeek.
    
    Recently they've even reduced the call requirement somewhat.
    
    The emergency room nurse was not like the one portrayed in the Blue
    Cross/Blue Shield ads.  They didn't require traveler's checks, just
    sent us a bill a month or so later which we forwarded to Cambridge.
    
    /s/ Jim Williams

At least one HMO that is made available by Digital screens the patients to
determine who will see a Doctor.  This is done by Nurse Practicioners (sp)
or by nurses.   

I don't choose to use the HMO (although I use their Doctors) as I prefer to
choose my own specialists as well as when I will see them.

         It definitely depends on the HMO in question.  For instance, two
    HMO's we have locally are Peak Health and HMO Colorado.  In my opinion, 
    Peak Health is overly concerned with their profit margin to the
    detriment of the patient, but HMO Colorado has provided excellent
    coverage (including hassle-free out-of-state coverage).  I know that
    HMO's in other states are similarly diverse.
    
                                        Greg

    High fevers, severed fingers, broken bones, etc. ... - most competent
    doctors work just fine on those things where there are clearcut, and
    well-known treatments.  Its' been my experience that medicine has 
    evolved to the point where the medical community is pretty advanced
    at  "...patching us up," especially in acute situations.  They can 
    treat or even replace a specific *part* of us.
    
    But beyond this things began getting more complex, and therefore,
    more costly.  Because of this, SOME (note the some, please) HMO's 
    (giving direction to their doctors), may try to keep costs down
    by limiting diagnositics and long-term treatments.  Especially 
    where treatments are only know to provide short-term relief, but
    not cure the illness..  
    
    For example, Systemic disorders have many treatments, including
    drugs, massage, periodic immunizations, etc.  A patient may have 
    to complain long and hard to *convince* their doctor these may
    help - given the patient found out about these on their own since 
    such treatments are not always mentioned, and even less encouraged.  
    
    A doctor may have to take some flack from the insurance company for
    prescribing indefinite treatment.  (In fact, I've never seen an HMO 
    doctor provide an indefinite treatment time-span).  This is where 
    other insurance, such as JH can be of most benefit.
    
    So, it sounds like I'm reiterating some of what has been said before
    - if you're healthy, and just want coverage in case of injury or
    sudden illness, an HMO is great!  If you need more specialized medical
    treatment, or haven't been able to get satisfaction on some medical
    problem - a health plan where you choose you're own doctor(s) may be
    the best choice.  
    

    Is there really any substance to this or are we still talking about
    baloon juice?
    
    Given the fact that the local management team in Albany has tried to 
    secure an HMO as an option for employees and was turned down because 
    the site (85 people) wasn't big enough, I find the rumor that an HMO 
    will be mandatory extremely silly.
    
    Al
    

    
    
      re -.1
    
      The version of the rumor I heard was that it was to start out
    being for new_england employees only.  I've heard it from enough
    different sources now that I suspect there must be some truth to
    it somewhere...
    
    
    						-al
    

    Could some of this be we're considering going to a
    preferred-provider plan or one of the "health care
    networks"?

    d

     re .32
    
   <<     The version of the rumor I heard was ...
   <<   			...  I've heard it from enough
   <<   different sources now that I suspect there must be some truth to
   <<  it somewhere...


Does this imply truth by repetition? Dangerous thinking!

	/Marvin

    
    
      re -.1
    
      Remember, the Salary freeze and voluntary severence plan 
    started out as just rumours as well...   
    
      Given the general erosion in the quality of the health coverage
    over the past 7 years I've worked at DEC, I'd say that this is at
    least a likely next step...    It's almost time for one of those
    "Employee benifit (bad news) bulletins" anyway...
    
    
    						-al

    I just finished reading a memo from my local Personnel group which said
    we should be getting a Benefits Bulletin in the mail shortly. Subject:
    
    			Health Care
    
    Dave

    The HEALTH CARE AT DIGITAL background report for Managers & Personnel
    is out.  Usual content around the rising costs of healthcare, why,
    what individuals can do, etc.  Highlights the trend towards MANAGED
    CARE, and the concept of POINT OF SERVICE PLANS.
    
    "Digital has been increasing its focus on the development of a health
    care program within the managed care delivery system.  The Company's
    specific interest for our current health care plan recommendations is 
    the possible development & delivery of a Point of Service program."
    
    The POS program is described briefly...ask your manager or personnel
    dept to show you the document & explain the concept.
    
    Mark
    

Your mother's on the roof....

    After calling MEM benefits, I was told that John Hancock (or a similar,
    non-restrictive policy) would still be available. They could not tell
    me the cost. ("This has not been decided.") The rest of the memo
    indicates how they would like to move people to lower-cost plans.
    
    This does make me think about how insurance is no longer fulfilling its
    purpose. At one time, it would spread out health care costs among an
    entire poplulation. Now, HMO's are getting the healthy people, with the
    other plans picking up those who need ongoing health care. As a result,
    the HMOs and other restrictive plans are showing a significant cost
    reduction - but not because they have better health care, but because
    the people who do not need health care select them. As a result, the
    other plans look even more expensive - because only the people who
    cannot afford to leave them stay.
    
    After reading the health care bulletin for Personnel and managers, I am
    convinced that this is the direction in which the company is moving.
    (This alone took 2 hours of my time  - a person in site personnel did
    not have the time to read the bulletin, so I had to call MEM benefits
    to get the explanation. They were quite willing to read the memo, but
    could not give details.) I understand a benefits bulletin will be
    mailed to employees this week.
    
    
    Lets wait for real meat to fill out this rumor.
    

An article in the latest issue of one of the health care trade rags contains a
story indicating that John Hancock just purchased a firm that specializes in
managed care, i.e. PPOs and POS.  Interestingly enough, there is also an ad
in the Dallas paper where John Hancock is looking for a person to head up their
managed care efforts in the "Southern Region", whatever that may be.

Bob

    A.	Digital does not now offer John Hancock insurance.  It is the
    	Digital Medical Plan, which is self-insurance by DEC.  JH just
    	has a contract to administer it.
    
    B.	There are other reasons than "need more health care" to go with
    	general insurance instead of HMOs.  Sometimes you want somebody
    	who is more competent than what the HMO offers.  It happened to
    	us, and we would never go back.

Why would the healthy people go with the HMO rather than the Digital
Medical Plan?

The Digital Medical Plan is _definitely_ cheaper if you rarely go to
the doctor.  In fact, without dependents, it's free!

The weekly deduction for HMOs is more than for the Digital Plan.

HMOs are becoming much more expensive and much less profitable as
their populations age.

/john

    Right on, John Covert.
    
    Another thing to keep in mind is that many doctors (at least in
    the Seacoast of NH) are dropping HMOs as insurance carriers.  An
    HMO may not offer the patient a doctor that matches his/her needs.
    
    As a former HMO patient, I found the program to be suitable to my
    needs.  However, after 18 months of playing musical doctors, I decided
    to switch back to JH and my original GP.  My wife also returned
    to her doctor.
    
    John's absolutely correct, though.  If one is healthy, it is much
    cheaper to stay with JH.
    
    Mark.

    Our family is currently covered under an HMO through my wife's
    employer. When we switched over, we did not have to change GP's, since
    virtually every one in our area subscribes to the HMO.  We are arguably
    "healthy". But...
    
    We have three kids.  One child getting sick guarantees each
    of the other two will.  Nothing terribly significant, your typical ear
    infections, colds, childhood illnesses. That happens at least three
    times a year.  Each time requires two visits to the doctor @ $30.00 each, 
    plus one or two bottles of pink medicine @ $15.00 or so.  Plus one visit 
    each for normal checkups.  Plus mom and dad end up going at least once a 
    year for checkups and minor problems.  That ends up costing about $400.00 
    per year without an HMO. With ours, the total tab comes to just $45.00.  
    
    Health maintenance for a family is not cheap, especially with
    deductibles and 80% reimbursements.  If you have a family, an HMO looks 
    like a pretty good deal to me.  But your results may vary, of course...
    
    Al
    

    re: .45
    
>                                           That ends up costing about $400.00 
>    per year without an HMO. With ours, the total tab comes to just $45.00.
    
    What is the difference in payroll deductions between Hancock and the
    HMO?
    

    re: .46
    
    This is an HMO paid for by my wife's employer.  I believe the
    difference in cost when we switched was only a few dollars a week,
    maybe a total of $150.00 a year.
    
    Al
    

    re: HMOs are more expensive for well families
    
    The HMO we belong to is cheaper than DM/JH by about $.75 per week (as I
    recall) for family coverage.  We use regular private practice doctors
    who have chosen to become associated with the HMO (MD-IPA).  Regular
    office visits are $5.  Visits to a specialist (by referral of your
    primary care physician) are $10.  Visits to emergency rooms have a
    copayment of 50% with a maximum of $50 (as I recall -- haven't needed
    this in a couple of years).  Prescriptions have an annual deductable of
    $50 per year per person (I think).  After that, each prescription is a
    flat rate ($3 per, I think).
    
    Suffice it to say that we have saved BIG dollars in the past several
    years on well-child office visits (pediatric costs are abominable for
    the regular shots and checkups).
    
    The only hangups we've encountered have been things like lab work.  The
    HMO has all lab work sent to its regional lab for processing.  As a
    result, results that normally would be available in 24 hours sometimes
    take 3 or 4 days.  It's inconvenient, but so far that's all it has
    been.
    
    -- Russ

Some comparisons for the Greater Maynard Area:

Plan	       Weekly Deduction
	       Single	Family

Digital 1	   0     7.50
Digital 2	3.50	17.50

HCHP		7.09	25.51
Leahy		7.55	23.47
Bay State	8.09	25.42

Need I say more?

/john

It's clear from this topic that HMOs are a better deal than the Digital Medical
Plans for some people.  For some, the Digital Medical Plans save some money.
For others, including my family, being forced into an HMO would be a major
hardship -- the quality care we need would cost us big bucks.

Could somebody elaborate on POS?

re: .50

POS - Point Of Service  This is basically a combination of an HMO and an
indemnity plan.  You have select a primary care physician from a list of
participating physicians.  Visits may or may not have a copayment involved.
There is no deductible as long as you visit one of the participating
physicians.  Your primary care physician can refer you to a participating
specialist with/without a copayment.  You can however decide to use a
physician not in the plan, but you have to meet a deductible that is
normally a lot higher than in most indemnity plans, and the percentage of
re-imbursement after paying the deductible is usually lower than with an
indemnity plan.

If you have any more questions, ask, as my wife works in the managed care
industry.

HTH,

Bob

Living in the GMA, I've never understood why anyone uses the HMOs.

Based on the comparisons in .49, I'd need medical bills of around $3150
before one of the GMA HMOs would be a better deal than Digital Plan 1.

This assumes the HMO is completely free, and that DEC pays 80% after a $175
per person deductible:

	$25/week(HMO)-$7.50/week(DEC) x 52 weeks = $910/year more for the HMO.

	But with that $910, I get $3150 of medical care:
	$350 (deductible for two persons) + $560 (my 20%) + $2240 (DEC).

A family of five would still be able to have medical bills of around $2450
before the GMA HMOs are a better deal.  (Max deductible per family is $525.)

Even if something catastrophic happens, DEC pays 100% after you've spent
$1200 out-of-pocket ($3600 per family).

/john

The cost of the HMO is not directly comparable to the other plan.   
The HOM establishes a charge for each type of visit and that is what you pay.
The other plan pays 80% of what they deem "REASONABLE AND PROPER" which is 
often 20 to 30 % less than billed by the doctors.

example 
		Dr bills	500.00
		Reasonable	300.00
		Difference	200.00
		Paid by ins 	240.00	(80% of 300.00)
		Patient pays	260.00  (20% of 300.00 + 200.00 diff)

There usually is not that much difference but most of our bill from specialists
are more than the allowed max.  I think that one reason is that this is not
adjusted by area of the country and our charges here in N.E. are higher.

Those charges over the R&P are not covered by the Maximum annual charges.

I choose to use the Digital Health Plan administered by J.H. for the freedom
of choice of specialists as well as the ability to see them when I choose.

Also I understand the H.C.H.P. now has established a process where the 
patient is screened by a nurse (practictioner(sp), I think) prior to your
being seen by a doctor.  

>are more than the allowed max.  I think that one reason is that this is not
>adjusted by area of the country and our charges here in N.E. are higher.

This is incorrect.  R&C charges are calculated based upon the ZIP code of the
provider.

However, I still don't see how it can be that NOBODY charges R&C.  I'll have
to see if I can figure out exactly how R&C is calculated.

Bob

re "reasonable and customary:"

We've been dealing with several highly-reputed specialists in Boston, and
have yet to have JH say that their charges weren't "reasonable and customary."

Herewith a little HMO humor:

In today's "Pogo," Howland Owl is running an HMO (stands for Healthy Members
Only).  He tells Churchy, "Go home, an' if you still feel sick in six months,
come back so we can cancel your policy."

I, too, have never seen the Digital Medical Plan pay less than 80%.

/john

	  I have, but it still beats an HMO, IMO :-) .

	  Jack

I did find out the approximate dates when more details will be
announced. The first (of 2) benefit bulletins should be (received,
sent?) by 3 August.
The second will come in mid-October.
The changes will take effect 1 January 1991, after the open
enrollment period. 

I was able to find out that there will continue to be a plan which
allows you to choose your own doctors. How much this will cost,
I could not find out (if indeed, that has been determined.)

I did get to read the notice sent to personnel and managers, and I
thought it was a waste of expensive glossy paper. It said almost
nothing beyond explaining the concepts of identity plan, HMO's, and
POS's, and talk about increasing medical costs.

I think we'll have to wait until October for the real meat.

re:< Note 1128.56 by COVERT::COVERT "John R. Covert" >


>I, too, have never seen the Digital Medical Plan pay less than 80%.

Maybe things work better when you are nearby (relatively), but in my
experience, it is NOT AT ALL uncommon for Hancock to:
A) Decide that R&C is about 3/4 of what most doctors in the area charge,
B) Lose paperwork for 1-2 MONTHS, causing the doctor/facility to come after
	me for nonpayment (or else I have to pay 100% and try to collect from
	JH...)
C) Put treatments for my son under MY deductible (or vice-versa) and refuse to
	pay my son's bills since MY deductible had not been met...

So, if they don't pay at all, or only after much hassle (consistently), what
are they worth?  Why should I opt for medical coverage that gives me ulcers???

Kevin

re .59:

>B) Lose paperwork for 1-2 MONTHS, causing the doctor/facility to come after
>	me for nonpayment (or else I have to pay 100% and try to collect from
>	JH...)

That's not your problem, that's the provider's problem.  Providers that I've
dealt with know that they might not get timely payments through JH, but that's
better than no payments at all (i.e., losing my business).  If you want to
be a nice guy, you can commiserate with your provider.

>Providers that I've
>dealt with know that they might not get timely payments through JH
    
    Ah, yes, the word has gotten out, hasn't it?  And one of my providers,
    as a result, requires me to pay in full for his services at the time of
    my visit.  Then he'll file the necessary paperwork with JH, and leave
    it to me to hassle with them until I'm repaid.
    
    Fun, ain't it?
    Karen               

>Providers that I've
>dealt with know that they might not get timely payments through JH, 

That's where folks in NE have an advantage too: JH is NOT well known in 
this part of the country (NW), so you get no sympathy for having an
insurance company that is slow (at best).

In any case, most or all of the providers I have come into contact with have a
clause which states that YOU THE PATIENT are responsible for charges incurred. 
They will, as a courtesy bill your insurance, but if the insurance doesn't pay,
they will come after YOU. ... thus it is MY problem, not my doctor's.

I also don't feel that its a real good plan to get into an adversarial
situation with a doctor whom I may come back to next month (or whenever)...

Kevin

    There is a medical [I use that term loosely] outfit in Worcester for
    diagnosing and treating allergies, which, if you pay the bill yourself
    in cash, you pay X dollars.  If they have to bill the insurance
    company, they increase it by a certain percentage.  
    
    Sounds like an illegal practice to me, but then, they ran some tests on
    me [around 8? years ago] which I never authorized, and then submitted
    them to the insurance company for payment.  I contacted the insurance
    rep, and the lab, and told them I never knew they were running those
    tests, my visits were over, and that I did NOT want the insurance
    company to pay.  The clerk's response at the lab was, "Why are you
    concerned about it?  The insurance company will pay the lab work 100%" 
    My response, "No, they won't pay it, because I won't allow it.  If you
    want the money, take me to court."
                                     

    I don't think JH is unique in its slowness in paying providers
    (although it was pretty bad when they switched over to a new
    system last year).

    Providers are used to dealing with insurance companies that don't
    pay promptly.  They'd all like to be paid on the spot, but I don't
    think they really expect to be.  I've dealt with several providers
    who have prominently posted signs that say "Payment is due when
    service is provided," but they all either bill me by mail, or
    file the insurance themselves.

    re discount for cash up front:

    I'm not sure about the legality of that, but it's probably legal
    to offer a discount for prompt payment (which insurance companies
    don't usually give).

    I was always under the impression that the purpose of health insurance 
    was to provide protection for you or your family so that an illness or
    accident did become catastrophicly damaging financially. (ie. one did
    not have to delare banckruptcy) 
    
    What I discovered was that with health insurance, (JH), a medical
    problem with one of my family members nearly did do me in, finacially.
    
    Only a second mortgage bailed me out and this was a one shot solution. 
    
    If this happens again, I have no fallback. 
    
    I believe this is a real failure of the health insurance system we have
    here. Perhaps this is a reflection on the rising costs of the medical 
    profession, however, this problem is not going to go away, it's only 
    going to get worse. 
    
    George
    

    re: .65
    
    I agree.
    
    What I want from health insurance is what I get (more or less) from my
    house and automobile insurance -- protection against catastrophe. 
    People could choose their deductibles and pay accordingly.
    
    My only worry is how they would deal with depreciation.
    
    
    Elliott

Of course, we don't even call the (JH) Digital Medical Plan "insurance."
It's the "Digital Medical Plan."

/john

    I got the Benefits Bulletin yesterday.  Reading between the lines,
    I think DEC will continue to offer an indemnity plan (like the
    Digital Medical Plans) and HMOs, both at increased cost to employees.
    POS will be added, but PPO won't.  I predict that they'll try to
    reduce costs of the indemnity plan, perhaps by requiring second
    opinions for more kinds of procedures.

    One statistic struck me as misleading.  It said that if trends
    continue, medical care will "consume 25% of the GNP" by 2000
    (I think that was the date).  This ignores the fact that medical
    care is *part* of the GNP.  Or am I all wet?

	RE: .69 Perhaps the working should have been "make up 25% of GNP".


			Alfred

How much does DEC spend per employee for the Digital Medical Plans?

(_Not_ counting the money deducted from employee paychecks)

    I seem to recall something around $3,000 per employee..
    
    Jim
    

>How much does DEC spend per employee for the Digital Medical Plans?

Though I'm sure you wanted an average, you should be aware that DEC spends
nothing for an employee whose medical expenses per year are less than the
payroll deduction.

Remember, it is not insurance.  It is directly paid out of DEC's cash.

/john

>             <<< Note 1128.73 by COVERT::COVERT "John R. Covert" >>>
>
>>How much does DEC spend per employee for the Digital Medical Plans?
>
>Though I'm sure you wanted an average, you should be aware that DEC spends
>nothing for an employee whose medical expenses per year are less than the
>payroll deduction.
>
>Remember, it is not insurance.  It is directly paid out of DEC's cash.
>
>/john

    Now I would never disagree with John, but I don't believe that Digital is
    paying cash to the HMO's for their costs :-).  My assumption is that there
    is a formula for the amount of funding needed on a per employee basis. 
    Otherwise there would be no way to define how much more the employees have
    to pay to be in the HMO's.  If Digital does not need to spend all of the
    allocated money on the "self-insured" part of the plan, it would be
    recovered by the company.  Likewise if there is a shortage, that would need
    to be paid for from company funds.

    Lee G.

    
    There's another average-cost-per-employee that the previous few replies
    have overlooked when comparing the Digital Medical Plans to HMOs,
    and that is ADMINISTRATION, the horrendous cost of processing claims
    and managing the system for that type of care.
    
    HMO ---
    Assuming that the company's base contribution is the same as for the
    Digital Medical Plans, the employee pays everything over and above that
    to belong to an HMO.  The HMO itself absorbs the administrative burden,
    so no additional cost to DEC.  As opposed to:
    
    Digital Medical Plan ---
    The employee pays his/her $7.50/$17.50, but Digital pays an enormous
    cost to ADMINISTER (or have J.H. administer - same thing) the Plans. 
    This is true whether or not the employee ever files a claim; there is a
    fixed cost per employee.  The incremental cost every time someone files
    a claim just adds to the overall mean cost.
    
    $ SET RELIGIOUS_WAR ON
    
    If this additional true cost-per-employee were properly applied, i.e.,
    tacked on to the Digital Medical Plan subscribers (and not subsidized
    by the HMO members), I wonder how many people would be so xenophobic
    about HMOs.....
    
    \Gary, who wishes HMOs were even an option here in Grand Rapids, MI
    ( or, doesn't _everyone_ like writing checks and filling out forms? )
    members

    To shift the direction slightly, I will assert that the centralized
    administration and contracting for health services; both by companies
    and government/quasi-gov't agencies over the past 30 years has
    inadvertently driven up the cost of medical/health services to the
    point where no one can  afford them any more.  So, now governments and
    companies are now saying it is the individual's problem.
    
    In fewer words, big groups believed the myth of scale economies and
    when it proved false, we are now being called on to take over.
    
    pope
    

re: .75
  <<   Digital Medical Plans, the employee pays everything over and above that
  <<   to belong to an HMO.  The HMO itself absorbs the administrative burden,
  <<   so no additional cost to DEC. 

I rather suspect the administrative cost is calculated into the rates set by the
HMO.  And quite possibly we pay JH on a per/employee basis for administrating
the Digital plan. Whatever the case, It seems that SOMEONE has calculated a
base cost/employee and this is the figure originally asked for.

  <<  $ SET RELIGIOUS_WAR ON
    
  <<  If this additional true cost-per-employee were properly applied, i.e.,
  <<  tacked on to the Digital Medical Plan subscribers (and not subsidized
  <<  by the HMO members), I wonder how many people would be so xenophobic
  <<  about HMOs.....
   
Oh, come on!  The vast majority of HMO bashing has been about quality of care
and issues relating to choice.  The bashers don't seem to be down to the level
of cost for the most part.  As for me, when I lived in Massachusetts, I grabbed
the HMO option as soon as it became available for the medical group I was using.
For my family's needs, it was less expensive than JH. And the switch made 
absolutely NO DIFFERENCE in our medical services since we kept the same
physicians.

I've since learned that Massachusetts requires HMO coverage of services that are
not available through HMO's in Illinois, so when I moved out here in '86 I went
back to JH.

But every family is different and everybody's unbudging opinion is largely based
on their own individual experience.

	/Marvin

re .71:

>How much does DEC spend per employee for the Digital Medical Plans?

Wasn't this information in a graph in the Benefits Bulletin?

    I just can't help thinking that all these insurance companies, including JH,
    are nothing more than middlemen, who add an enormous "cut" to the
    overall medical costs. ( just think of how many people work for
    insurance companies just to handle paperwork!)
    
    Add to that all the obnoxious forms that we have to fill out,
    (wanna talk PCS here??) and there HAS to be a more efficient 
    method of transferring our income to doctor's pockets. 
    
    Somethings gotta give. 
    
    George

    I recently heard that within the next 6 months, ALL medical, HMO's and
    Digital Health plan will DOUBLE in employee cost!  This is from someone
    that has some pretty good contacts in the insurance field.
    
    Chris D.

Managers have received a pamphlet about the changes to medical coverage.
I glanced at it, and I didn't see any specifics about the payroll deduction.
For the Digital Medical Plans, both the deductables and the out-of-pocket
maxima are going up, I think about 20%.  New options are POS and opting
out of coverage (for those covered under other plans).

    For employees who have spouses (in-DEC or out) who are covered by
    an insurance plan. The employee can option out of his/her Digital
    insurance, be covered by the spouses insurance, and receive $20 a week
    on the paycheck. 
    
    This includes DEC-mates. For example my wife will opt-out of her 
    John Hancock and become a dependant on mine. She will then receive 
    an additional $20 a week on her paycheck.
    
    - John
    
    

RE: .83

    I believe you're mistaken about getting anything back for opting out of
    coverage (if covered by your spouse's plan).  My wife is also employed
    by Digital.  She is covered as a dependent on my plan.  We each filled
    out the paperwork so that she would be covered only under my plan.
    She does NOT get anything back.

    Do you know anyone actually getting $20/week for opting out?

    --Steve

    ... and the cost per week for dependent coverage is being raised to
    *$20*, right??
    
    There has to be a catch somewhere - my husband works here too (I was
    here first, though!).  Maybe I'm getting shell-shocked, but all of
    the budgetary schemes happening around me (state, local, federal
    government, this company, the phone company, the heating company, ad
    infinitum) have all boiled down to schemes to shift more of the cost to
    ME.  I've got the bottom-of-the-food-chain blues!
    
    /Charlotte

The $20 for opting-out because you can prove you are covered elsewheres has not
been implemented yet, but is going to be. What these folks are talking about is
information managment has been given already, but has not been fully communiated
to the troops because they wanted to educate managemnt first.

    re: .84
    
    No mistake.  Starting in January, that will be an option for employees.
    There are many other changes, including changes in coverage,
    deductibles and the addition of something called HealthNet in areas
    where Digital has an HMO agreement. The weekly  costs will change as
    follows:
    			Within HealthNet Service Area
    			Plan 1		Plan 2
    Individual		$ 5.50		$10.25
    Family		$21.75		$34.00
    
    			Outside HealthNet Service Area	
    			Plan 1		Plan 2
    Individual		$ 0.00		$ 4.50
    Family		$ 8.50		$20.50
    
    And no, I'm not going to detail all the changes here (in case anyone
    asks).  Managers and supervisors received a copy of a report entitled 
    "Health Care at Digital" last week.  Ask yours if you want to see it.
    
    Al
    

    When will the medical plan reflect the changes in society and the 
    difference in cost by having something in the middle of 
    Individual/Family to cover spouse/significant_other but no children?
    
    mike

    Well, I have plan 1 family coverage. Since I work in Southern N.H., I
    would assume I'm within a HealthNet area. Does this mean my weekly
    deductible is going from $7.50 to $21.75? Gee, that sounds like a good
    deal. There goes my gas money. I guess I have to work from home from
    now on.

                      <<< Note 1128.89 by STAR::DIPIRRO >>>
                     -< Am I interpreting this correctly? >-

>    Well, I have plan 1 family coverage. Since I work in Southern N.H., I
>    would assume I'm within a HealthNet area. Does this mean my weekly
>    deductible is going from $7.50 to $21.75? Gee, that sounds like a good
>    deal. There goes my gas money. I guess I have to work from home from
>    now on.

        That's how I'm interpreting what the booklet says.  The increase
     is due to the fact that we live in an area that offers the new
     Healthnet option.  

        Healthnet is being called a point of setvice program ... it's
     being offered through 4 existing HMOs ... but one is supposedly
     supposed to be able to use either the HMO or pick medical care
     outside of the HMO ... cost will be more if you go outside the HMO,
     of course ... no reference on how much more though ... and it
     doesn't state how much this HealthNet business is going to cost per
     week/family/individual/whatever.  

        I'm not a happy person right now.

        Vicki

   I must have read that document a hundred times trying to understand
   what they are changing. The document is "Health Care at Digital".
   Your manager should have received a copy. Ask him/her to see it.
   The booklet is full of the usual medical insurance double talk.

   Here is my cut at what "Digital Healthnet" is:

   Disclaimer: I do not work for personnel and do not speak for them.

1. There will continue be the Digital "Plan 1" and "PLan 2". These
   plans will continue to work as in the past except that the weekly
   deduction will go up and the deductibles will also go up. This
   there way of telling you that they want you to switch to healthnet.

2. Healthnet is combination of HMO's and the plan 1 or 2.
   You decide whether or not to use the HMO or go to a nonHMO doctor. 
   If you use the HMO you pay the HMO copayment. If you go to a nonHMO
   doctor, you pay and try to get reimbursed.

   The nonHMO portion has higher deductibles than the straight plan 1
   or 2. They are:

   $250 deductible ($750 family)
   70% reimbursement for submitted claims at reasonable and customary
   levels.
   $2500 out of pocket maximum per year ($7500 family)

3. The booklet doesn't say what the Healthnet costs are going to be.
   The implication is that it will be less than the straight plan 1 or
   2. It will probably depent on what HMO you select.


   Joe

I got the Benefits Bulletin yesterday.  The payroll deductions for the
Digital Medical Plans for those who live in the areas served by the
new POS plan (HealthNet) have increased dramatically.  Here's a
comparison (note that the rates for those who don't live in the areas
served by HealthNet are up only slightly):

		DMP 1 (1990)	DMP 1 (1991)	DMP 2 (1990)	DMP 2 (1991)

Individual	    $0		   $5.50	   $3.50	  $10.25

Family		  $7.50		  $21.75	  $17.50	  $34.00

The deductables are up from $175/$525 to $200/$600, and the out-of-pocket
maxima are up from $1200/$3600 to $1500/$4500.

Here's a quote:

    "The weekly payroll deductions for the Digital HealthNet HMOs are not
    available yet, but will be provided in the Open Enrollment materials.

    "The payroll deductions for the Digital Medical Plans will be higher
    than those for standard HMOs and the Digital HealthNet HMOs due to
    the increased costs of offering these plans.  Generally, depending
    on how efficiently the individual HMOs operate, the payroll deductions
    for the Digital HealthNet program will be higher than the costs for
    standard HMOs due to the additional cost of indemnity benefits
    outside the HMO."

Since the payroll deductions for all the HMOs in my service area
in 1990 were higher than the DMP 1 deductions in 1991, the statement
above implies that HMO deductions are going down.

    Does the document "Health Care at Digital", which the managers are
    supposed to have, contain any significant information not contained
    in the Benefits Bulletin?

    I am outraged and I am surprised that other Digital employees are not
    equally as upset as I am.  If I read the health update I received correctly
    the cost for providing basic medical coverage for my family will
    rise $17 week or close to $900/year unless I choose to abandon my
    families doctors and join an HMO/PPN.  Talk about boosting morale.

re: 1128.95 by SHEBA::GUEST

You have good reason to be outraged, but not at DEC: the medical and medical
insurance (and legal, and sue-ers, and ...) community has been out of control
for years and HMO's seem to be a valid and necessary attempt to control costs
while continuing to provide good care (and they appear to be doing it!)

Yes, there is an obligation to the employee that I think DEC has satisfied and
is continuing to address to the extent that it can.  But given the obligation
to stockholders, DEC cannot continue to be held up by vendors who persist in
pushing prices/costs up.  If you want 'custom' healthcare, you'll have to
continue to pay your fair share.

Pete

P.S.  I am not in personnel, etc., etc.; I am in Plan 1 and will switch to HN
or some HMO due to the increase in cost in Plan 1.  I'll have to say 'so long'
to my, my wife's, and my 3 kids' doctors but it's really their fault, isn't it?

>I'll have to say 'so long'
>to my, my wife's, and my 3 kids' doctors but it's really their fault, isn't it?
    
    If you think that you should have left them years ago. Personally I
    do all I can to keep my families (and DECs) medical costs down. If I
    thought we could get as good care and save money at an HMO we would
    have switched years ago. But I don't. I guess I'll wind up paying
    more. My family is worth it. I'm not going to short change them. In
    the long run DEC will save a bunch at my expense.
    
    			Alfred

    And don't think because you haven't seen it here that people aren't
    outraged. I know I am, and so are many others I've talked to. Like
    someone else pointed out, you can't *just* be mad at Digital for this
    one. However, I really don't know what to do about this. I have two
    little kids who are finally happy with their pediatrician. My wife and
    I go to the doctor pretty infrequently. So we're rather indifferent on
    the issue...But I'll be damned if I'm going to switch doctors on my
    kids. Sounds like I should choose HealthNet and go "outside" for my
    kid's care...which basically means I'll be paying for it all out of my
    own pocket for the most part, with the high deductible and my 30%
    contribution after that. Terrific.
    
    I'm also looking at Digital's complete benefit package now...along with
    the less-than-perfect work atmosphere. Most people don't jump ship
    during tough economic times like this...However, when the economic
    situation improves, I hope Digital keeps its overall benefit package
    competitive by doing more. Otherwise, this "downsizing" trend may take
    on ridiculous proportions.

    Actually switching to an HMO does NOT automatically mean that you have
    to abandon your current doctors.
    There are two types of HMOs. I do not know how they are characterized,
    but the difference is like this. In one you have to go to a group or
    center to get traetment and have to choose from the doctors there. In
    the other - I think it is called the physician centered or something
    like that - the HMO has a large group of doctors spread over its
    region, sometimes even two or more in the same area. You choose the
    physicians you want for the primary care for yourself, your spouse and
    your kids (don't have to be the same). They would recommend specialists
    as and when needed.  
    A lot of physicians DO subscribe to this form of HMO. You MAY be
    surprised to find that there is one HMO in which all your physicians
    are members. At worst you may have to change one. 
    I would suggest talking with your physicians to see what HMOs if any
    they subscribe to, and you may wind up choosing an appropriate HMO. That
    is what happened with me - The main problem will turn out to be not
    physicians but affiliated hospitals - but that is another discussion.
    
    It IS worth investigating. Good luck
    
    Krishna           
    

    Nothing I've seen in either the benefits bulletin or the manager's
    advance warning adequately explains to me why the Digital Medical Plans
    1 & 2 cost different amounts depending upon whether or not you are
    within or outside of the HealtNet area.  That makes no sense to me.
    
    Can anyone explain why plans 1 & 2 cost about 30% more within the
    HealthNet service area than they do outside?  This fact alone sort of
    shoots down the "cost-of-service" argument, since indemnity plan costs
    should not vary by 30% based upon some arbitrary "blue line"
    HMO/HealtNet availability criteria.  Now, THIS looks to me like an
    attempt to *force* one to use HealthNet via artificial cost
    manipulation.
    
    What am I missing here?
    
    Dick.

    Delayed, low or no raises, heathcare going up, taxes up, gas up,
    family costs going up....This must be a test that is preparing me
    and my six dependants for something better in the future?.
                               
    As in all bureaucracy each individual plan, action or whatever, is not 
    unreasonable when looked at in isolation. It is the "sum" that proves 
    to be unacceptable.

    I really do agree that the timing is bad from a moral point of view.
    I must ask what are we trying to do?. Hurt and insult good, hard
    working, people, or make this company a winner?. It does feel like
    things are not being thought through and that no one is looking
    at the big picture. 
    
    Now the "brave ones" who would speak out do not feel secure enough 
    to do so any more. The words "package" or "transition" strike fear 
    into the hearts of many of us. 
    
    But I digress. Cycling back; the health cost increase, for whatever 
    reasons, is another "Tax" to solved overspending by someone else. Why 
    complain, we shoud be used to that by now in this state!.
    
    Eric, who too, is angry.
    
    

    re .101
    
    Eric, I totally agree with you!  It looks like yet another take-home pay
    cut to me too.  We had a family pow-wow last night to try to figure out
    how to afford this one, and no conclusions were reached.  After two
    years of no pay raises, big increases in state taxes, and now federal
    taxes too, and much larger heating and gasoline bills, things are
    getting REAL tight!  We have been going to the same doctors for years -
    I've used the same gyn. since I was in college!  The local medical
    clinic turned into an HMO a few years back, and while we still see one
    doctor there, the service offered by that place has become real
    impersonal, a regular assembly line, and I don't plan on switching to
    them in place of our regular allergy doctor, my husband's physical
    therapist for his knee injury, etc.  They used to be patient-oriented!
    
    I just hope I get a pay raise in 1991 - it's been a *long* time!  But I
    bet it won't even bring my take-home pay up to what it was before all
    these new increased expenses started taking hold, let alone give me any
    additional breathing room!  It is getting real depressing, and causing
    a lot of family stress; there doesn't seem to be any way to avoid
    paying sharply higher costs for all sorts of family necessities, which
    means that family fun items have been greatly cut so everyone is upset!
    We are beginning to feel cheated, victimized, etc.!  Maybe it will be a
    relatively warm winter (not like last year!), so the heating bill will
    only be half again what it was last year instead of twice as much - but
    I'm not counting on it.  Sigh.
    
    /Charlotte
                                      

    I live in MA...well inside the "health-net" area.  But, my children
    live in San Antonio, Tx... and it's not available there.  Neither is an
    HMO available (thru DEC) there.  So, it's plan 1 or plan 2 for me.
    
    I currently am on plan 2, because of the additonal "in hospital"
    benefits.  But, for the last two years, non of my kids have been in a
    hospital...so maybe it's time to revert to the less expensive plan 1?
    
    my wife is also a DECCIE, so we will probably "opt out" for her... the
    extra income in her salary may offset the new higher cost of my
    insurance..  I hope so, at least.
    
    Some earlier replies complain about the cost of medical service these
    days.  There are some things you and I can do about that...but, very
    little.  We can scrutinize each bill sent to the insurance company, and
    question services and billings.. but, how effective that is, I'm not
    sure.  As long as insurance companies, including medicare and medicaid
    appear to have limitless funds to the service provider, the service
    provider is gonna put his/her hand ever and ever deeper into that
    pocket.  And as long as the consumer allows the medical community to
    get away with saying "we provide the service we are asked for" as the
    reason for escalating the service (type and cost) they will continue to
    do so.  When was the last time you were asked what service or treatment
    you wanted?  
    
    tony

I don't have the Benefits Bulletin in front of me, but I believe it says
something about DEC subsidizing the DMP for those in non-HealthNet areas
*until HealthNet gets set up in them*.

There's no doubt that DEC wants us to all switch to HMOs.  The only reason
for HealthNet is that many people object to the lack of flexibility of HMOs,
and DEC is betting that they'll be willing accept the compromise of a POS
rather than pay the exhorbitant rates of the Digital Medical Plans.

BTW, people in DMP 2 might want to consider switching to DMP 1.  The only
difference is that DMP 1 requires a 20% copayment for hospitalization
and surgery.  If your non-hospital expenses are high, you'll hit the
out-of-pocket maximum anyway.

    re: .100
    
>    Nothing I've seen in either the benefits bulletin or the manager's
>    advance warning adequately explains to me why the Digital Medical Plans
>    1 & 2 cost different amounts depending upon whether or not you are
>    within or outside of the HealtNet area.  That makes no sense to me.
    
    The intent, plain and simple, is to use economic pressure to attempt to
    force people to use HealthNet rather than the Digital plans.
    

        Re: .100

>    Can anyone explain why plans 1 & 2 cost about 30% more within the
>    HealthNet service area than they do outside?  This fact alone sort of
>    shoots down the "cost-of-service" argument, since indemnity plan costs
>    should not vary by 30% based upon some arbitrary "blue line"
>    HMO/HealtNet availability criteria.  Now, THIS looks to me like an
>    attempt to *force* one to use HealthNet via artificial cost
>    manipulation.

        Since I haven't seen the HMO or healthnet prices I'm only
        guessing, but I suspect they want to provide one `low cost'
        option for everyone ($0 per week for individual and around $10
        for family).  Within the healthnet area this will be available
        through an HMO but outside the healthnet area they feel they
        have to do it with lower cost for the Digital medical plans
        (because they don't want to force people into an HMO if they
        don't feel there is a good HMO in the area).

        The healthnet area is currently the coverage area of four HMOs,
        Fallon Community Health Plan and Harvard Community Health Plan
        in Eastern Massachusetts, one in Southern New Hampshire and one
        in Colorado.  There are lots of other HMOs in various areas but
        Digital won't try to force you into an HMO for 1991 unless you
        live near one of those four.  The bulletin says they were chosen
        by cost, service, and ability to take new subscribers.

        There is a chart in the bulletin showing the average cost of an
        HMO versus the average cost of a standard plan with the HMO
        being cheaper.  The chart shows Digital's cost being the same
        for both plans with the employee paying lots more for a standard
        plan.  From what I have heard, healthy people are more likely to
        choose an HMO--if this is true than the chart is something of a
        fraud unless it adjusts for this bias.

        					B.J.

    What makes me truly angry is the real lack of choices here. It would
    be one thing to do this when things were easier. But to attempt
    to call this farce a choice is ridiculous. I fully expect the cost
    of the Healthnet HMO's to be less than the cost of other HMO's in
    the same service area. However, this never takes into account the
    needs of those HMO's serve most - people with children. I second
    the thoughts of the other noter who spoke about children being
    comfortable with a physician. The lack of choice of HMO's within
    Healthnet will force people to travel alot farther to receive
    medical service. I don't know about the CXO HMO but both Harvard
    and Fallon are clinic based and those of us who live and work along
    RTE 495 will find it alot tougher to deal with child illnesses that
    never occur during times when it's easy to get to the doctor.
    
    I left Harvard 2 years ago because they couldn't be bothered to
    deal with my child's need to see the same physician most of the
    time. What I found interesting was that most of the physicians 
    who seemed to show compassion for their patients left around
    that time too. Clinic based care is, IMHO, simply "manufactured"
    health care. 

re:  <<< Note 1128.104 by NOTIME::SACKS "Gerald Sacks ZKO2-3/N30 DTN:381-2085" >>>


>> BTW, people in DMP 2 might want to consider switching to DMP 1.  The only
>> difference is that DMP 1 requires a 20% copayment for hospitalization
>> and surgery.  If your non-hospital expenses are high, you'll hit the
>> out-of-pocket maximum anyway.

I wouldn't recommend it. Having just gone thru surgery and a 
hospital stay myself, I can tell you that the 20% co-payment
is *A LOT* of money even if you count the out-of-pocket maximum.
I'm glad I chose to keep the DMP 2 that's for sure.

Jenna

re .107:

>                                               I fully expect the cost
>    of the Healthnet HMO's to be less than the cost of other HMO's in
>    the same service area.

from the benefits bulletin (quoted in .93):

>                                                "Generally, depending
>   on how efficiently the individual HMOs operate, the payroll deductions
>   for the Digital HealthNet program will be higher than the costs for
>   standard HMOs due to the additional cost of indemnity benefits
>   outside the HMO."

re .108:

    Perhaps I should have stated more clearly, "your mileage may vary."
    It depends on how much you have to shell out in copayments for
    office visits.

    The way I figure, with family coverage (and either 2 or 3 people
    covered), if you have at least $3515 each in expenses that are
    80% covered under both plans (office visits, tests, etc.), you're
    ahead of the game by choosing DMP 1 over DMP 2, regardless of the
    costs of hospitalization and surgery.  If some of your expenses are
    only 50% covered (e.g. psych over $2000), or there are more than
    three people covered, the break-even point is lower.  

    I'm not sure I understand what the problem is that Digital is trying
    to address: is it that health care providers are charging too much
    or is it that Digital employees are wantonly using up healthcare
    resources?
    
    Most of the changes to the existing plans and the additional plans seem
    aimed at "solving" the latter problem. Most of the changes seemed
    directed at reducing my choices and, in effect, make it more difficult
    for me to obtain medical care. If this little straw horse isn't
    completely off base, that does more than anger me: it insults me. 
    
    I do not go to the doctor on a whim. I use healthcare as little as
    possible. I have worked for more than 10 years to build up a nice set
    of widely scattered effective providers with whom I feel comfortable
    and in whom I have confidence. I deeply resent being told, in so many
    words, that they are inefficient, costly, and need checking up on. And
    not for a minute do I believe that the economic coercion being passed
    off so matter-of-factly by the propaganda cranker-outers is really "my
    choice." 
        
    Why am I going to have an additional and expensive someone whom I have
    never seen looking over my doctor's shoulder telling me how sick I am,
    what doctor is approved for me to see, and what the appropriate
    treatment for me is? What am I, too gullible to be trusted? As the
    customer here, I don't like being treated like I'm stupid and don't
    know what's good for me...hey maybe there is a business message in
    there. 
    
    This managed healthcare sounds a lot like medicine by the automotive
    rate book. I hope my managing physician (service advisor) keeps
    the books straight. 
        
    Are we trying to improve the quality and reduce the cost of medical
    care by testing, by inspection, and by a hostile relationship with the
    supplier? Hasn't long experience with our own products taught us
    anything? Hasn't anybody paid any attention to what DFM, Six Sigma, and
    JIT have to say about simplification and reducing non-value added
    activities and eliminating layers of complexity? Were any of the
    customers of these plans surveyed to determine what we wanted? And
    surely we are at least as much a customer as is the company. 
    
    John H.

re Note 1128.110 by ISLNDS::HAMER:

        My sentiments exactly. I want to know how the same doctors,
        clinics, and hospitals giving the same care cost so much more
        when "patient managed" than when "primary care physician
        managed" -- especially considering all the reviews imposed on
        "patient managed" care these days.

        Are the HMO's and other "managed" options being subsidized by
        the traditionally-insured patients?

        Bob

    
    re: .0
    
    After I joined an HMO, I've never been happier. John Hancock was 
    very bad in my case. I like only paying 3 dollars a visit, no
    matter WHAT I go in for!
    
    /prc

    Is this HealthNet option only in New England? If so,
    it seems terribly unfair to increase the costs of 
    medical coverage only in a certain area of the country.
    Is there something wrong with this picture?
    

    The booklet says that you can only opt out of the plan and get the $20
    per week if you're covered by some other medical plan. This seems like
    discrimination to me. What's it got to do with the company whether I'm
    covered by medical insurance or not. If I choose to self insure or
    go to a rich relative that's my business not the companies.
    Anybody know why there is this discrimation? In particular it hits
    single people such as myself. $20 * 52 = $1040 per year. Not much but
    not worth dismissing. Added to that is the money we're now forced to
    pay.
    
    Dave

	Pete (-.1), I'd have to agree with you.  I really like being
	in an HMO.

	I must admit that I do have some hassles with my HMO when it
	comes to specialized/non-life-threatening care (I've had to wait
	eight weeks to four months for some appts), but if you're firm
	enough with them, you get what you want.


	If I'm wicked sick, I know the clinic is open 7 days a week,
	I know I can get in RIGHT THEN to see someone and I know I won't
	have ANY paperwork to fill out and only have to pay $3.  Only in
	specialized cases do I really need to see the same doctor over
	and over......and I can.


	Deductible/paperwork/percentages/etc are a HIGH cost
	to Digital/John Hancock....If you want Digital to operate
	in an efficient manner, you have to accept these sorts of
	changes (I've seen many companies formulating the same plans over
	the last 2 years.....it's NOT only Digital, everyone is going this
	direction).


	From my experiences, Digital has probably one of the BEST benefit
	packages out there right now......For a family of three, my father
	was paying almost $50 a week with his company......in small
	businesses I know people paying that much for themselves only!
	One computer company I interviewed with in college didn't even
	OFFER medical benefits to it's 100+ employees.


	I actually commend Digital for the change.  They're streamlining
	their benefit plan while still offering affordable, acceptable
	medical insurance for their employees and their families.  Digital
	isn't the FAT CAT company many of you worked for a few years ago,
	perhaps some people are losing sight of that fact.


	Or would you rather Digital keep the benefits the way they are
	and transition a few more thousand of us?  Personally, I'll thank
	Digital that I still have a job at all in these trying times and
	I'll thank Digital for doing everything we can to make this company
	better without resorting to substandard health care.


	Digital's HMOs are not substandard, if you have urgent medical
	needs they WILL be addressed promptly...if you have low-priority
	problems, you'll have to be a little more patient, that's all.


	Some Digital employees are going to have to learn the meaning
	of the word "compromise", something I think some employees aren't
	willing to do for the sake of their company and THEIR JOB.

	We don't live in lala land anymore.....the economy out there is
	ROUGH.  It's not just hard on each and every one of us employees,
	it's hard on Digital as a company as well.  Perhaps your kids
	will have to get Levis instead of Guess jeans this month....and
	perhaps Digital will have to cut back on benefits as well.

	It's all a matter of survival......do you really give your children
	everything they want, whenever they want it and do they get the
	best or sometimes do they have to "settle"?


	kath

    
    RE: 115
    
    In my, no so humble, opinion and in my case, it isn't a question of
    "Levis or Guess" and it isn't a question of discretion. Sure the
    company has problems, sure the economy has seen better times but the
    old WW II bromide of "There's a war on, you know." dosen't cut it as
    far as real answers or real reasons. Lot's of dumb decisions are hidden
    by this call to the obvious. 
                           
    I just don't like people trying to tell me the yellow water running
    down my back is rain. That's the real core of my problem with this
    modification.
    
    And by the way, you ask if I'd rather the plan didn't change and
    instead DEC 'transition' thousands more, or whatever? It's okay by me.
       

    I for one sure don't like the constantly escallating cost of everything
    but,let's keep our perspective here,no matter how bad it gets
    here,things are lots worse elsewhere in the world...
    
    I just keep telling myself that!

    re: .114

    I believe that in the U.S. there is some law that requires a company
    that provides health benefits to provide them on an equal basis for
    all.  This is to prevent employers making one group subsidise (sp?)
    the health care costs for another and to prevent companies from forcing
    employees with 'lots' of claims off the plan by raising their rates above
    the rest of the employees.  Please note that an employee with many
    dependents could generate 'lots' of claims simply by having each
    dependent sick once a year.

    My wifes employer requires proof of other insurance before allowing any
    of their employees to opt out.

    Bob
    

    Re .-1
    
    I'm not sure I understand. Why am I only allowed to say I don't want
    DEC's health insurance if I have health insurance somewhere else?
    Why is it effectively a condition of employment for me that I now PAY
    for health insurance. Before I didn't really care because it didn't
    cost me anything out of my pocket. Next year it is going to cost me
    real money. Why don't I have the option of saying to DEC, I don't want
    to be covered by your health insurance plan? It appears that employees
    who are covered by someone elses plan can say to DEC that they don't
    want to be covered and DEC will refund them $20 a week in lieu of the
    health insurance benefit.
    
    I'm not sure that in the final analysis I'd decide it made sense for me
    to decline the health insurance benefit but it sure annoys me I'm being
    told I have to pay for something I may not want.
    
    In case anybody wants to jump in and discuss how mad I'd be not to be
    covered by DEC's health insurance I want to say I'm not interested in
    that argument. I feel that's a personal decision for me to make taking
    into account my own individual circumstances.
    
    You refer to this 'equal basis' law. That's what I'm arguing, I feel I
    should be equally entitled to the $20 rebate. I don't think it should
    be conditional on having health insurance elsewhere. As far as I'm
    aware (at least I hope that is the case in this 'land of the free'!)
    there is no law that mandates that an individual has to have health
    insurance.
    
    Dave

re: .119
 
>    I'm not sure I understand. Why am I only allowed to say I don't want
>    DEC's health insurance if I have health insurance somewhere else?

I suspect this was done to prevent unethical employers from coercing 'high risk'
employees into declining health insurance benefits.

>    Why is it effectively a condition of employment for me that I now PAY
>    for health insurance. Before I didn't really care because it didn't
>    cost me anything out of my pocket. Next year it is going to cost me
>    real money. Why don't I have the option of saying to DEC, I don't want
>    to be covered by your health insurance plan? It appears that employees
>    who are covered by someone elses plan can say to DEC that they don't
>    want to be covered and DEC will refund them $20 a week in lieu of the
>    health insurance benefit.

See above.  Plus, I agree with you.  You should not be required to pay for
health insurance you don't want.

There is a similar situation here in Texas with automobile insurance.  About
a year ago I received a letter from my insurance company stating that per
Texas Automobile Insurance regulation mumble-mumble, I was required to pay
for UNDER-insured motorists insurance.  I called my agent and asked what this
was all about.  UNDER-insured motorists insurance will cause my insurance
company to pay my claims if I am in an accident and the driver at fault didn't
have high enough limits to pay my claims.  I asked how I could avoid paying
for this unwanted insurance.  The only way I could get out of it was by
dropping my collision coverage.  Not something I would want to do, and not
something that my lien-holder would permit.

Does anyone know whether the restrictions on opting for no coverage are indeed
due to some U.S. law concerning health insurance?

Bob

re .112,.115 ("I love my HMO"):

I'm glad you like your HMO.  You're fortunate that you enjoy good health,
and have no need for top specialists.  You're lucky that you don't need
psychological services.  There are DEC employees who have different
medical needs, and those folks are being hurt by the change in benefits.

re .113: ("New England only?"):

The HealthNet areas cover most of Eastern and Central Massachusetts,
Southern New Hampshire, and the Colorado Springs area.  According to
the Benefits Bulletin, the rest of the country will be covered soon.

    My GUESS is that you're required to have health insurance for similar
    reasons to being required to have auto insurance -- if you *don't* have
    it and you can't pay, then it's the taxpayers (at least in the case of
    health care) who have to pick up the tab.
    
    Frankly, I don't want to subsidize people who prefer to pocket the
    $20/wk and take their chances only to get some major illness and end up
    on Medicaid (my tax dollars) when they *did* have an option!
    
    I'm not thrilled, either, with DEC calling this a "choice."  Why not
    say, "This is it, folks -- this is what we are offering for your health
    care insurance," rather than offering a "choice" that is so financially
    prohibitive as to not constitute much of a "choice."
    
    My husband and I are both in our 50's -- he has a cardiologist and I
    have a gynocologist.  After "training" these specialists to understand
    our particular and peculiar health situations, we are now torn between
    starting over with strangers -- and possibly repeating expensive tests
    or previous experiments with medications -- or paying really high
    prices for these specialists and any resulting medical care involving
    them.  Natrually,  these are the health problems where we are the most
    vulnerable and the most likely to *need* tests, surgery, or
    hospitalizations in the future.
    
    Consequently, if we are in a HealthNet zip code area, I don't feel we
    have a *real* choice!
    
    In addition, we will now have to leave our neighborhood pharmacist who
    is about 1 mile away and who knows our needs and our drugs and,
    instead, load up monthly at the HMO, which is in another town!
    
    Adjustments!  Adjustments!
    
    Not happy either,
    Nancy

    I've got mixed feelings about this change.  On one hand, the company is
    finally pricing the options in direct relationship to the alleged
    costs.  Prior to this, DECplan 1 was the lowest cost per week, yet the
    company (and others) kept telling us how expensive traditional
    insurance is, and how HMOs control costs.  So why did HMOs cost more per
    week? 
    
    When I first read about "Opt-out", I broke out laughing.  $20/week is a
    ridiculously small sum to pay for health insurance.  If any sort of
    coverage was available on the open market for that price, I'd be
    surprised. Does anybody know what the typical cost per employee is for
    health insurance?  I've heard (years ago) numbers like $150-$200 per
    month. Someone earlier in this note said $250.  What basis does DEC
    have to refund less than half that cost if the employee "opts out"?
    
    I was also mystified by the requirement that you have other coverage
    available.  I don't know if this might be a requirement of US or state
    law, though.  I wonder what they will accept as evidence of alternative
    coverage?  Would enrollment in the Health Care Reimbursment Account
    (HCRA) program be sufficient?
    
    Speaking of HCRA, that is a new "benefit" noone's mentioned.  You can
    put up to $40/week pre-tax into the HCRA and then get reimbursed for
    medical expenses that come out of pocket.  It's "use it or lose it"
    like the Dependent Care Reimbursment account.  It essentially allows
    you to deduct some of your medical expenses without meeting the 7.5%
    threshold in the tax code.  Since it pays for contacts, eyeglasses,
    etc, I'll probably join for a small amount that I can be sure of using
    up.
    
    Tim

    
    
    Suppose one opts out of DEC plans and goes to another health plan. 
    Does that mean DENTAL is also lost ?  Or is DENTAL separate from DEC
    PlANS ?
    
    Re: - last few
    I also this $20 /week is very low considering what DEC will say for us
     people to opt out! 

    
    I also have an HMO, Pilgrim Health Plan, from New England.  Originally
    I was carried under Blue Cross B/S which is similar in administration
    to our Digital plans.
    
    I changed to an HMO because I didn't have to collect all my slips
    and hand them in one or twice a year.  I was lucky I didn't have
    to change doctors as they also carried the HMO.
    
    My wife had to have a major operation earlier this year and the
    doctor recomended another specialists and hospital that wasn't covered
    under my HMO.
    
    No problem!  My primary care doctor sent the form to my HMO requesting
    out of plan and it was approved.  Total out side of plan cost was
    43,000.00 and it was all covered, including 3 month follow up visits.
    
    Cal.
    

It is clear from the preceding entries, and from conversations with fellow 
DECcies, that we have become a society of CRYBABIES, SORE LOSERS, and people 
who expect SOMETHING FOR NOTHING with somebody ELSE to pay for it.

If you DEMAND the PRIVILEGE of retaining your personal choice physician or 
specialist, then you should be prepared to PAY for that privilege, and stop 
expecting the rest of the company or society to SUBSIDIZE your PREFERENCE, 
which is exactly what has being happening.

If you are unwilling to deal with the crisis in health care costs, and expect 
your little corner of the world to fixate on 1965-era costs, then this is a 
wake-up call.  If you are unwilling to do anything about the problem, then 
don't expect it to go away by itself.  You are part of it.

If you insist on dredging up anecdotal evidence or catastrophizing about why
an HMO won't work for you, then go PAY EXTRA for what WILL WORK, and leave the
rest of us out of it. 

It is CLEAR that there is a crisis in health care costs.  The sole mechanism 
that has demonstrated an ability to CONTAIN COSTS while preserving QUALITY is 
the 25-year old HMO/PPO concept.  Socialized medicine sacrifices quality and
distributes costs politically rather than economically, a rathole I bring up
only because some well-educated people can't seem to distinguish between
HMO/PPOs and socialized medicine (this includes -*-surprise-*- much of the
medical community). 

I grew up living next door to our family doctor, a GP (general practitioner 
--- remember them?).  My family and I were also served by U.S. Navy medicine
for 6 years and by the Lahey Clinic HMO for the 8 years I lived in Mass.

Somebody complained about lack of choice... You want to know what lack of 
choice is?  I just relo'ed to Grand Rapids, MI with DEC and there is no HMO 
available here through DEC.  I am forced to use the DMP and it stinks.  I do 
nothing but fill out forms, make phone calls, and write checks.  How anyone 
could say that they like this system, let alone _prefer_ it, is beyond me 
--- and it is costing both me AND the company more than the HMO did!!!

(I hope this also puts to rest once and for all the absurdly untenable notion 
 that both HMOs and the DMP are equally costly for DEC to administer.)

We tell our customers that there is no free lunch when it comes to investing
in technology to become more competitive.  But we personally expect a free 
lunch when it comes to health care.

Look at the facts, people.  You don't always get things your way.  If you're 
all such authorities on medicine that you know exactly which doctor to go to,
then you should be willing to pay extra for your choice, and not expect
me and everyone else to help you pay for your "champagne" tastes.  When the
medical community is willing to do something to contain costs (other than
the HMOs), then I'll be more sympathetic to all of this whining. 

Go look up "xenophobia" in the dictionary.
\Gary

>  Note 1128.121 by NOTIME::SACKS 

>I'm glad you like your HMO.  You're fortunate that you enjoy good health,
>and have no need for top specialists.  You're lucky that you don't need
>psychological services.  There are DEC employees who have different
>medical needs, and those folks are being hurt by the change in benefits.

	How do you draw these conclusions?  I have seen specialists
	in my HMO, I don't exactly have "good health" and where did
	I say that I don't need psychological services?


	My HMO adequately provides for all of the above....granted,
	I do NOT have the best doctors in the country at my disposal,
	but I do have good ones.  Sure, there ARE people out there
	that NEED coverage like JH, but it's my impression that those
	people are a very small percentage of Digital's workforce.


	Notice, there's a difference between the words "like to have"
	and "need."


	kath

re Note 1128.126 by GLDOA::REITER:

> If you DEMAND the PRIVILEGE of retaining your personal choice physician or 
> specialist, then you should be prepared to PAY for that privilege, and stop 
> expecting the rest of the company or society to SUBSIDIZE your PREFERENCE, 
> which is exactly what has being happening.

        The problem is that some of us are unwilling to buy the
        propaganda that if the doctor chooses it's less expensive
        than if we choose.  The managed options are a fraud in this
        regard; it isn't really the doctor who manages the care, but
        the plan administrators who are managing the costs.

        It just so happens that my children's pediatricians are all
        part of a clinic that belongs to HCHP (we started with them
        before they joined).  One of my daughters has developmental
        problems.  We have always involved her doctor in the choice
        of specialists, but it is clear to us that the doctor himself
        feels a much greater freedom to recommend a specialist, and a
        greater range of specialists, because we are not a part of
        HCHP.

        I prefer to have a doctor whose primary objective is to
        manage the care, not to manage the costs.  It is clear that
        for the HCHP patient, this doctor's primary concerns are
        warped to consider plan guidelines.  The plans' literature
        would have you believe otherwise.


> Socialized medicine sacrifices quality and
> distributes costs politically rather than economically, a rathole I bring up
> only because some well-educated people can't seem to distinguish between
> HMO/PPOs and socialized medicine (this includes -*-surprise-*- much of the
> medical community). 

        Perhaps they believe in a system that distributes costs
        medically, rather than either politically OR economically.


> (I hope this also puts to rest once and for all the absurdly untenable notion 
>  that both HMOs and the DMP are equally costly for DEC to administer.)

        As you say, anecdotal evidence is meaningless! :-)

        There is no doubt that managed options offer more convenient
        billing and payment options.  I would think that more
        convenient, and less costly, methods could be developed for a
        plan that was otherwise managed traditionally.


> Look at the facts, people.  You don't always get things your way.  If you're 
> all such authorities on medicine that you know exactly which doctor to go to,
> then you should be willing to pay extra for your choice, and not expect
> me and everyone else to help you pay for your "champagne" tastes.  

        The problem is that even the DOCTOR has less choice in a
        "managed" situation.  The choice isn't layman vs. doctor, the
        choice is layman and doctor vs. administrator.

        Bob

re Note 1128.127 by SELECT::GALLUP:

>         Sure, there ARE people out there
> 	that NEED coverage like JH, but it's my impression that those
> 	people are a very small percentage of Digital's workforce.
  
        But if everybody who doesn't need it opts out, then the costs
        for traditional coverage will become so astronomical that
        even those who do need it won't have the option or won't be
        able to afford it.

        Bob

re .127:

In regards to HMOs being for those without health problems:
  We've gone through two top specialists until we found one we could deal with.
  Under the Digital Medical Plan, we could change specialists when *we* felt
  the need, without asking anyone's permission.  Try that in your HMO.

In regards to psychological services:
  According to the open enrollment booklet I got last year, none of the HMOs
  available in my area will pay for more than 10 or 20 sessions.  That's
  not my definition of adequate psychological care.  And again, try changing
  specialists when *you* feel a need.

In the Pogo comic strip a few months ago, Howland Owl was running an HMO.
HMO stood for "Healthy Members Only."

    re .126
>Go look up "xenophobia" in the dictionary.
    ok. xenophobia n. Undue fear or comtempt of strangers or foreigners
    
>It is clear from the preceding entries, and from conversations with fellow 
>DECcies, that we have become a society of CRYBABIES, SORE LOSERS, and people 
>who expect SOMETHING FOR NOTHING with somebody ELSE to pay for it.
    This amounts to a pay cut. I fail to see why I should be pleased about
    a pay cut.
    
    gary

See 1208.76.

    Re .126
    
    Are you always this tolerant of people who don't share your point of
    view?
    
    You may have brought up some valid points, but your tone is so
    offensive that I found myself totally turned off to the point I 
    didn't hear your message.
    
    Why don't you go back and read what you wrote - and think about
    how you'd like somebody speaking to you like that.
    
    ep 

    re: some previous notes concerning HMOs
    
    I feel a need to defend the quality of care provided by at least one
    HMO. 
    
    We have Fallon, in central Mass. One of our children was critically ill
    for 6 years, requiring *hundreds of thousands* in medical care (10
    major brain surgeries, various types of chemotherapy, many treatments
    at various Boston hospitals, many, many specialists). We did not have
    to pay for any of this. We were referred to the best hospitals in the
    area (Children's and Brighman & Womans). They were going to pay for
    treatments in San Fransisco. They *did* pay for an experimental set of
    treatments done by a team from Children's, Brighmans and Sidney Farber.
    
    This may be anectodal, but given the tremendous support we were given
    by these folks I feel a word in their defense is needed.
    
    BTW, we met with some of the HMO's senior mgmt when this all started,
    to get their agreement on how much they would cover, etc. Our doctor
    suggested we get their approval for a long-term strategy right up
    front. Later, when there were questions about coverage we were able to
    refer to the agreement and it went through quickly. We were *never*
    aware of any expense being spared...we were consistently given the best
    treatments, and referred to the best in the medical business!
    
    One experience, but a positive one for HMOs.
    
    Tim
    

RE: the strong criticism of HMOs

I was a member of Matthew Thornton Health Plan in Nashua NH for 4 years.
My daughter came into the plan when she was 8 months old (back when we were
covered by John Hancock), and my son was born under MTHP.

Financially, I loved it.  The weekly deduction from my paycheck was smaller 
than it was with JH.  We started with no co-payment whatever, later raised 
to $5.00 per visit (which I wasn't thrilled with, but did not represent a 
major hardship for us).  

In terms of the care I received, I also loved it.  I am not a medical expert.  
I define "satisfactory medical care" as:

1. How cooperative MTHP was in making fast appointments with medical people,

2. Whether MTHP ordered tests which appeared to aid in diagnosis,

3. Whether MTHP provided the treatment which cured the problem, 

4. Whether MTHP provided (and paid for) references to other medical people 
   when the MTHP people could not handle the problem.

In all of those categories, MTHP came through with flying colors.

Because of COD, I now live in an area without an HMO, and I am back on DMP 2.  
I miss MTHP *A LOT*.  Two kids under 5 (even though both of them are healthy) 
is costing me a *LOT* of money for doctor bills, which I was not paying with 
MTHP.  If an HMO started in this area, I would be the first to sign up for it.

I appreciate the points of being able to select doctors under JH, but being
stuck with a small set of doctors under an HMO.  I personally have never
found this to be a problem.  There was one pediatrician at MTHP whom I
didn't like, but I simply indicated that I wanted another pediatrician at 
MTHP, and MTHP cooperated fully.  No problem.

Your mileage may vary, but I *HATE* medical insurance (whether JH or DMP 
or BC/BS), because of the excessive paperwork and incredibly high fees.  I
would go back to an HMO in a second.

-- Ken Moreau

    Someone asked a while back if dental is separate from the rest of the
    medical coverage.  Yes, it is.  It is and will continue to be covered
    under John Hancock-- regardless of which medical plan you select.
    
    Keep up the conversation.  I switched last year from John Hancock to an
    HMO.  Since then, I've wanted to get back into John Hancock, and had
    been anticipating doing so... until now.  Now, I'm not sure what to do.
    Perhaps HealthNet is the only real affordable option.
    
    Rgds,
    marcia

    I have Central Mass Health Care (CMHC), and since we are going down
    an HMO rathole, I would like to bring up a peeve I have with them
    and would like your comments.  They advertise (on the radio, brochures)
    that you can choose from over a 1000 doctors.  This actually isn't the
    case.  It turns out that you must have a primary care physician who
    you must see for EVERY ailment.  I had a situation recently where I 
    wanted to see a specialist (simply because I wanted to, I felt I had
    a right to since I can 'pick' between 1000 doctors) for something my
    PCP could do.  I felt like I had to defend my desire to my PCP that 
    I wanted another  one of my '1000' doctors.  I had to get this 
    stupid referral from him, a pain in the butt to put it nicely.  I feel
    somewhat mis-represented to as CMHC never tells you this little detail
    up front when they are trying to get you to sign up.  They set the
    system up to try an keep you away from the specialist.  I found out
    from my doctor that they actually monitor the doctors, and will financially
    penalize them if they give to many referrals.  Is this the right way to
    run a medical program??  It seems like a slippery sales job to me.
    
    Brad.

        I just want to say that I don't believe, nor claim, that
        HMO's and other "managed" options give poor health care.

        What I do claim, and what their literature and advertising
        never states, is that the economic criteria play a much
        larger role in selecting patient care than in traditional
        coverage.  Undoubtedly medical criteria still play an
        important role, one would hope a dominant role, but
        nevertheless a smaller role than in traditional plans.

        This makes sense;  economic benefits don't come from thin air
        -- they come from the fact that economic criteria are much
        more influential in the doctor-patient relationship.

        You do give up something, or rather you accept something
        which you might not have chosen on your own, to get the
        financial benefits.

        Bob

Well said, .138.

As an aside, I had just hung up my phone from cancelling all my optional
auto insurance when I happened upon this note.  I'll probably regret it when
I get into an accident, but it at least made me feel that I still have *some*
"choice".  I bet that the auto insurance industry would do an about-face
pretty fast if half the people in the state did the same thing.

I wish there was some way to defy the medical insurance beauracracy :-)

I've thought about writing this for a long time, but after receiving the 
Benefits bulletin, and reading some entries here, I've decided to enter 
this perspective.

	My sister-in-law is the office manager for the chief of cardiac
	surgery at Childrens' Hospital in Boston.  Childrens' Hospital never
	refuses any child based on ability to pay.  Dr. Casteneda performs
	"Free-care" (i.e. waives his bill) more often than not.  That
	does not mean the hospital waives its charges.

	As Office Manager, she's responsible for billing and collection, among
	other things.  Here's a few of her reasons why costs are so high:

	.  HMO's contract annually with hospitals for rates.  Depending on
	   terms (15 days to pay, 30 days, etc), the hospital and its
	   departments give discounts.  Generally, 25% discount.

	.  HMO X (one that's included in our new HealthNet area and 
	   referenced just a few notes back) called her 2 years ago 
	   about a child who needed a heart transplant and 
	   told her that if Childrens didn't agree to do it for 25% payment
	   (75% discount), they'd send the child to Mayo Clinic, who would
	   do it for 50%.  She knew Mayo doesn't give discounts...said,
	   send that in writing (re: Mayo) and we'll do it for free.  They
	   finally agreed to 50% billing.  

	   In a transplant case, the child is hospitalized prior to the
	   location of a donor when he/she is sufficiently ill.  If that
	   family had gone to Mayo, one parent would have had to set up
	   house out there for n amount of time, costing hardship ($, 
	   emotion, stress, etc).

	   The operation was performed successfully.  Two years later, her 
	   office hasn't seen a dime in payment...even with a 50% discount.

	.  Medicare and Welfare pay 18 months late, if they pay at all, and
	   then it's about 25-40% of the bill, and the hospital is bound
	   to accept that as payment in full.   Blue Cross is the same.

	.  One Rhode Island Ins. Co. was 2 yrs late on payments.  She (with
	   the hospital's lawyer) stated that if they didn't start paying and
	   meet the contracted price, she would send a letter to every
	   pediatrician in RI stating that if they referred patients to 
	   Childrens for surgery, the parents would have to bring $6K to be
	   put in escrow, because their ins. co. wasn't paying.

	.  She has a long list of HMO's and private ins. companies who pull
	   this stuff.

	.  One full nursery for AIDS babies - the majority of whose parents
	   do not have insurance coverage...

	.  One full nursery for susbtance abuse babies...the majority of
	   whose parents, etc.

	.  The building of a bullet-proof dispensary, after the pharmacist
	   on duty was shot and killed by a thief.

        .  Extra security (never in uniform - scare the children?) because
           there have been 4 robberies IN THE CAFETERIA in the last few 
	   months.

	.  Parents from foreign countries who arrive with very sick children 
 	   and can only pay x.  (hard to dun/bill across an ocean 8-) )
	   Last week, Italian parents arrived with six month old twins who 
	   both had life-threatening heart defects.  Kathy arranged a 
	   2-for-1 price at the hospital.

	.  Parents from foreign countries who meet with the doctor on the 
	   day of discharge to "barter" with the surgeon..."Your fee is
	   $4K?  I'll give you $1500".  Now, if they have the money, they
	   pay.  (Understand, bartering is a way of life in many countries...)  

	My point is that, in my little suburban life, where the only
	major medical problems are ear infections in the children, I wouldn't
	know the other side if it weren't for Kathy's experiences.  I put them
	here as information.

The next paragraphs are purely emotional soapbox, so next unseen if you've got 
this far, and don't want my opinion.

If the HMO is taking your money each week, don't you want to know that your 
doctor/hospital is being paid?  

I never think about catastrophic illness - but, two years ago, my husband had 
his ascending aorta and aortic valve replaced.  Open heart surgery is very 
frightening.

Digital (through John Hancock) paid 100%.  I could hold my head high and look 
that caridac surgeon straight in the eye when he told me my husband would 
live....when he told me that if we hadn't found this condition accidentally, 
Alan would not have lived 2 more years.  I could look him in the eye 
knowing he'd just saved my husband's life and knowing that he would be paid 
for that...(emotional, yes!  You bet!)  I'll be eternally grateful to that man,
to the internist who found the problem, the cardiologist who still monitors
Alan's condition, and the nurses who took charge of him (48 hrs in the 
recovery room!) that I didn't end up a widow with 3 children at this point
in my life.  They earned every dime.

Pat MilliganAbber

    RE:<<< Note 1128.137 by VAXWRK::BSMITH "I never leave home without it!" >>>
    
>    you must see for EVERY ailment.  I had a situation recently where I 
>    wanted to see a specialist (simply because I wanted to, I felt I had
                                 ^^^^^^ ^^^^^^^ ^ ^^^^^^ ^^
    
         Maybe it's just me, but I'm glad to hear that they gave you a hard
    time about this.  This PCP could possibly be responsible for keeping
    several cents a week off the costs of other HMO members by at least
    questioning the whims of patients.  It does not appear to be a case of
    lower-quality treatment, but a case of lower-priced treatment.  
    
         As for the 1000-physician choice claim, how many physicians were
    on the list of PCP's when you chose the one you got (if you chose).
    
                                    Greg

Just an observation, relevant to earlier replies on economics:

Insurance in many fields, notably health insurance, is shifting from a pardigm
of sharing the RISK of significant finacial outlay to sharing the almost
CERTAIN EXPENSE that WILL arise during most of our lives.

In other words, insurance used to be a gamble, where you were betting 
against yourself;  now it's an investment plan, where the participants
(all of them/us) have more responsibility to evaluate the impact of 
the near certainty that everyone will need significant amounts of 
medical intervention/financing at some point.

- tom] (editorial urge suppressed)

PS:  Yes, insurance companies have been primarily investment houses since
they were founded, since they were playing at a level of statistical
certainty.  Now we get to play at that level.

The stereotype about HMO's being for "Healthy Members Only" is just that,
but the element of truth is there...   I'm glad people have good experiences 
with HMO'S, but our experience has been one where we were denied access to 
the doctor until we screamed bloodly murder.  The attitude to avoid commitment
to treatment was real.  At one point, we were told it was "our" problem and that
the trouble was psychosomatic.  When we finally did get to the specialist, his 
treatment was exactly what was needed (Amazing, isn't it? Training and expertise
do matter sometimes).   I think the overemphasis on "cost management " by some
HMO'S is very real.  

Besides Plans 1 and 2 and "Digi-net", what are our choices for HMO'S.  Is there
a full discussion of benefits in VTX somewhere?

		Bob 

    re: .131
    
    >	This amounts to a pay cut. I fail to see why I should be pleased
    >	about a pay cut.
    
    Let's see. Is the point that every time I have to increase my 
    contribution to the cost of benefits, that I am taking a pay cut? Yea, 
    looks like I've taken about a 10% cut in net pay over the last two 
    years. That's not counting taxes, oil and everthing else that has gone 
    up lately. So, my salary increases (average - not great) aren't even 
    allowing me to tread water! Gee, wonder what I should do? 
    
    Perhaps I should work another 10 hours a week for Digital? I'm on 
    salary, but my extra productive (hope I don't get too tried) will help 
    Digital. And then if I am lucky, I'll keep my job! Also, the family and 
    I could eat less and spend less and cut down on that tremendous life 
    style we have. Of course I could supplement my pay with a second job - 
    sorry, we computer professionals call it consulting - with McDonalds or 
    K-Mart or somebody. 
    
    I could get a job with another company, but while I "might" get a 
    salary increase, I'm sure the benefits will be about the same and I 
    doubt that the working environment will be as good as Digital's.
    
    Gee whiz, this is not what I thought it would be like when I got my 
    degree. Well the real world is sure different than I thought it was. I 
    wonder where I will be in five years with the constant contribution 
    cost increases, increased intervals between salary actions and lower 
    percentage of base salary increases. 
    
    What should I do? Does this bother anyone else like it is bothering me?
    

    Although I can understand Digital (and other employer's) efforts to
    contain health care costs, I find the latest health benefits bulletin
    to be really disturbing. I feel that I'm essentially being forced to an
    HMO if I want the lowest cost, regardless of how "well" I am, or how
    much effort I put into not using medical care frivously. Granted, these
    are all intangible things that can't be measured, but there's no room
    for flexibility in here. The expectation is that employees will give up
    physicians because of the rising/decreasing costs of medical care. What
    happens to ongoing, established relationships with a doctor? 
    
    In my case, I have a family practitioner who sees both me and my
    husband, and my son. We go to a family clinic, and often seen medical
    residents for emergency care.  I also see a chiropractor. None of this
    would apply any longer if I had to choose an HMO.
    

Re .130:

> In the Pogo comic strip a few months ago, Howland Owl was running an HMO.
> HMO stood for "Healthy Members Only."

Details of the Pogo strips from 7/30 and 7/31/90:

Churchy (the turtle) comes in to Howland's HMO medical stand (looks like a 
wooden box half as tall as Howland) with the complaint "Doc, I is feelin' a 
mite Peaked."  Howland replies "We don't treat sick folks here... read th' 
sign", pointing to the front of his stand, which reads "_H_ealthy _M_embers
_O_nly".

Churchy pleads "C'mon, jes' this once...", and Howland relents "Well, okay...
but y'gotta join the Plan first..."  Churchy takes the pencil proffered by
Howland and starts to fill in the forms, asking "Where do I sign?"  Howland
points "Here... an' here, too... an' right here... an' here..."  Churchy
finishes and asks "Now what?"  Howland answers "Go Home, an' if you Still
feel sick in Six Months, come on back so we can cancel your policy."

Next strip, Howland is examining Churchy.  Churchy shows Howland a painful
foot, saying "Y'see, Doc, it hurts when I do this..."  Howland, instead of
pulling out the old "don't do this" routine, comes up with a thoughtful 
"Oh?  Let's check yer Cholesteroil then..."  Churchy asks "My What?" and
goes "...Awg!" as Howland sticks his hand into Churchy's throat with a
"Good... open Wide, please" and shoves in a dipstick (sound effect:  zlip!).
In the last panel, Howland is wiping off the dipstick and tells Churchy
"Hm... 'bout a quart low... Eat two Deep Fried Pork Pies an' call me in
the mornin'."  Churchy smiles and says "Thanks, Doc!  I feel better already."

Re .137:

>    They set the
>    system up to try an keep you away from the specialist.  I found out
>    from my doctor that they actually monitor the doctors, and will financially
>    penalize them if they give to many referrals.  Is this the right way to
>    run a medical program??  It seems like a slippery sales job to me.

One of my friends is a physician with an HMO in New York.  His administrator 
has made it abundantly clear to him that an important factor in his performance
is how well he limits referrals outside the plan.  Most of the time, he deals
with this in stride.  Yet there are a number of cases in which his referrals
to "outside" specialists are overruled by his administrator.  This happens
a couple of times a year, and he has gotten _extremely_ upset when this has
resulted in patients dying because the plan denied them the proper care they
needed.

The whole purpose of insurance is to cover you if something bad happens to
you for which you don't have the financial resources to cope.  The HMO
philosophy is a perversion of this, since if you need medical care out of
the ordinary, they may deny you coverage for the only specialists who might
give you the care you need.

>    I could get a job with another company, but while I "might" get a 
>    salary increase, I'm sure the benefits will be about the same and I 
>    doubt that the working environment will be as good as Digital's.
>    
>   Gee whiz, this is not what I thought it would be like when I got my 
>    degree. Well the real world is sure different than I thought it was. I 
>    wonder where I will be in five years with the constant contribution 
>    cost increases, increased intervals between salary actions and lower 
>    percentage of base salary increases. 
 
 I'm hoping it's the recession (or "economic downturn", if we're talking 
 newspeak) we're currently in.  If you can remember the boom 80's, companies 
 did need to be competitive in terms of both salaries and benefits.  I just 
 hope the economy continues to work in cycles and not screw up totally!!.

 But currently, to me, the increase in health costs is just another shot to the
 nose, between higher taxs, increased fuel etc. etc.. 

 			Bob 

 

    
    Has anybody called the HMO.
    
    My wife called the Fallon Clinic in Leominster where we live.
    
    We were told the doctors were not taking any NEW patients.
    
    This is just groovey.......
    
    I can join The CMHC health plan....most of our doctors already belong
    to it....however.....it does not allow the added benefit of going
    outside the plan as the DEC NET ALLOWS.......
    
    
    Lou

    
    
    I recently was admitted to Marlboro Hospital in the emergency ward,
    received some stitches and had some X-rays. My HMO is Fallon and I've
    had no problems with them picking up the charges.
    
    /prc

        Re: .149

>    My wife called the Fallon Clinic in Leominster where we live.
>    We were told the doctors were not taking any NEW patients.

        Well, the benefits bulletin explicitly said that Fallon was
        chosen because of its ability to take a significant number of
        new members (among other reasons).  I can think of three
        possibilities:

          1)  Fallon isn't letting random people join now because it
              is reserving space for new Digital members in a few months.

          2)  Fallon will be hiring a bunch more staff soon.

          3)  Digital made a big mistake.

        						B.J.

    re:several back   When someone sells me a car with 4 forward gears and
    			reverse, I have every right to expect that.  When
    			an HMO sells me 1000 doctors, and charges $23.54 a 
    			week, I have a right to expect a choice in doctors.
    I also think a specialist that has 10 times the experience as a
    generalist is worth it for me.
    
    Brad.

    RE:  .151  Somebody just wrote me, who belongs to Fallon, and said that
    they recently received a flyer which highlighted the new staff that
    they have added.  Perhaps in anticipation of more members...?

    re: .151
    
    I believe that Leominster is going to be excluded from the net
    *because* Fallon cannot take on more patients there at the present
    time.  When Personnel does their information presentations, we'll find
    out. 

    Re. .144 SWSEIS::WILSON -<my pay is going down >-
       ...Does this bother anyone else like it is bothering me?
    
    Gee, I had to look at the author field of the note to be sure that I
    hadn't written it -- I guess that means it's had the same impact on
    me...


    RE: example of the hospital's view

    I guess I'm missing some important point.  Why should I feel better
    about HMO's, the medical industry, and the insurance industry when I
    find out that I'm being charged EXTRA just because I'm dumb enough to
    pay my bills?

    Before you label me a compassionless twit and hit <next unseen>, I'm
    not saying that I'm angry with people who can't pay.  I just think it's
    more than a little deceptive to quote a "price" which supposedly
    reflects the "cost" of the service, when in reality that price factors
    in the costs of other peoples' service.  The MA DPU would be all over
    any utility company that tried to pull a similar stunt...

    The system is obviously broken, and there are no easy answers.  But I
    think the worst thing we can do is continue to take control and
    information AWAY from the people who are paying the bills and using the
    services.

    If it weren't for these occasional peeks behind the scenes, would you
    even know why your bill is as high as it is?  What other information is
    kept away from us as consumers?  A lot of money is changing hands --
    who is getting rich?

    Will a new beauracracy solve the problem, simultaneously meeting our
    needs and keeping costs down?  Remember, along with POS will come a new
    organization of secretaries, go-fers, and "plan administrators"; some
    of the latter will take in more per year in salaries than you do...

    RE: CMHC

    Just one more data point.  When my wife worked as an OT, she heard lots
    of horror stories about CMHC not paying their bills, and the hospital
    had "special" rules for dealing with CMHC patients.  This was three
    years ago, and I believe that CHMC may have gotten better.  But what
    that says to me is that one way the HMOs are showing a good return is
    by stiffing the hospitals on behalf of themselves (note, I don't say on
    behalf of their patients).

    The net result: hospitals start treating the patients of bad HMO's with
    the same suspicion and disgust they have for people who have no
    insurance and who obviously can't pay.  Only the HMO patients have the
    privilege of paying the fees before dealing with the disdain.

    re: .155
    
>    of horror stories about CMHC not paying their bills, and the hospital
>    had "special" rules for dealing with CMHC patients.  This was three
    
    What type of special rules?
    

        Re: .155

>    I just think it's
>    more than a little deceptive to quote a "price" which supposedly
>    reflects the "cost" of the service, when in reality that price factors
>    in the costs of other peoples' service.  The MA DPU would be all over
>    any utility company that tried to pull a similar stunt...

        Every business consider the possibility that they won't collect
        from all their customers.  Some handle it by only taking cash,
        but most factor expected losses into price.  Public utilities
        are no exception--electric rates are set to allow the electric
        company to make a profit even though there are people who don't
        pay their bills.  The MA DPU doesn't discourage it.  In fact,
        they encourage it--their regulations increase the uncollectible
        bills by prohibiting electric service from being disconnected
        under various circumstances (e.g., for families with small
        children and in the winter for residences where the heat depends
        on electricity).

        Massachusetts Electric regularly tells me the address of a fund
        that will help pay for electricity for poor people who can't pay
        their winter heating bills.  If I sent a contribution most of
        the money would be used for to pay the bills of people that the
        electric company can't legally disconnect, which would increase
        the profit of Massachusetts Electric.

        					B.J.

Well, thankfully, we have once and for all settled this ugly HMO thing:

	*****************************************
	*					*
	*	    W A R N I N G! 		*
	*					*
	*	      A L E R T!		*
	*					*
	*   Fellow Noter David Ellis now has	*
	*  proof positive that (pay attention)	*
	*					*
	*           HMOs ARE FATAL!!!		*
	*					*
	*****************************************

Read on.....

> Note 1128.147    ULTRA::ELLIS "David Ellis"                           
> 		-< Confirmed:  HMO's do deny proper care >-

Well, David, if you say so.

> One of my friends is a physician with an HMO in New York.  

I don't know about the rest of the file, but I'm _real_ impressed.     :7)
(Maybe soon he can leave the HMO and make some REAL money for a change!)

> ...and he has gotten _extremely_ upset when this has resulted in 
> patients dying because the plan denied them the proper care they
> needed.

Did you say DYING!?  That's a pretty serious charge.....
[Rhetorical Question: What has your buddy --- true to the Hippocratic Oath ---
done about this? Or is he more concerned about his performance evaluation?]

This whole string is getting silly --- up to the point where irresponsible 
noters are publicly saying that HMOs MURDER their patients!  Then it gets
plain sicko.  Scare tactics... the works.
\Gary

re .158:

Since hospitals have been documented to deny proper care (sending indigent
patients to public hospitals in life-threatening situations), I don't find
it particularly unbelievable that HMOs deny proper care.

	*****************************************
	*					*
	*	    W A R N I N G! 		*
	*					*
	*	      A L E R T!		*
	*					*
	*  High Health Care Costs directly	* 
	*  related to SICK People		* 
	*					*
	*****************************************

		I like it...

re: -1

> This whole string is getting silly --- up to the point where irresponsible 
> noters are publicly saying that HMOs MURDER their patients!  Then it gets
> plain sicko.  Scare tactics... the works.
> \Gary

Unfortunately, the opposite technique is to blame you for being the sick one.

 "It must be psychosomatic" or 
 "Everybody today is just a spoiled yuppie trying to get something
  for nothing"		    or
 "Health Care costs would be much lower if there weren't so many poor
 deadbeats around"          or
 "Health Care costs would be much lower if there weren't so many AIDS patients
  around"

 etc....

 While HMO'S may not be temples of death, let's not assume they are blameless
 either.

				Bob 




 

>       <<< Note 1128.161 by CSSE32::M_DAVIS "Marge Davis Hallyburton" >>>
>                       -< DVN Broadcast - from Livewire >-

>        1991 U.S. health care options & strategies to increase revenue:
>         topics of employee telecasts scheduled for November 5 & 19 

I wonder just how many employees work at sites that have DVN.  I know 
that I don't!  So just how are were supposed to "get the word"?  

    When the tranition package was offered, managers where cautioned to
    not single out one person or group and that would keep Digital out
    of court.
    
    Now we in 4 areas of the country are told that we must either pay
    300% or 200% more for J.H. Plan 1 & 2 or join a HealthNet that is
    now forming in our area. I'm in Colorado Springs and have this 
    choice. Now if I lived in Denver or ABO or PNO, I would face a ~10%
    increase in the J.H. Plan 1 & 2. 
    
    If everyone in the country where offered a 300% or 200% increase or
    join a HealthNet, I'd say that was fair. Or if everyone was offered
    a 10% increase or join a HealthNet, I'd say that was also fair. I'm
    being singled out. 
    
    	Will this keep Digital out of a class action court case?
    
    	I'm not sure, but sign me up if someone wants to start one.
    	One pissed off employee who is looking at another pay reduction.
    
    	Greg
    

Re .158:

> Did you say DYING!?  That's a pretty serious charge.....
> [Rhetorical Question: What has your buddy --- true to the Hippocratic Oath ---
> done about this? Or is he more concerned about his performance evaluation?]
>
> This whole string is getting silly --- up to the point where irresponsible
> noters are publicly saying that HMOs MURDER their patients!  Then it gets
> plain sicko.  Scare tactics... the works.

To the Moderators:  Aren't personal attacks of this kind out of line?

I suggest that my note (.147) be re-read carefully.  My charge is that in
a relatively small number of individual cases, an HMO administrator denied 
patients coverage for medical care they needed.  These patients had little
recourse, and some of them did die.  

Here is some perspective.  When my friend feels that a patient needs an
outside referral, he has to get buy-in from his director.  Sometimes the
director goes along, sometimes not.  The denials for necessary care (after
appeal to the director) have occurred on average a couple of times a year, 
out of thousands of cases.  And my friend attributed a total of two patient 
deaths in his career to what he referred to as "administrative malpractice".  

As for my friend and the Hippocratic Oath, he advised the patients about
the appropriate outside care that they needed.  He couldn't authorize 
coverage, and he lost the political battle to get the coverage authorized.

My point is not that HMOs are fatal.  In most circumstances, they are fine.
But in certain situations, they fail to cover members for necessary medical
care.  In such cases, a member has no recourse other than the Hobson's choice 
of not getting the care or of paying for it without coverage (if he can 
afford it).

At present, I have family medical needs beyond the usual.  The Digital Medical
plans provide partial coverage, while the local HMOs do not cover these needs.

As I said previously, the point of medical insurance is that if you need 
expensive care, then you should be covered for it.  HMOs are set up to 
contain costs, sometimes at the expense of a patient's best medical interests.

Bottom line:  HMOs will do the job well in normal circumstances.  But if
something out of the ordinary happens, they may not meet your medical needs.

    I checked with my wife about CMHC and their non-payment, and I did have
    the facts a little mixed up.  Indeed, three or four years ago, CMHC would
    routinely refuse to pay for procedures at local hospitals, and it was
    widely known among hospital workers that any CMHC claim was likely to go
    unpaid.  There was no policy of "special treatment" for these patients.
    Hopefully all hospital employees were able to suppress their attitude
    toward CMHC when dealing with a CMHC patient...

    At this same time, my wife had a conversation with a freind who was of
    the opinion that any doctors who could make it on their own had already
    bailed out of CMHC participation.  Again, this was just a rumour and a
    widely held attitude among medical professionals who dealt with CMHC.

    The "special treatment" I remembered was unrelated, and applied to all
    indigent patients who were paying (or not paying) out of their own pockets.
    There are a lot of nifty gadgets which OTs introduce people to, to help
    with overcoming disabilities.  These gadgets are sold to hospitals the way
    hammers are sold to NASA -- high price tags.  If my wife was aware that
    someone was uninsured (or actually I think she may have done this for all
    patients), she would show them the appropriate gadgets in the catalog and
    describe how they worked.  Then, she would say something to the effect of
    "you can go look for something like this at K-mart and then modify it, or
    I can order one through the hospital.  If you get it at K-mart or make it
    yourself, it should cost $n.00.  If you get it through the hospital, it
    will cost $[n]nn.00."

    My apologies for the confusion.  By the way, I still don't like the idea
    of being forced to join an HMO which was widely regarded as providing
    inferior care in the not-so-distant past.

   RE: Note 1128.163 by SSDEVO::EKHOLM "Greg - party today, tomorrow we die! (Cluster Adjuster)" >>>

>>    Now we in 4 areas of the country are told that we must either pay
>>    300% or 200% more for J.H. Plan 1 & 2 or join a HealthNet that is
>>    now forming in our area. I'm in Colorado Springs and have this 
>>    choice. Now if I lived in Denver or ABO or PNO, I would face a ~10%
>>    increase in the J.H. Plan 1 & 2. 
    
>>    One pissed off employee who is looking at another pay reduction.


Count me as one more pissed off employee!  I have an ex-wife & son who 
live in the Phoenix area and are covered by my insurance while I'am in 
Mass.   It looks like I have no choice but to go with JH at the higher 
cost!

BTW,  I remember seeing something in one of the preliminary 
announcements about DEC not providing medical coverage irregardless of 
court ordered coverage in a divorce.  Does anyone have any more info on 
that?  (I can see now having to pay for COBRA policy IN ADDITION to my 
own coverage!!!!!!!!)

    That was my concern also, but it seems there is a grand-father clause
    for ex-spouse coverage.
    
    - John

Jackie,

	Below is listed the information I need to determine whether I can 
support the change in health care benefits

1) A comparison of Digital's cost, after employee contributions, of Plan 1, 
Plan 2, and an average for the HMO's, in the Colorado Springs area, for the 
last 12 quarters.

2) A statement of the potential savings for Digital for the next fiscal 
year if 25%,50%, or 75% of the folks currently on Plan 1 and Plan 2 switch to 
HealthNet.

3) A statement that the people responsible for this decision live/work in a 
HealthNet area.

4) A clear and concise statement from Ken or the Executive Committee as to 
why the HealthNet area increases in Plan 1 and Plan 2 are equitable.

Mark D. Jilson

    Something I hadn't seen mentioned in this note, was that 
    fact that certain rising costs were perhaps the fault
    of the employee requiring medical services. The benefits
    bulletin pointed out that:
    
    1. Too many unecessary tests are being performed, hospital
    stays are sometimes longer than they should be, and 
    maybe a patient makes "too many visits" to their doctor. 
    
    I was under the impression that things like 2nd surgical
    opinions (and 3rd opinions) concurrent hospital review, 
    etc were designed to hold down such costs as these? Also
    how would the average employee know whether or not a 
    test is un-necessary? 
    
    2. Lifestyle makes a difference. No kidding. You think 
    people are going to be their healthiest, mentally and
    physically, during times such as these? Stress related 
    illnesses are on the increase, and for many, Digital
    itself plays a major factor in the illness itself. How 
    can we live a healthy lifestyle with less money every 
    paycheck we get? 
    
    
    I think the above points were somewhat insensitive, 
    considering this plan was conceived by a committee 
    of senior management, which by the way, have no worries 
    about their health care. (I imagine they are on a 
    more comprehensive plan, commensurate with their 
    job title). Try getting some input from the little 
    people next time. 
    
    
    PS - a personal medical sidelight.......
    JH, several years ago, paid a local hospital $10,000+ 
    for an operation for a family member, which the 
    hospital screwed up....they opened up the wrong side
    of the patients _ you fill in the blank _ , realized
    it was the wrong side, closed back up, did the right
    side the next week. Why did Digital allow the hospital
    to charge an exorbitant amount of money for an operation
    they REALLY made a mess of, and then pay for the 
    second one as well? It was brought to the attention of JH, 
    who said they would pay it.   Maybe we are paying 
    for all those years of bad administration.......
    you figure 
    
    

    If anyone would like to complain about the change in health care
    benefits here are two names in corporate benefits:
                             
    Peter Hawker	VMSmail: MTS$::"CFO::Peter Hawker"
    Kathleen Angel	VMSmail: MTS$::"CFO::Kathleen Angel"
    
    I believe Peter is in charge of benefits.

    I just finished watching the DVN broadcast on Healthnet. Here are some
    of my notes. They restated a lot of the stuff that is in the Healthcare
    Bulletin. In addition they added some more $ info. Here are there
    breakdowns of weekly deductions. (They mentioned that the HMO numbers
    were approximate and they would vary somewhat from HMO yo HMO
    
    Weekly Deductions
    
    			Single		Family
    --------------------------------------------------
    HMO			$2.54		$11.62
    --------------------------------------------------
    Healthnet           $3.54		$16.62
    --------------------------------------------------
    DMP1		$5.50		$21.75
    --------------------------------------------------
    DMP2		$10.25		$34.00
    --------------------------------------------------
    
    They also mentioned something called the "Health Care Reimbursement
    Account" program. This is similar to the "Dependent Care Reimbusement
    Account". The difference is that now you use HCRA for paying for
    excluded health care payments with pretax dollars. You have money
    deducted from your paycheck from $5 to $40 per week. It can be used for
    any noncovered health care expense that you incur. Of course like the
    DCRA, if you don't use up the fund at the end of the year, you lose it.
    
    
    Joe
    

    .158:
    
    I believe that the legal definition of MURDER requires action to be
    taken, and also malicious intent (behind that action).
    
    A death that results from refraining from an action, from essentially
    doing nothing, would probably be considered either negligent homicide,
    or manslaughter;  if one could prove malicious intent in the inaction,
    and knowledge that the inaction would result in death, there *might* be
    grounds for an indictment of murder (but that is uncertain).
    
    Mr. Ellis and the person he mentioned appear to be aware of this
    difference.  Are you, or are you merely attempting to inflame tempers
    by ignoring some serious differences of meaning?
    
    Dick

    Unfortunately, I missed the DVN broadcast.  Can someone please tell me
    exactly how the healthnet will work?  If the healthnet includes 3 or 4
    HMO's in Massachusetts, does that mean if we join, we can go to any
    doctor at any of those participating HMO's and be covered (not pay
    30%)?  Or, if we join, must we be associated with only 1 of the
    partcipating HMO's?
    
    Here is our situation:  my husband currently belongs to Fallon.  I
    belong to JH1.  My obstetrician belongs to Harvard Medical, but not
    Fallon (I think we live in the Fallon area, but I'm not sure about
    the Harvard area).  Anyway, if we joined the healthnet family plan,
    do we as a family have to choose 1 primary care physician at 1 HMO?
    In that case, I'd have to pay 30% of my obstetrician's fees since I'd
    be "outside" of Fallon, but still under an HMO that belongs to
    healthnet.
    
    If this is the case, I think the term "healthNET" is ridiculous. 
    There's no network about it at all...just the option to go to 1 HMO
    and go outside of it as well.  Big deal.
    
    Thanks for any clarity you can offer,
    Robin

    So, what can we do about it, other than complain?  We can't vote them 
    out, unfortunately.
    
    If we were a union we could strike.

    An interesting point is why is family coverage a fixed amount,
    regardless of the number of children in the family. It would seem
    fairer if the amount that an employee had deducted for his/her medical
    plan was geared to the TOTAL NUMBER of persons covered, not just  two
    catagories.
    
    Eric

>                   <<< Note 1128.175 by FSDB00::FEINSMITH >>>
>
>    An interesting point is why is family coverage a fixed amount,
>    regardless of the number of children in the family. It would seem
>    fairer if the amount that an employee had deducted for his/her medical
>    plan was geared to the TOTAL NUMBER of persons covered, not just  two
>    catagories.

Insurance statistics demonstrate that medical expenses do not vary
in direct proportion to family size, but take a step from individual to
family (spouse or spouse plus one child) and then climb only slowly
as the number of children grows.  We've talked about this before, 
probably the last time medical plans were changed.

- tom]

    re: .176
    
>Insurance statistics demonstrate that medical expenses do not vary
>in direct proportion to family size,
    
    Not in direct proportion, but they do increase.

I've never heard of a health insurance plan that had different rates for
different size families.  I wouldn't be surprised if such a plan would
be illegal in some states.

	... if the auto industry can do it by person AND age, why can't
health coverers?

    RE: .179
    
    They said on the DVN that you are covered for pre-existing
    conditions when you sign up during the open enrollment
    period.
    
    Also, you can't change your coverage after the open
    enrollment period until next year's open enrollment period. 
    
    You can change some things, for instance if you're covered by
    spouse's plan and spouse is laid off (or vice versa). You
    can't change from DMP to HMO.

    The fairness of the insurance industry is a topic for SOAPBOX or
    INVESTING.

    re: .176 Insurance statistics demonstrate that medical expenses do not
             vary in direct proportion to family size ...
    
    I would like to see these statistics. My experience says children are
    at the doctor's office and hospital far more often than middle age adults. 
    
     thanks,
              miek

    re: .174 Too many unecessary tests are being performed, 
             hospital stays are sometimes longer than they should be, and
             maybe a patient makes "too many visits" to their doctor.
    
    I do not know anyone that intentional gets "unecessary" tests, but I do
    know several people that should go get tests and don't. And of course
    everyone loves being the hospital so much they request to stay longer.
    People do not have access to sufficinet information to take  control
    over the medical care they get. However, DEC can help by buying access
    to expert medical systems and giving employees a chance to find out
    what tests are really needed.
    
    mike
    
                         Canadian Health Line

    Memorial University in St John's Newfoundland has established a
    Telemedicine Center that provides on educational and health
    services to remote areas around the Canadian coastline.  The
    network handles 3,500 hours of traffic, and was recently adapted 
    to handle certain medical diagnoses over the same telephone
    line. X-rays and EEG/EKG data will soon follow.
    {Communications of the ACM September 1988}
    
    
                           Medical Data

    Unisys has been awarded a $15.9 million five-year contract by the 
    Government to operate a database on malpractice suits and
    disciplinary actions filed against doctors and dentists nationwide.
    The database will prevent incompetent health officials to move from
    hospital to hospital or state to state while withholding
    information. The legislation that authorized the project requires
    state medial licensing authorities to report any disciplining
    actions and malpractice suits to the Federal  computer file. The
    data base will eventually be expanded to include nurses and other
    licensed health-care providers.
    {NYT, 12/31/88}

        Reimbursement For Computer Assisted Literature Searches

    To the Editor: Computer-assisted literature searches are sometimes
    the most important diagnostic studies performed for patients.
    Today, many physicians use the literature search as a medical
    decision making tool comparable to the orthopedist's arthroscope,
    the gastroenterologist's endoscope, or the radiologist's CT
    scanner.  A computer assisted search is particularly valuable in
    patient care because it is designed to identify specific items of
    information needed for a specific patient's problem. At our
    hospital, for example, McClatchey has used his personal computer to
    search MEDLINE for diseases associated with "numb chin", the
    presenting symptom of his young patient. Because his search results
    suggested the possibility of a lymphoreticular cancer, McClatchey
    promptly ordered a CT scan that located a tumor involving the
    mental nerve.  The cost of the CT scan was more than $300; the
    literature search cost less than $10.

    We propose that the costs of computer assisted literature searches
    for patient care, like the cost of arthroscopies, endoscopies, and
    CT scans, be reimbursed by Medicare, Medicaid, and private
    insurance  carriers. If reimbursement for literature searches were
    allowed, there would be a number of beneficial results. It would
    encourage physicians to seek up-to-date information from the
    literature before ordering tests. Indeed it would send a strong
    message to physicians that the use of intellectual skills is as
    important as the use of procedures. It would promote the
    development of improved data bases for medical practice. It might
    even prod medical schools to teach modern information gathering
    techniques recommended by the report on the Panel of the General
    Professions Education of the Physician.

    We recognize that for both quality-control and cost containment
    reasons, guidelines for reimbursable literature searches would need
    to be established. We suggest, at least initially, that for a
    search to to be reimbursable, it should be performed at an
    institution accredited by the Joint Commission on Accreditation of
    Hospitals, and the need for the search should be recorded in the
    patient's chart. The use of the information obtained, a copy of the
    search, and the search strategy should also be documented. It may
    be necessary to limit the number of searches for a given patient in
    a given period. A minimal charge, say $20 or $25, might also be
    necessary. The guidelines for use would need to be developed
    carefully, perhaps by pilot studies conducted jointly by the
    National Library of Medicine and the Health Care Financing
    Administration.

    Computer-assisted literature searches can provide an effective way
    for physicians to locate quickly the information they need to
    diagnose and treat their patients. Currently, charges for searches
    can not be passed on to the patient's insurance carrier as can the
    charges for a complete blood count, chest film, or CT scan despite
    the fact than an information search is often quicker,  cheaper, and
    much more helpful.
                                                Nicholas E Davies, M.D.
                                                Alice A DeVierno, M.L.S
                                                Piedmont Medical Center
                                                Atlanta GA

    {New England Journal of Medicine Vol 319, No. 15}
    

    Here's anecdotal evidence of why there's a massive jump from 0-1 child
    and then small incremental jumps for child n+1.

    We have one child.  We've never had one before.  They do wierd things.
    When our child does something new and wierd, we get all bent out of
    shape and bring him to the expert to see if something's broke.  We also
    bring him for the regular scheduled maintanance.

    We're starting to pay our doctor bills now.  If we have another one,
    we'll skip the scheduled maintenance, because it's too expensive. 
    We'll get innoculations without "well-baby" care.  I've seen Timmy
    weighed and measured enough now, so that I think I can do the same
    thing with my wife's tailor tape, some bricks, and a fulcrum :-)

    The next kid will do the same wierd things (mostly). We won't panic
    quite as often though.  With parental experience, unnecessary visits go
    down.  No matter how many books you read, that jump from 0 to 1 is a
    major hurdle, and you panic a lot.  Once you've got 1, you've seen at
    least 70% of the stunts kids pull.  And if you're lucky, you don't get
    the full variety pack, so that 70% covers 99% of your kids.

    Until you're a parent, it's really hard to understand why there is so
    much panic when something wierd starts happening.  I thought Timmy was
    dying the first time he laughed.  His shirt was over his head; he was
    laughing because it tickled him as I pulled it up to change him.  I
    yanked the shirt off to give him mouth-to-mouth, then guessed what the
    big smile meant...  When you're a parent of >1 kid, I bet it's equally
    hard to understand the behavior of a first-time parent.

    There is a second-order affect, which I think of as pipelining.  I have
    been coughing for three weeks.  I've felt like the old lady who
    swallowed a horse for two weeks.  My ribs feel awful.  At the end of
    week one, I got some antibiotics.  They didn't help.  At the end of
    week 2, I got a blood test and an X-ray.  It's not bronchitis, or the
    antibiotics would have kicked in by now, and/or my white blood count
    would be high.  It's not pneumonia (yet).  If my ribs still hurt next
    week, I'll have the doctor check for pleurosy.

    Anyway, my wife is two weeks behind me.  She is coughing, and just
    starting to feel like she swallowed a horse.  We can probably skip some
    steps which didn't work for me, when it comes time to get her patched
    up.  Timmy is just starting to cough.  He can't say "horse" yet, so we
    won't know when he feels like he swallowed one.  But now we have a good
    idea that it will be next week.

    If we had more kids, they'd all get it either in series or in parallel. 
    If they got it in series, one would end up at the doctor.  If they got
    it in parallel, they'd probably take turns, or the doctor would give
    wholesale rates.  Either way, once 1 has it, the other n-1 probably get
    treated by the parents rather than the doctor.  Especially if it was
    just another manifestation of wierdness, and didn't require a
    prescription remedy.  Also, as n approaches infinity, the parents
    either know what the doctor would say, or can't afford to see the
    doctor anyway -- because of the baby-sitting bills for the n-1...

    re:183
    
    	I think you will find that the average gall bladder operation
    costs more than 500 visits to the pediatrician.  This is an old
    rathole.  Talk to any doctor, the main reason for high medical
    insurance is *MALPRACTICE* lawsuits and the resultant insurance.
    My doctor said his insurance was $41,000 last year.  My wifes
    insurance was $89,000 last year.  Think about it.
    
    Brad.

                          Question RE: HealthNet.
    
    Scenario:
    
    You belong to an HMO/HealthNet.  You have "X" illness, and the doctor
    at the HMO treats you for months, but without success.   You're tired
    of this, and start investigating and discover that there is a doctor
    who specializes in this "X" illness-- but he is not part of the HMO you
    belong to.  The HMO knows about the specialist, too, but they don't
    refer you.
    
    So you are forced to go outside the HMO to see the doctor who
    specializes in the "X" illness.  You are treated, successfully, and you
    have to pay the bill, submit it through HealthNet, get reimbursed 70%
    [of what J.H. considers "REASONABLE & CUSTOMARY"] under HealthNet.
    
    End Scenario
    
    My point is... what's to prevent the HMOs from denying you treatment
    for $3.00 - when they know you want to see that specialist-- even if
    you have to absorb part of the cost?  Let's face it, like any other
    business, HMOs are profit oriented, too.  What kind of policies will be
    in effect to monitor this type of situation with HMO/HealthNet
    coverage?
    
    One other thing that I bring up, HealthNet will pay 70%, after a high
    [$250] deductible-- but if this is J.H. we're talking about as the
    adminstrator [and I believe it is], remember, 70% of what they
    consider REASONABLE & CUSTOMARY.                          ^^^^
    
    I my two years with J.H., and the 80% coverage, REASONABLE & CUSTOMARY
    was one phrase that used to bug the heck out of me.  I wanted to chal-
    lenge that term so often... It's really their way of paying out alot
    less than the expected 70 or 80%.  
    
    Rgds,
    marcia

We've used top specialists in Boston and have never had the Digital Medical
Plan say any charge wasn't "reasonable and customary."

    re: .187
    
>    My point is... what's to prevent the HMOs from denying you treatment
>    for $3.00 - when they know you want to see that specialist-- even if
    
    Absolutely nothing.
    

Re: .187/.189

>>    My point is... what's to prevent the HMOs from denying you treatment
>>    for $3.00 - when they know you want to see that specialist-- even if
>    
>    Absolutely nothing.
>    

Except, presumably, our HealtNet management firm (ie JH) will sack the HMO if
it tries any such thing? (I know it's n�ive, but you have to trust someone:-)

    JH may be further removed from the situation than the HMO, but it is
    hardly a neutral arbiter.  If Digital management decides to stress
    cost control, JH has little reason to side with the subscribers in
    these disputes.

>    JH may be further removed from the situation than the HMO, but it is
>    hardly a neutral arbiter.  If Digital management decides to stress
>    cost control, JH has little reason to side with the subscribers in
>    these disputes.

At the DVN it was *claimed* that cost control is just one of five seperate
metrics that will be applied to HMOs (I can't remember all five, but
Delivery/Access and General Performance were two others).

There's been no mention here of one facet of the Health Net plan that
I thought I heard during the DVN briefing, and I'm wondering if I heard 
it wrong.
Isn't it part of the plan that you can go outside the plan on your own
initiative and get reimbursement only during the first year?  
I understood the presenters on TV to say that Health Net was a 
transitional plan, and that after the year, you'd just belong to the HMO
and depend on them for outside referrals.

Did I mis-hear?  I don't have the benefits booklet yet.

- tom]

    
    re:188
    
    Almost all of my doctor bills are considered over the "reasonable and
    customary" of JH. These aren't fancy specialists, either, just my 
    regular internist and dentist. Given that these "excess" charges don't 
    apply to the "maximum out of pocket", I consider the MOOP to be
    misrepresentation. If my bill is $130, R&C is $100, JH pays 80% or $80, 
    the MOOP applies $20, but I really paid $50 out of my pocket. 
    
    I'd like the name of just one doctor or dentist in my area that charges
    "reasonable and customary". I haven't been able to find one. 
    
    Linda

I've also never had JH pay less than what I expected for any physician's
charge.

Dentists charges are something totally different; the dental plan is a totally
different plan.

---------------

What really annoys me about this, as a participant in Digital Medical Plan 1
who hasn't even exceeded the deductible this year is that my salary has just
been reduced by $741 (and more, if I were to exceed the higher deductible).

I have only one dependent.  Why do I have to pay as much as a family of five?

/john

re: .195

 >   I'd like the name of just one doctor or dentist in my area that charges
 >   "reasonable and customary". I haven't been able to find one. 
 
I can't help you there, but I can tell you that R&C is calculated by ZIP code.
Perhaps you need to find a doctor in a higher priced ZIP code.

Bob

    I just spoke with my personnel representative.  I have a daughter in
    college out of state (I'm in Colorado) and wanted to know what this
    means for her.  I was told that if she is ill and needs to see a
    doctor, she should call me and I will in turn call my participating
    physician and explain the situation to him.  He can then refer her to a
    doctor in Phoenix and the charge will be covered by the HMO.  
    
    On the other hand, if she needs emergency treatment she can only go
    directly to the emergency room if the condition is 'life threatening'. 
    Otherwise, I guess if she breaks her arm I have to go through the
    procedure of calling the doctor for a referral.  The personnel rep did
    tell me that she would be willing to help fight the battle for me if I
    had any problems getting coverage for an incident such as this.
    
    This information helps me feel a little more comfortable with switching
    to the HMO as her medical care was my primary reason for staying with
    JH.

Re: .196

>I have only one dependent.  Why do I have to pay as much as a family of five?

'Cos he (oops, sorry, 'that person') only gets the same salary as you!

I know the health plans aren't run strictly as insurance, but that is their
intent, and the whole idea of insurance is that everyone pays (approx the same)
towards the bills of those few who need it most. If that doesn't convince you,
think of the increase in admin costs that would result from trying to calculate
an apppropriate amoount for each individual to pay (based on age, family size,
medical history, etc, etc).

Simon

re:                     <<< Note 1128.198 by CSC32::J_KILLA >>>

>>    ...		I was told that if she is ill and needs to see a
>>    doctor, she should call me and I will in turn call my participating
>>    physician and explain the situation to him.  He can then refer her to a
>>    doctor in Phoenix and the charge will be covered by the HMO.  

ugh..that's all fine and good but what if you're not home? We have the same
situation. I'm covered under my husband's plan (he's a DECcie). We live in
NH and his son goes to school in MA. We go away whenever we can. What if
his son breaks his arm and he can't get in touch with us? Does he have to suffer
until we come home? Or what if it's a weekend or something? How long is it
gonna take to get in touch with a doctor who can tell us who his son can get
in touch with? 

Our situation is further complicated because I just had surgery and will be 
under my doctor's care for close to a year. My doctor unfortunately, is also
in MA. The way I look at it we have no choice but to stay with JH.

Jenna

        Re: .192
        
>    JH may be further removed from the situation than the HMO, but it is
>    hardly a neutral arbiter.  If Digital management decides to stress
>    cost control, JH has little reason to side with the subscribers in
>    these disputes.
        
        It costs Digital less if the HMO pays for the visit to the
        specialist instead of having Digital pay 70% of R&C for a visit
        outside of the HMO.  It seems like cost control would encourage
        JH to place pressure on HMOs.
        
        					B.J.

    RE: .l98
    
    	I also have a son in Texas going to school. I will be FORCED to
    pay the higher $'s to stay in J.H. #1 as I will NOT play politics
    with my son's health. If he needs medical attention, he and I decide
    when,where and how much. Not someone many miles away. 
    
    Yet if I lived in Denver, this would have never come up. Just a 10%
    increase in my weekly deduction. 
    
    So what happens to HealthNet when Texas is covered? Will it be like the
    HMO's and Colorado Springs HealthNet will have to talk with Texas's
    HealthNet to decide if my son's broken what-ever needs treatment today
    or tomorrow? Sorry, my Son's health is worth more that the $5.00 a week
    difference between HealthNet and JH #1.
    	Greg

    When do we receive the forms to make changes?  We are traveling
    for the holidays - and I don't want to miss the submission 
    deadline.

        If JH reasonable  and  customary  charges  are  based  on  data
        gathered in that same  way  as  those  for the dental plan, you
        shouldn't be surprised to find some charges considered too high
        by JH:  the data used in the dental plan are 3 years old!
        
        I learned this when obtaining estimated charges for some dental
        work last  fall,  and  was  advised  to hold off the work until
        January because the  r&c info was based on 1986 figures and was
        going to be updated  after  new years.  True to their word, the
        info was updated...to 1987 figures,  which was not quite enough
        to cover the increase my dentist charged beginning 1990.

    Here are the weekly HealthNet costs:
    
    			Individual	Family
    
    Harvard Community	$3.43		$19.02
    Fallon		$1.00		$ 9.05
    Matthew Thornton	$3.54		$16.62
    Lincoln National	$2.30		$13.01
    
    I'm told the employee packets are late getting out and that we
    should receive them next week sometime (19-24 Nov).
    

RE Cost to Digital: the personnel-person that "explained" the
health care costs said that the cost to DEC is the same for both
DMP or HMO; the difference being is the employee's share of the
cost is higher; ie employees pay the difference in selecting
their health care.

RE Health-net: As the person tells us, the use of a doctor out of
state is the same as going to a physician within health net. What
needs to be done is to set up a communications with the
health-net doctor and the out of state doctor so that a
student/dependent might be covered.

Correct me if I am wrong but when I was in college (1960's
through early 70's) each of the colleges that I went to had a
health clinic taht we could get emergency and illness care for a
small fee (like an HMO).

calvin

re .206:

>Correct me if I am wrong but when I was in college (1960's
>through early 70's) each of the colleges that I went to had a
>health clinic taht we could get emergency and illness care for a
>small fee (like an HMO).

If you were desperate.  Most college infirmaries had pretty bad reputations
when I was in college.

RE :.20

Not much difference between Healthnet/HCHP and DMP1 (Deductions).

Any ideas on why so much difference between different HMO's that are
participating in Healthnet?

Joe

>  <<< Note 1128.205 by HPSCAD::FORTMILLER "Ed Fortmiller, MRO1-3, 297-4160" >>>
>                              -< HealthNet Costs >-
>
>    Here are the weekly HealthNet costs:
>    
>    			Individual	Family
>    
>    Harvard Community	$3.43		$19.02
>    Fallon		$1.00		$ 9.05
>    Matthew Thornton	$3.54		$16.62
>    Lincoln National	$2.30		$13.01
>    

     Here is some additional information re HMO cost WITHOUT HEALTHNET:


    			Family (Healthnet cost)	    Family (Lockin)	
    
    Harvard Community		$19.02			$14.02
    Fallon			$ 9.05			$4.05
     

     The difference?  It buy you (@$260/yr) the privilege of going 
     outside your HMO for additional care that the HMO will not 
     pay for and getting reimbursed at 70% of REASONABLE & CUSTOMARY 
     rates (ala dental?)!  

     
     

    
    RE: .205
    
    
    >  Fallon              $1.00           $ 9.05
    
    Are you telling me that I'm actually going to be paying 50% of what
    I'm paying now for more coverage?  (I'm currently paying $2 a week
    for Fallon).  
    
    Or is this figure the incremental difference between Fallon and Fallon
    WITH HealthNet?
    
    kath

>    I'm paying now for more coverage?  (I'm currently paying $2 a week
>    for Fallon).  
>    

At the DVN we were told that the cost of the 'bare' HMO would be dropping
by about half on average, so you are going to be paying 50% of what you pay
now for the *same* coverage

>    Or is this figure the incremental difference between Fallon and Fallon
>    WITH HealthNet?
>    
The incremental difference between the straight HMO and HealthNet is $5/week.

re .210:

>    Are you telling me that I'm actually going to be paying 50% of what
>    I'm paying now for more coverage?  (I'm currently paying $2 a week
>    for Fallon).  


As I pointed out way back in .93:

>    "The payroll deductions for the Digital Medical Plans will be higher
>    than those for standard HMOs and the Digital HealthNet HMOs due to
>    the increased costs of offering these plans.  Generally, depending
>    on how efficiently the individual HMOs operate, the payroll deductions
>    for the Digital HealthNet program will be higher than the costs for
>    standard HMOs due to the additional cost of indemnity benefits
>    outside the HMO."
>
>Since the payroll deductions for all the HMOs in my service area
>in 1990 were higher than the DMP 1 deductions in 1991, the statement
>above implies that HMO deductions are going down.

        One of the questions that came up when I attended a
        presentation on the HealthNet option was the degree of
        difficulty in "integrating" the care provided by non-HMO
        providers and HMO specialists.

        For example, my children's pediatricians are already a part
        of the Harvard HMO, and thus would be accessible either under
        a straight HMO or HealthNet.  My wife's favorite doctor, on
        the other hand, is an OB/GYN who is not part of any plan.  He
        functions as her primary-care physician, and I understand the
        degree to which HealthNet would pay for his charges.

        However, it is conceivable that my wife's non-plan OB/GYN
        might want to refer her to a specialist.  Are specialists who
        are a part of the affiliated HealthNet HMO accessible to my
        wife -- at the HMO level of coverage?  My suspicion is that
        this would be very difficult, if not impossible, unless an
        HMO primary-care physician was also involved and effectively
        took over the management of her case.

        Could she still use the HMO for emergency care, at the HMO
        level of coverage (e.g., for a broken bone), even though she
        wasn't seeing an HMO primary-care doctor?

        Is a person who signs up with HealthNet but uses a non-plan
        primary-care physician effectively locked out of HMO
        coverage?

        Bob

Folks, My apologies in advance about the length of this. Up front please note
I received the permission of the author who replied to my message to quote him. 
At the end of this note are some editorial comments about this situation by me.
   Ted

From:	USEM::USEM::MRGATE::"A1::STRADINSKI.JOHN" 15-NOV-1990 16:03:42.22
To:	MEMCL1::STROLLO
CC:	
Subj:	RE:  DVN QUESTION

From:	NAME: JOHN STRADINSKI               
	FUNC: SSMI BENEFITS/RELOCATION        
	TEL:                                  <STRADINSKI.JOHN AT A1 at USEM at PKO>
To:	NAME: STROLLO <STROLLO@MEMCL1@MRGATE@USEM@PKO>


       Feel free to share the question and answer.
       Thanks for checking, Ted.

From:	MEMCL1::STROLLO      "DTN 232-2404 M/S ACO/E36 POLE MOD-1/C5" 15-NOV-1990 10:45:50.17
To:	MEMCL1::USEM::USEM::MRGATE::"A1::STRADINSKI.JOHN"
CC:	STROLLO
Subj:	RE:  DVN QUESTION

Thankyou for your reply. As you may know, the Digital changes on medical
coverage are being discussed in several of the notes conferences. I am
requesting your permission to quote my question and your reply verbatim in
these three or four conferences. 
   Sincerely, Ted

From:	MEMCL1::USEM::USEM::MRGATE::"A1::STRADINSKI.JOHN" "14-Nov-1990 1217" 14-NOV-1990 12:17:17.48
To:	MEMCL1::NM%STROLLO
CC:	
Subj:	RE:  DVN QUESTION

From:	NAME: JOHN STRADINSKI               
	FUNC: SSMI BENEFITS/RELOCATION        
	TEL:                                  <STRADINSKI.JOHN AT A1 at USEM at PKO>
To:	NM%STROLLO @MEMCL1@VAXMAIL


Ted,

Thanks for the question.

I am responding for Kathleen Angel because she had a previous commitment 
in Washington relative to Managed Care but wanted to be sure employees 
that raised questions had their concerns addressed.

I was listening to the broadcast when you raised your question and it 
was interesting to me because I was involved with writing the Benefits 
Bulletin and remember the language you refer to as being contentious at 
the time of writing.  I agree that we could have written that piece 
better.  I think you're reading it to imply that we are ignoring a 
provision of law that is state-mandated.

I'd like to make two points:

1)  Covering ex-spouses as eligible dependents is only required in the 
    state of Massachusetts when an insurance contract is involved.  
    Digital's Medical Plans are self-insured with John Hancock acting as 
    an administrator only.  The state mandate does not apply.

2)  We want to be consistent across the country.  Massachusetts was the 
    only state where we were allowing ex-spouses to be covered as 
    dependents (even though we were not required to do so).  The change 
    effective 1/1/91 causes us to be administratively consistent across 
    the country.

Therefore, in a situation where an employee is divorced after 1/1/91 
they can only pick up coverage for the ex-spouse under COBRA for up to 
three years.


                  I N T E R O F F I C E   M E M O R A N D U M

                                        Date:     05-Nov-1990 08:28pm EST
                                        From:     STROLLO
                                                  STROLLO@MEMCL1@MRGATE@ACOMTS@ACO
                                        Dept:      
                                        Tel No:    

TO:  KATHLEEN ANGEL@CFO


Subject: Hi


Kathleen,
I asked the first question from the DQR/DVN studio audience yesterday. I am
still not sure I understood your answer completely. Is it the case that for
a Massachusetts resident employed by Digital in Massachusetts that if he/she
divorces after 1/1/91 Digital will be denying divorced spouse coverage
despite Mass Law and the wording of the divorce decree??
   Thanks, Enjoyed the session very much,
      Ted

========

Below is a verbatim quote from Massachusetts Law. We do not have the paragraph
symbol which is used in the Mass Law to designate sections. Instead I have used
the four characters "para" in place of this symbol.
========

C. 175 para 110I. Health Insurance Coverage; Continuation as to Divorced or
Separated Spouses.

(a) In the event of the granting of a judgment absolute of divorce or of
separate support to which a member of a group hospital, surgical, medical, or
dental insurance plan provided for in section one hundred and ten is a party,
the person who was the spouse of said member prior to the issuance of such
judgment shall be and remain eligible for benefits under said plan, whether
or not said judgment was entered prior to the effective date of said plan,
without additional premium or examination therefor, as if said judgment had
not been entered; provided, however, that such eligibility shall not be
required if said judgment so provides. Such eligibility shall continue through
the member's participation in the plan until the remarriage of either the
member or such spouse, or until such time as provided by said judgment,
whichever is earlier. The provision of this section shall apply to any policy
issued or renewed within or without the commonwealth and which covers residents
of the commonwealth.

(b) In the event of the remarriage of the group plan member referred to in
subsection (a), the former spouse therafter shall have the right, if so
provided in said judgment, to continue to receive benefits as are available
to the member, by means of the addition of a rider to the family plan or the
issuance of an individual plan, either of which may be at additional premium
rates determined by the commissioner of insurance to be just and reasonable
in accordance with the additional insuring risks involved.

(c) The name, address, and policy number of a person eligible for health
insurance coverage pursuant to subections(sic) (a) or (b) if available shall
be forwarded by such insurance company to the department of public welfare
within thirty days of the date when coverage of said person under said
subsections is commenced (1981, 735; 1984, 414, para 3, approved Dec. 27, 1984,
effective 90 days thereafter; 1986, 579, para 5 approved December 9, 1986,
effective 90 days thereafter.)

(d) Notice of cancellation of coverage of the divorced or separated spouse of
a member shall be mailed to such divorced or separated spouse at such person's
last known address, together with notice of the right to reinstate coverage
retroactively to the date of concellation. (Added by 1988, 23, para 49, approved
and effective by act of Governor, April 21, 1988.)

(e) Claims paid on behalf of a divorced or separated spouse or on behalf of a
dependent who is not residing with the member shall be paid to the physician,
hospital, or other provider of covered services or to the person on whose
behalf such services were performed, unless the person is a minor child.
In the event the person on whose behalf such services were performed is a
minor, payment shall be made to the physician, hospital or other provider
of such services or to the parent or custodian with whom the child resides.
(Added by 1988, 23, para 49, approved and effective by act of Governor,
April 21, 1988.)

========

The above is current through March of 1990.

========

My commentary follows:

    First I would like to comment about Stradinski's position that the
    state law does not apply. What Digital has done is they have formed an
    entity which they call the Digital Medical Plan. It is administered by
    John Hancock Insurance company, but Digital would have you and the
    state believe Digital is NOT providing medical insurance.
    
    I would like to point out that Wang Labs circa 1985 took this same
    stance, was dragged into court, and made to conform to the Mass Law no
    matter what the hell they called their Medical benefits (Strikingly
    similar in Wang's case it was the Wang Medical Trust/Plan again
    administered by John Hancock Insurance company).
    
    I have a lot of trouble when the company starts taking away benefits
    because they think they have found a loophole in a law. And, I have
    very little doubt, that if this were to come to court -  Digital would get
    reprimanded and they would be required to support the theme of this Law.
    
    My major concern here, is once we start finding this kind of loophole
    and taking away benefits from a segment of the DEC population that
    would have been eligible in the past, what is to stop them from doing
    more of same. I recognize this is a time when we must cut costs. This is
    not an acceptable way.    

    The reference to Cobra, by the way, is a reference to Federal Law.
    Federal Law mandates this coverage but only for 3 years and then at a
    cost equal to 102% of the cost to DEC for providing the coverage. That
    is to say DEC can recover the full amount of their cost for the average
    employee plus the employee portion of this cost with a 2% processing
    fee adder. I've been under Cobra medical for a brief period of time,
    and it is VERY EXPENSIVE.
        Ted
    

    I received the new forms and the book this weekend.  
    
    I have some questions about the Health Reimbursement account.  Does
    anyone here know how it actually works if you choose the automatic
    reimbursement option?
    
    The book says "This feature wil allow you to have your deductible,
    eligible, out of pocket expenses and amounts over your dental
    reasonable and customary limits to be processed automatically through
    your HCRA if ....you are covered by plans 1, 2 ...claims will be
    reimbursed for payment on the 9th of the following month".
    
    Suppose I have a doctor who bills JH for 80% and ordinarily lets me pay
    20% at the time of service.  Will the doctor be able to bill JH for
    100% and have the remaining 20% paid directly to them out of my
    account...or do I have to pay the 20% out of pocket and have all
    reimbusements come directly to me later?  
    
    The booklet didn't go into this level of detail, so I'm not sure what
    the automatic option really gives me - or the differences between it an
    the non-automatic option.
    
    The reason I ask is that many doctors expect you to pay at the time of
    service.  If I expect high medical expenses this year, and choose to
    have $20/week deducted for HCRA for example, and then have to also pay 
    20% at the time of service for weekly treatments for a period of time,
    it could negatively impact the cash flow for a while to be making
    simultaneous payments.
    
    I would like to hear that it can all take place between the doctor and
    JH as long as I submit the form.  I also want to let my medical
    practitioners know what to expect while we're getting used to this new
    system.
    
    Also, are prescription copayments reimbursed from this fund?  
    
    And if I buy eyeglasses, is the total amount reimbursed from this
    pretax fund, or just the lenses?
    
    Thanks for any help you can give.  (I will verify any information I
    receive once I have a better sense of how this all works.)
    
    Holly
    

    I just got my book in the mail and have a question. (I have been
    out of town and have missed all the presentations.) 

    My book says that if I choose Individual Medical Plan 1 I must
    pay $5.50 per week ($23.84 a month, $286.00 a year). It also
    states that if I happened to live outside a HealthNet Service
    Area I would pay $0 for the same coverage.

    Has there been any explanation of this discrepancy? It seems like
    a blatant attempt to force me to choose HealthNet which is less
    than half the cost. Now, I don't see any problem with the company
    offering "incentives" for me to choose the plan they would like
    me to. On the other hand "penalizing" me because I happen to live
    in a certain geographic area seems discriminatory. I live in the
    Colorado Springs area. An employee that happens to live a few miles 
    up the street in Denver (where I believe medical costs are slightly
    higher) will pay significantly less for the same coverage. 

    I find it interesting that these tactics are being used when layoff
    rumors are rampant. Maybe they figure that no one will complain 
    when they figure if their voice is too loud that they may be first 
    on the layoff list.

    Is it time to contact my attorney?

    					Dick

        Re: .215 (questions about the Health Reimbursement account)

        I haven't looked at the details of the Digital plan, I only
        know how similar plans have worked in other companies.  In
        particular, Wang where my wife currently works.  The plan
        covers prescription copayments and all the cost of eyeglasses,
        including the cost of the exam.  Because we had a drop in our
        applicable medical expenses one year, I used the excess money
        in the fund to replace my 10-year old frames with a really nice
        pair of frames and there was no hassle--they just paid.

        I have no knowledge of the automatic reimbursement.

        					B.J.

>                 <<< Note 1128.209 by FRAGLE::RICHARD "Dave" >>>
>
>     Here is some additional information re HMO cost WITHOUT HEALTHNET:
>
>    			Family (Healthnet cost)	    Family (Lockin)	
>    
>    Harvard Community		$19.02			$14.02
>    Fallon			$ 9.05			$4.05
     
        Dave picked up these numbers from a presentation by a personnel
        representative.  Can anyone in the HealthNet area verify these
        numbers, especially the cost of Fallon HMO without HealthNet?

        I live in Leominster, Massachusetts.  I am not in the HealthNet
        area, but I have the option of being covered by either Fallon or
        Harvard Community.  The numbers in my booklet don't agree with
        the numbers above.  My choices state that the weekly costs are:

                        Fallon     Harvard     DEC 1      DEC 2
        Individual      $ 3.05     $ 7.72     $ 0.00     $ 4.50
        Family          $14.06     $28.43     $ 8.50     $20.50

        Since Digital is providing increased subsidies for health care
        outside of the HealthNet area, it doesn't make sense that HMOs
        should cost more outside of the HealthNet area.

        					B.J.

Re: .218

>        I live in Leominster, Massachusetts.  I am not in the HealthNet
>        area, but I have the option of being covered by either Fallon or
>        Harvard Community.  The numbers in my booklet don't agree with
>        the numbers above.  My choices state that the weekly costs are:
>

It turns out that is you live OUTSIDE the HealthNet area, you pay more (like
100% more) for all HMOs.

>
>        Since Digital is providing increased subsidies for health care
>        outside of the HealthNet area, it doesn't make sense that HMOs
>        should cost more outside of the HealthNet area.
>

You can say that again!

Simon

    RE:  .216
    
    	Dick, it's even worst than that. If you lived in Woodland Park
    you would only see a $1.00 increase in Digital Plan 1. By living
    in the Colorado Springs area you get to see a 300% increase.
    ($ 7.50 > $21.75) You don't have to live 60 miles away, only 12
    miles. I'm sure there are placed in Mass that you could live on
    one side of the street verses the other side and see the same
    problem. 
    
    I believe the whole thing stinks and everyone should be treated
    that same. Oh, well, there is alway the USSR if this country/company
    doesn't get it's act together.
    		looking forward to a 300% increase in Digital Plan 1
    		Greg

    Some answers based on the Health Care Options presentation given in the
    Salem NH plant this week:
    
    re: automatic reimbursement
    
    DMP will pay 100% of the bill. The doctor should send the entire bill
    to John Hancock and not collect any money from the patient.
    
    Also, if you use the reimbursement option, they will pay the 20%
    whether or not you have accumulated the money (up to the maximum amount
    you will contribute for any given year).
    
    And although you can't change (increase or decrease) the amount you
    contribute, you can stop making contributions. This would be useful if
    you think your fund is going to be more than you'll really need.
    
    Keep in mind that if you have any unused money at the end of the year,
    you don't get any of it. It goes to JH for adminsitering the fund.
    
    re: different rates
    
    The options available are based on the ZIP code of where you live. Each
    booklet has been customized to each employee based on ZIP code. Why one
    ZIP code has certain coverage over another one close by wasn't covered.

    
    
    This may be a repeat of what has already been mentioned, but the more
    people who question this situation the better.

	I was wondering if there are any kind of discrimination
laws being broken here.  The way I see it, a person who lives
5 miles away from me but falls just outside the HealthNet Area only has to
pay 20.50 per week for DMP2. (a $3 per week increase). But because I
happen to live within the HealthNet Area I must pay $34 per week (if I
choose to keep DMP2) which is double of what I'm paying today.  


	Also what about the split families that are so popular today.
My kids live in a town outside the HealthNet area, I live inside the
area.  In order to provide easy accessible health care, I am almost
forced to carry the most expensive plan DMP2.  I know I have the option
using the HealthNet Plan for myself and then just pay the deductible plus 
30% difference for the kids, this just seems like a lot of extra paperwork
and hassles amongst the insurance companies.

	Bottom line is, I just don't see where its fair that I should have
to pay $14 per week more, just because I chose to live in a certain part
of Mass.  Sure does seem like a case of DISCRIMINATION to me.

mark

    re .222: "The options available are based on the ZIP code of where you
              live."
    
    I *believe* what your personal data record has is your MAILING address.  I
    don't think they both an entry for MAILING address and residence and if
    that is true what happens if someone happens to have a mailing address
    (eg: a PO Box address) in another city?  Who does one have to disclose
    their actual residence address to except for the tax folks?
    

Re: .223

>        I was wondering if there are any kind of discrimination
>laws being broken here.  The way I see it, a person who lives
>5 miles away from me but falls just outside the HealthNet Area only has to
>pay 20.50 per week for DMP2. (a $3 per week increase). But because I
>happen to live within the HealthNet Area I must pay $34 per week (if I
>choose to keep DMP2) which is double of what I'm paying today.  
>

On the other hand, you get real cheap HMO coverage (say $14 for Harvard) whereas
I get to pay $28 for EXACTLY the same service.

>forced to carry the most expensive plan DMP2.  I know I have the option
>using the HealthNet Plan for myself and then just pay the deductible plus 
>30% difference for the kids, this just seems like a lot of extra paperwork
>and hassles amongst the insurance companies.

Surely it's less paperwork; now you only get involved with filling in forms when
your kids need treatment, rather than ALL the time.

>        Bottom line is, I just don't see where its fair that I should have
>to pay $14 per week more, just because I chose to live in a certain part
>of Mass.  Sure does seem like a case of DISCRIMINATION to me.

I think I agree; just remember that both sets of people are being discriminated
against!

SimGr

    Currently for those folks in DEC Medical Plan (DMP) 1 or 2 receive
    a prescription card which can be used to fill prescriptions from
    dentists.  Once you go to a HMO or a HMO/Healthnet you will lose
    that card and will have to pay for the prescriptions out of you own
    pocket unless your HMO would happen to honor a prescription from
    your dentist (not likely).  As far as I can tell the dental plan
    does not cover prescriptions.

re .226:

I doubt if dental prescriptions are a significant factor in most people's
medical expenses.  I mean, how often do you get a pain killer for a root canal?

And what of the families that have both spouses working for the 
company?  They get their medical either paid for by the company
or depending on where they live and the options they choose, they 
actually can make money on the deal.

Seems like these's an swful lot of discrimination going on all over
the place.


Vicki

Re: .226

My HMO (HealthSource New Hampshire) gives me a prescription card with which
I can get prescriptions for a small co-payment, much like the PCS card. 
There's nothing that seems to restrict its use to prescriptions written
by my primary care physician.

			Steve

Has anyone else noticed the wool that DEC is trying to pull over our
collective eyes?  We are inundated with the myth of "preventive health care"
is where it is at. HMO's stress this and that is the way to go. Maybe so, but,
I find it appalling that DMP 1 and 2 makes you pay a deductible first. In
short, they want you to go to the hospital but not the doctor. DMP 1 and 2
only pay for physicals in certain years??? Is that preventive?? If in fact,
preventive care is smarter, more cost effective, healthier, etc., then why
doesn't DMP 1 and 2 offer these at minimal cost.
Example:
		HMO		DMP
Cold    	$3		$50(doctor's fee) before deductible
Sprained ankle	$3 	 	  0 (go to hospital)
(maybe a trip to hospital
after seeing primary care Phys)

With a $200 deductible, I am ONLY going to the doctor if I REALLY need to. If
I have a cold, I am not going to the doctor unless it turns into something
worse, that could result in hospitalization. To me, they are not offering
apples and apples. That doesn't sound preventive to me!


DEC wants out of this business and wants budgetable figures. They want to pay
$X amount for Y people and know that figure won't change. With DMP, they don't
know what their costs will be for the coming year. That is understandable. It
makes proper business sense to do that. I don't have a problem with that. I
don't have a problem with raising the cost of DMP's, if justified.
I DO have a problem with the way they are going about this. If HMO's and that
type of plan are the way to go, then don't offer us a noncomparable DMP and
say it is an option. The coverage is in no way the same.

Another myth is "a primary care physician to coordinate all your care." What
is different with me going to my personal physician (through DMP 2) who also
works for Harvard Community Health Plan and my joining HCHP and picking the
same doctor as my primary care physician? I am happy with the service I
receive now from my doctor. I would only change to this HMO because of
prohibitive costs. Can I expect "better" care now that he can "coordinate all
my care"? Was this doctor not providing me with proper care before, when
I belonged to DMP 2?? What will be the difference in care I receive? I hope I
would be getting at least the same care. If I am receiving the same care, then
why the difference in cost??? $3 vs $50(or more)???
Or can I expect "worse" care ???

I think DEC will continue to offer DMP at outrageous and escalating costs, so
they can tout "more options" to the benefit package.
    

re .230:

>                                                            If HMO's and that
>type of plan are the way to go, then don't offer us a noncomparable DMP and
>say it is an option. The coverage is in no way the same.

Are you suggesting that DEC should stop offering an indemnity plan because
it's not like an HMO?  That doesn't make sense.  If two plans were pretty
much the same, it would make sense to drop one.  Since HMOs and the DMPs
are very different, it makes sense to offer a choice.

    Re: .230
    
>Another myth is "a primary care physician to coordinate all your care." What
>is different with me going to my personal physician (through DMP 2) who also
>works for Harvard Community Health Plan and my joining HCHP and picking the
>same doctor as my primary care physician? 
    
    No difference.  That's the point.  We made a similar change some years
    ago in the same situation and receive just as good care from our family
    doctor (now "Primary Care Physician") as we did before, but at lower
    cost and greater convenience (no paperwork, etc.).
    
    -  David

    Last night we went to the open house at the Fallon Clinic on Pleasant
    Street in Worcester.  (We live in Dudley, which is on the CT border)
    
    At this meeting, we were told that the Auburn facility is closed to
    all new members that work for DEC.  Then, we asked about the
    availability of physicians at the Pleasant St. location.  Unless we
    are willing to wait approximately 6 months for a physical (which is
    required to establish a primary physician), there are no openings.
    Out of the physicians located nearby at the Lake St. facility, only
    2 were accepting new patients.  (These are internal physicians).  One
    of those 2 I wouldn't even consider.
    
    We also asked about pediatricians who are accepting newborns...again
    most are not accepting new patients.
    
    For an HMO that DEC selected in part for their access/coverage, I
    find it appalling that new members are restricted to a very small
    number of physicians (some of whom are not board certified) and that
    the locations that are accepting new patients are also limited.
    
    When we got home, we checked the CMHC list of pediatricians...same
    thing there!  Hardly anyone is accepting new patients.  If we can't
    really choose a doctor from their extensive list, why were these
    health plans promoted so favorably?
    
    Sure makes Healthnet or JH plan 2 look good!
    

    RE: Automatic reimbursement
    
    Does anyone have any details on how this will work?  Someone suggested
    that your physician will send in the bill for the entire amount and
    then the auto reimbursement will pay him the 80% from insurance and
    also pay him the 20% out of your "escrow-type" fund.  What about
    doctors who *require* you to pay the 100% up front and then you have to
    submit it yourself?  I'm assuming that the doctor's bill will show that
    you've paid 100%, and they will send the doctor 20% from your fund and
    send *you* the other 80%.
    
    Also, supposedly you can get reimbursed for travel expenses to and from
    you doctor out of this fund.  How do you submit for this?  I travel
    from Worcester to Boston to see my specialist (and I'm not giving him
    up!)  Anyone know how this gets submitted??
    
    L.

    Oops, I meant to say that the auto reimbursement will send *you* the 80%
    that's covered by insurance ALONG WITH the other 20% that it will
    remove from your fund.   Is this right???
    
    This is confusing!
    

    re .234
    
    What we were told in a benefits meeting this week is that this is a
    "reimbursement" account.
    
    For example (and assume you have met your deductable)...
    
    If you are billed $100 by a doctor and your insurance pays 80%, then
    your insurance will pay $80 to the doctor.  Your reimbursement account
    will pay YOU the $20 (ie. reimburse you for the amount you had to
    pay).  If you checked off the "automatic" reimbursement box on youyr
    enrollment form for the HCRA, you will not have to file a claim for to
    get your $20.  If you did not check the box then you will have to file
    some sort of claim form to get your reimbursement.
    
    If your doctor required you to pay the $100 up front and then  settle
    directly with the insurance company, you should get $80 from your
    insurance plan and $20 from your reimbursement account.
    
    All this, of course, is subject to the maximum annual amount you will
    have in your HCRA account.
    
    The key is that it is an account to reimburse YOU for any eligible
    expenses that are not covered by your regular insurance.

re .236:

>    For example (and assume you have met your deductable)...
>    
>    If you are billed $100 by a doctor and your insurance pays 80%, then
>    your insurance will pay $80 to the doctor.  Your reimbursement account
>    will pay YOU the $20 (ie. reimburse you for the amount you had to
>    pay).  If you checked off the "automatic" reimbursement box on youyr
>    enrollment form for the HCRA, you will not have to file a claim for to
>    get your $20.  If you did not check the box then you will have to file
>    some sort of claim form to get your reimbursement.

This contradicts what I read in either DIGITAL or MEDICAL.  Someone said
that he/she was told that the full $100 would go directly to the doctor.

I also read that the reimbursement account will pay out based on the
total amount to be contributed over the year.  If you are contributing
the maximum $2080/year and have an out-of-pocket expense of $2080 on
January 1, they'll reimburse the whole thing.

Until I see something official in writing, I don't know what to believe
about either of these claims.

    re .233: Fallon
    
    A friend just called Fallon (Plantation St) and they gave him an
    April appt for his physical.

    Maybe we need to start a new base note just to deal with the auto
    reimbursement issue.  This note seems to be a catch-all for all of the
    issues around the new benefit choices.
    
    Also, does anyone know who you call to get your questions answered
    about auto-reimbursement?  Or do you have to find one of the remaining
    "workshops" they've been running and ask someone there?
    
    L.

re: several

Except as noted, everything I'm about to put here is from memory, based on 
material I've received sent to my home address. It's all at home so I can't
give exact quotes. Material includes mostly the special, personalized, booklet
with specific options for me, but might also have been in the earlier more 
general Benefits Update.

Reimbursement is either via claim form or automatic.  The claim form choice
(submit a claim on some special form and get reimbursed) is always available.
The HCRA authorization has a box at the bottom
	|_|  Check this box for automatic reimbursement
Instructions say:
   "Automatic Reimbursement (optional feature)
    If you submit medical and/or dental claims to John Hancock and want your
    o  deductible
    o  eligible out-of-pocket expenses and
    o  amounts over your dental reasonable and customary limits
    processed automatically through your Health Care Reimbursement Account, 
    check the Automatic Reimbursement box in Section III. This option applies
    only to claims processed through John Hancock and does not apply to HMO
    expenses."

I read this all to say that Hancock will automatically process the deductibles
and uncovered 20%, etc. if you check the box. I categorize a claim as being
divided into two parts: covered and uncovered. Without automatic reimbursement,
they pay out only the covered portion and you have to submit a special form for
the rest. With automatic coverage, they pay out the whole thing [up to the max
limit] without a special form.

Yes, you set your weekly payment and the TOTAL amount you'd contribute over the
course of the year is available on day 1. You cannot change your weekly contrib-
ution, but you can stop then entirely until the next year. You have to re-enroll
each year.

We've been told to contact our PSA if we have any questions. These are the same
folks who are out making the presentations.  I'd suggest calling your personnel
folk - or corporate - with questions.

Unanswered questions:
	Where does JH send the check?  Based on previous JH experience, they'll
	send it to the doctor if the doctor has authorized direct payment or to
	you if you submit a paid receipt. [This is what they've always done for
	me in the past on the normally covered 80%. Aside from normal paranoia,
	nothing indicates included the previously uncovered portions should
	change this.]

	Who tracks the entire process?  Obviously I can submit some claims
	directly (such as mileage mentioned in a earlier note). Until I see
	the claim form, I don't know whether JH is administering this for us
	or not. Someone has to know when you've reached your limits.

Ain't this fun!
	/Marvin

    sure are a lot of accusations and imcriminations here about
    so called "discrimination".
    
    Why do we jump on that old horse so often...?  and why are we so
    inconsistent about it?  (do we do it just when it suits our purpose?)
    
    i just moved to mass... and found out that lobyists forced the state
    legislature to stop automobile insurance companies from "discriminating" 
    against sexes by charging different amount for young men and young
    women's car insurance.  in spite of statistical proof that young men
    cost the companies more than young women.
    
    yet, those same insurance companies are allowed to charge more for
    insurance coverage in Boston than in Concord...because it costs more.  
    
    So, why is it wrong for DEC to charge more in those areas of service
    where costs are higher?  Why is that discrimination?  
    
    Do you wail "discrimination" when your car insurance bill is higher
    than the neighbors?
    
    Come on folks...  
    
    tony
    (who's also caught with "split family" insurance uplift... but, frankly
    is quite happy to HAVE insurance...)
    
    

    re .233: Fallon - 6 months
    
    We've decided to give Fallon a whirl this year.  Last Friday my wife
    called up to make appointments with the doctors we would like to
    be our primary care doctors.  The one I picked was recommended to me
    and my wife wanted a female doctor.  The doctor I choose only accepts
    patients after a 2 part physical.  So my first part is at the beginning
    of April which is lab work to be done by a nurse and the second part
    where I finally see the doctor is on April 28 (4.5 months away).  My
    wife got an appointment for the end of March (3.5 months away).  This
    was at the Plantation Street facility.  Seems like a long wait to
    to me to establish a primary care physician.

    Re: choosing a primary care physician
    
    I'm in Colorado Springs and when I first joined the HMO here I had to
    choose a Primary Care Physician.  I think it was just another blank on
    the form they had to fill out because I didn't make an appointment and
    see him.  In fact, I think the first time I saw him for service was
    about three or four years later!  They probably have a limit to
    the number of people they are PCP for - maybe that ratio of part of the
    contract (?).
    
    karen (who would love to see the contract DEC has with this HMO)

re .241:

>    So, why is it wrong for DEC to charge more in those areas of service
>    where costs are higher?  Why is that discrimination?  

That's not what's happening.  In areas where there's no HealthNet,
DEC is paying a larger share of Digital Medical Plan costs, and a
smaller share of HMO costs than in other areas.  They're doing the
former because they want to reduce the number of people using the
DMP.  I have no idea why they're doing the latter.

    re .241
    
    	at -.1 stated in other areas of the country, DEC is paying more.
    If I lived in Woodland Park (many Decis do) which is only 15 miles
    away, I would pay only $1.00 more for DMP #1. Now Woodland Park does
    not have a hospital and most people come to Colorado Springs for
    their Doctors anyway. These people only pay $1.00 more and my costs
    are increasing 300% (7.50 to 21.75). That is what I'm pissed about.
    	Still Pissed and enjoying it less.
    	Greg
    

    I signed up for Fallon HealthNet but as of this morning I have not
    received any information from Fallon saying that I'm a member or
    providing information on what to do if medical attention is needed.
    Anyone else receive anything from Fallon?

    Re .246: Fallon
    
    I just called Fallon to see if they had my application and they claim
    they never received it.  They said even if they have it that it might
    be another 3-4 weeks before one receive the pack from them which
    contains your ID card.  They asked me to have my PSA FAX them a copy
    of my application.
    
    In case anyone else needs the FAX number it is 508-835-2880.  I spoke
    to a Joan at 508-835-2550 x4183.
    

    Same for me with Tufts...   

    Ditto Harvard. I tried to make an appointment this morning, and
    they'd never heard of me.
    
    
    Linda

Well, I've got a letter from my doctor saying "Come see me" so I'll make an
appointment and see what happens when I tell the billing office that I'm
making my $3 copayment instead of paying the bill myself since I've changed
from the DEC plan (which they insist on calling John Hancock) to HCHP.

/john

    Our new (much-more-costly) HMO, Pilgrim, has not heard of us yet,
    either.  I'm not sure what to do about this since my husband now has
    only two days' worth of his thyroid medication left since the
    mail-order prescription we sent in last month has not shown up (maybe
    because they knew we were changing systems).  I guess we may have to
    pay for one month's worth ourselves (ouch!) until the redtape catches
    up.  Sigh.  He is checking with the doctor now to see if there is
    anything else he can do - the mediciation is 1) necessary on a daily
    basis, and 2) expensive.
    
    /Charlotte

    I suspect that since none of the HMOs have heard about the
    new DEC enrollments, it could be Digital's problem. DEC may have
    been too slow/inefficient in sending out info. to these HMOs.
    
    During the same time when DEC employees were choosing new HMOs,
    I opted out and joined an HMO thru my wife's employer. And guess what?
    On Jan. 2nd, the facility I joined (HCHP in Welleseley) sent me the
    id card and I was all set.
    
    If DEC needs more days to pass on the info. to these HMOs, they
    should have moved the enrollment date early.
    
    - Rajesh

    I was in the neighborhood of the new Burlington HCHP office yesterday
    afternoon, so I decided to stop in and see if my membership could be
    acknowledged. It was the first day this clinic was open, so there were
    no patients in most of the areas. The people at the front desk were
    very helpful and friendly, took my copy of mt DEC enrollment form, and
    set me up with a temporary number and card. I then walked over to the 
    Internal Medicine area and obtained an appointment for a new patient
    physical for the date, time, and physician of my choice. So far so
    good. I'll see what happens at the physical, since I'll need an
    Orthopedic referral immediately. 
    
    As I remember, three years ago I enrolled in Baystate. It took almost
    the whole month of January for them to get the information from DEC
    and for me to appear on their database. Maybe I'm naive, but I think
    that insurance changes should go through in time for us to have cards,
    etc., for the first week in January. Anyone put in the position of 
    having made a coverage change and needing confirmation of insurance
    from a new company this week will have a hard time. Not everyone 
    will accept our little goldenrod copies!!
    
    
    Linda

My appointment is for next Wednesday (the 9th) so we'll see if DEC has
notified HCHP by then that I am a member.  If not, I'll still pay the
$3 and let the paperwork catch up later.  No problem.

/john

    I anticipated problems with the possibility of mass conversion to HMOs.
    To that end, we enrolled earily as we could make an intellignet
    decision, then proceeded to make new patient visit appointments for
    all family members.  Before we enrolled, all new docotor staffs were
    fimilar with my family.  I got all our past medical records for
    transfer.
    
    Today, our new carxs arrived from MTHP.  But even before this, we had
    to schedule a patient visit for severe sickness.  They knew about us.
    
    Our daughter requires monthly medication that I did not want to see
    interrupted.  That part of the reason why we didn't leave anything to
    chance.
    
    Although we are would not 'choice' an HMO [cost forced us in], we have
    been pleased with the progress to date.  But it has meant co-operative
    work between us and MTHP in the past two months.
    ed
    

    I tried to do the same thing. The Burlington clinic of HCHP was not
    open until yesterday. When I called the main HCHP information 
    number in their literature, I was told there was no way to make
    an appointment in Burlington until the clinic opened. 
    
    Linda

    	Interesting memo in .257.
    
    	One thing that struck me was the fact that new PCS cards will
    	be sent out soon if you are in one of the DMPs.  Last year
    	I was in DMP1 (now an HMO), and got new PCS cards in early
    	December.  I chuckled at the waste because I knew I was going
    	to leave DMP on 1/1 and the new PCS cards would be useless.
    
    	With the possibility of so many people leaving DMP under the 
    	current structure, and in light of the fact that they will be
    	sending out new PCS cards for 1991 DMP members, why would they
    	go through the expense of sending out PCS cards in December?
    
    	Joe Oppelt

    And for those of us who just signed up with an HMO, I need to find out 
about a temporary card for perscriptions. I just picked up a perscription 
today and had to pay full price because I did not have any proof of signing 
with HCHP. It cost $26 instead of the usual co-payment. I never realised 
what that perscription cost by itself! The co-pay is a heckuva benefit when 
you have medicine like this that we buy regularly.

    Vic

    
    I'd like to know, too. I got lucky, in that my small-town pharmcist,
    whom I've been using for years, offered to foot the bill minus the
    co-pay until the paperwork got straightened out. But he has a lot of
    DEC customers, and this is no more fair to him than it is to us.
    

    According to Central Mass Health Care (an HMO), DEC employees are still
    in process of being registered. Last week when I called they said I
    might have to pay full price for prescriptions and then be reimbursed.
    Today I called again, and they said that CVS will accept a copy of my
    Benefits Enrollment form as proof that I'm part of CMHC, and charge me
    the HMO price. We shall see - tomorrow.
    

I just received my first Explanation of Benefits form of the year.  I had
signed up for HCRA with the automatic option, so I was expecting a check
for the full amount.  No check, just a message that the amount had been
applied to the deductable.  I called up JH, and was told that all HCRA
checks go out on the 9th of the month.  If I'm not mistaken, this is even
less generous than the way they treat providers, who get paid twice a month.

    
      I just filed with HCRA for a reimbusrement. I called them first to
    verify what I needed to send, and was told that the application had
    to be there two weeks before the ninth of the month. Checks would be
    sent on the fifteenth of the month. Sounds like the IRS, the answer
    varies with the "EXPERT".
      Either way, I expect it'll take two to three months to receive the
    check.
    
    -Greg

    Are all the details about HCRA spelled out in writing anywhere?  I
    called a personnel representative, asked for this, and was asked why I
    hadn't attended a presentation on this subject an hour away in the next
    state!  I told the rep that I had not heard about it.
    
    When I repeated my question, I was told (by this same individual) that
    'all the information I needed' was on the enrollment form and in the
    booklet.  Right.
    
    This kind of 'support' from personnel people is less than useful.
    
    Someone must know -- and have in writing!! -- exactly how this is
    supposed to work, no?  How can I get the details so that I know
    *exactly* what to submit, when to submit it, to whom, how it interacts
    with my plan 1 insurance, how 'automatic' really works, and so forth?
    
    Holly

    I received a copy of the IRS publication from our benefits folks.   It
    was better than nothing, and it was clearer than a similar publication
    the IRS sent me directly.  The publications lists what medical costs
    are tax deductable.    
    
    I found the publication to be very clear in defining the eligibility of
    medical services performed by professionals, such as doctors,
    osteopaths, dentists, physiotherapists, and so on.  Even though
    accupunture is not covered by a lot of insurance, accupuncturists are
    at the head of that alphabetized list.  From what I've been able to
    find out, your claim to HCRA is covered if the IRS says it would
    normally be tax deductable.  There seem to be no written examples of a
    typical claim that is both not covered by regular insurance and tax
    deductable.                                                           
    
    However, I could not find a clear answer to a situation like when a
    physician writes a prescription for massage therapy that is performed
    by a licensed massage therapist. In this instance, one person at the
    IRS said this would be considered tax deductable.  John Hancock's
    answer to this was on the order of, if the IRS told you it is tax
    deductable, then you will be reimbursed from the account.  I don't know
    what happens if you get more than one answer from the IRS, and John
    Hancock could not tell me how they would handle the situation of
    getting more than once answer on the eligability of a medical service.

    If this has not told you much, that's exactly how I felt after persuing
    this issue.  I'm just going to start submitting claims, and see what
    happens.
    
    Charles McKinley Norton
    Decnet For PCs
    LKG1-3/A17 
    226-5457

re: .265

Ah, give 'em a break.  They're trying to figure it out just like we are.
When I called John Hancock they had to do some research and call me back.
They were very polite and eager to give me "right" answers, even though
they too were struggling with understanding the rules.  They called back
a couple of hours later.

re: what's deductable

It's largely between you and the IRS.  In most cases, if you insist that
it is deductable it's not really up to John Hancock to contest that.
I suppose they have some responsibility to filter out the absurd, or
the mundanely wrong, but it's the IRS tax rules that matter, not JHs
usual coverage rules and guidelines.

Once again, JH is _merely_ a plan administrator, not judge, jury, and
definately not the payer.  In reality, they don't care all that much
what they payout, even less that they would for Digital funded expenses
where one might expect Digital to require they keep a reasonably tight
approval procedure.  It's your/our money ... they just hang onto it for
a time.

- greg

re Note 1128.267 by STAR::ROBERT:

> re: what's deductable
> 
> It's largely between you and the IRS.  In most cases, if you insist that
> it is deductable it's not really up to John Hancock to contest that.
> I suppose they have some responsibility to filter out the absurd, or
> the mundanely wrong, but it's the IRS tax rules that matter, not JHs
> usual coverage rules and guidelines.
  
        I wonder if it's as simple as that.

        In the case of HCRA (and DCRA) disbursements, the money never
        shows up or is accounted for on the individual's tax return. 
        Thus it would seem that the administrator (or Digital, on
        whose behalf JH is administrating) has some responsibility to
        ensure that the disbursements meet the guidelines.

        (Or is there some 1099-type form for reporting the
        disbursement to the IRS per individual?  Even then, it isn't
        income that would show up anywhere on a return.)

        Bob

    Re: <<< 1128.268 by XANADU::FLEISCHER (381-0899 ZKO3-2/T63)" >>>
    
    >>  In the case of HCRA (and DCRA) disbursements, the money never
    >>  shows up or is accounted for on the individual's tax return. 
    
    Actually in the case of DCRA, it is reported on your W-2, and you
    must fill out a form 2441 with your tax return. I know, each year it
    is a pain to get the form 2441 since it is not carried in your local
    post-offices, banks, etc, and I must make a special trip to
    Manchester,NH or Boston to get one.
    
    /jim
    

>                                                   I know, each year it
>   is a pain to get the form 2441 since it is not carried in your local
>   post-offices, banks, etc, and I must make a special trip to
>   Manchester,NH or Boston to get one.

You can call 800-TAX-FORM and ask them to mail you whatever forms or
publications you need.  It's supposed to take about two weeks.

I have a booklet entitled "Your Choices for 1991" which was mailed to my home
address last November. It was a personalized 32-page booklet, which I believe
is based on either my work location or my home zipcode, and includes specific
lists of options for me.  I believe every employee received one of these.

It has sections (pages 17-20) on the Health Care Reimbursement Accounts (HRCA)
and the Dependent Care Reimbursement Accounts (DRCA). On page 22 there's a 
section on How to File a Claim, and on page 23 a section entitled Health Care
Reimbursement Account - Automatic Reimbursement.  This section ends 

	"Claims received by the end of the month will be reimbursed
	for payment on the 9th (for Health Care Accounts) or the 10th
	(for Dependent Care Accounts) of the following month."

The gold (employee) copy of the authorization form has general instructions
for filling out the form, but does not include any statement of how the process
is administered.

The "Your choices for 1991" booklet seems to be fairly extensive and complete
in its descriptions about options and how they work.

	/Marvin

    Marvin, I agree.  It is complete up to a point - it gives you enough
    information to help you decide whether to sign up.  
    
    Once you have signed up, there are a number of procedural issues that
    remain unclear.  I don't think they are single case issues, which would
    of course require one to call John Hancock.
    
    Suppose you or your family are currently seeing a dentist, a
    chiropractor, and a pediatrician, and an internist.  The dentist
    submits bills and bills you for whatever JH doesn't pay; the
    chiropractor makes you pay 100% up front and get reimbursed yourself;
    the pediatrician wants you to pay the 20% copayment on the spot; and
    the internist wants to know how it all works, who should bill for the
    deductible, what payment arrangements are best for you, and you can't
    tell them.
    
    There are a number of different payment arrangements one can make with
    medical people under plan 1 or 2.  It is not clear whether the employee
    has to have weekly receipts for regular treatments, or whether the
    provider can submit the bill and have the 20% taken from the HCRA, how
    the deductible will be distributed among the providers, and what
    choices are open to the providers.
    
    I think the biggest unclear area is how it works when you are
    simultaneously submitting claims to JH under plan 1 or 2 and want the
    balance of your claim to come from your HCRA.  Ideally it would be
    completely transparent, but it doesn't seem to be.
    
    Speaking as a course developer, a new system should have good training
    and documentation!  If I were documenting this system, I would lay out
    all the most commonly asked questions about HCRA in terms of each of
    the different plans, and then provide a couple of simple case studies
    that explain what to get, where to send it, what JH does, what you do,
    and what you tell the practitioners, and who gets the reimbursement.
    
    The booklet was a good start; more detail is needed.
    
    Holly

  re: .272
  <<    Speaking as a course developer, a new system should have good training
  <<   and documentation!  If I were documenting this system, ...

Yeh, Holly, but you're too logical about this.  I give the INDIVIDUALS I've
dealt with at JH over the years a lot a credit for trying, but the system is
very typical of a lot of administrative systems, which turn out to be cumbersome
and confusing.

Oh well, I've just submitted some claims for 1991. I've signed up for automatic
reimbursement, so I'll see what happens.

	/Marvin

Re: .26

I got copies of form 2441 in my 1040 forms and instructions.  I know
they have several different packages they send to people, but 2441 is not
a hard form to find.

There's also an IRS office in downtown Nashua which has forms, if that's
convenient.  I would presume there are other offices closer to you than
Boston.

Forms can also be copied at libraries.

				Steve

    re: .274
    
> Forms can also be copied at libraries.
    
    This is worth elaboration.  Most, perhaps all, public libraries in the
    U.S. have a loose-leaf binder of forms and instructions published by
    IRS.  They are there to be copied, they are even finished/produced for
    best copying.  You may have to ask for the binder(s), I think they are
    typically in the Reference section or behind the desk.
    
    For all practical purposes this is the fastest, cheapest, most reliable
    way to get whatever you need.  A very comprehensive selection.
    
    Gordie-who-has-been-filing-some-very-obscure-stuff

>    For all practical purposes this is the fastest, cheapest, most reliable
>    way to get whatever you need.  A very comprehensive selection.

Fastest and most reliable, maybe.  But calling an 800 number is cheaper
and more convenient.  You can also get publications like "Your Federal
Income Tax" by calling the 800 number.  Copying that in your library
would be expensive (it's a couple hundred pages).

    Having been a 9-year veteran of John Hancock before making
    a switch finally to an HMO during the last enrollment period
    I sure didn't know all the questions to ask before jumping
    ship.
    
    I was mighty surprised at the mail the HMO sent to my home last
    month.  In particular, the restrictions page (an entire page
    front *and* back) outlining the pharmaceuticals which are either outside
    of the HMO coverage plan or have certain limitations on them.
    
    This restrictions page has two rules that really seem incredible:  
    a prescription for insulin can only be written and covered for a
    single vial of insulin, and there is no coverage of syringes
    (insulin needles).  If I had this information in December I would
    not have changed from J.Hancock; these restrictions will cost me
    a lot this year.  Plus I now no longer have access to mail in
    prescription services.
    
    I'd like to know if other HMO's have long lists of pharmaceutical
    restrictions? 

    Not all HMOs are the same.  Healthsource New Hampshire is
    fairly liberal.  Here's what the agreement lists:
    
    Extent of coverage:
    
    $3 copayment for generic drugs, $10 copayment for brand-name
    drugs.  Copayments for brand-name drugs are limited to $2000.
    These copayments apply to each 34-day supply.
    
    Covered expenses:
    
    1.  Legend drugs (?)
    2.  Insulin
    3.  Pediatric flouride
    4.  Birth Control pills (note, Digital Medical Plan (aka John Hancock)
    	doesn't cover these
    5.  Fertility drugs (four month supply per year)
    6.  Ana-kits/Epipens
    
    Exclusions:
    
    B.  Non-prescription drugs other than insulin.
    C.  Drugs for treatment related to non-approved procedure, such
        as dental, cosmetic or experimental procedures.
    D.  Medical supplies (such as bandages) and other items required
        for certain medical procedures, medical tests, and maintenance
        care such as ostomy and diabetic supplies to include needles
    	and syringes.  [So HS won't cover syringes either.]
    E.  Devices of any type.
    F.  Drugs labelled "investigational use" or "experimental".
    G.  Immunization agents
    H.  Growth hormones
    I.  Diet formulas
    J.  Any drug which comes onto the market after the effective date of
        this agreement, unless the Plan specifically agrees to include
    	the drug as a covered item.
    K.  Prophylactics, spermicidal jelly, contraceptive cream and foam.

re .277, .278:

Don't most insulin-dependent diabetics use disposable syringes that already
have insulin in them?   I wonder what Healthsource does about this, since
they seem to cover insulin but not syringes.

Does Healthsource charge $10 if there's no generic on the market?

Is there a political agenda in different coverages?  According to .278,
Healthsource only covers four months worth of fertility drugs (which are
*very* expensive), but covers all birth control pills.  DMP covers all
fertility drugs, but no birth control pills.

Is the drug used for treating AIDS (AZT?) considered experimental?

It seems that you've really got to do your homework if you have special
medical needs.

    RE:  Don't most insulin-dependent diabetics use disposable syringes
    that already have insulin in them?  
    
    No, not necessarily.  My insulin-dependent sister uses disposable
    syringes and mixes the insulin herself.

    	Regarding generic versus non-generic drugs and Healthsource, what
    we were told is that we MUST get generic unless the perscription
    specifically calls for a non-generic drug. So the choice isn't yours to
    make.

    re: .281 and generic vs. brand-name
    
    Massachusetts law *requires* that all prescriptions be filled
    with a generic equivalent (if one exists) UNLESS the prescribing
    physician writes "do not substitute" in the appropriate space
    (or perhaps otherwise indicates that brand-name is *required*).
    
    This is different from the requirements/restrictions that any
    HMO's or insurers may have.
    
    Obviously, for patients in other (not Mass.) states, those
    state laws will apply instead.
    
    	Pennie

    From what I understand (in NH) with regards to Healthsource
    and generic/brandname, you have a choice, but if generic is
    not available, you pay the $10.00 anyway.

    Re: .283
    
    That is correct.  
    
    Another thing to watch for with Healthsource which is different
    from the DMP and PCS plan - with Heathsource, the copayment applies
    to each 34-day supply, whereas for PCS, it is (or was last I was
    on it) for each fill of the prescription, no matter what size.
    So for a 100-day fill, you'd pay $9 (or $30) with Healthsource,
    and only $4 (or whatever it is now) for PCS.  I ran into this
    with my son's vitamins with flouride, which come in 100-tablet
    bottles.  It was cheaper for me to just pay the straight generic
    price ($5.50 or so) than the HS copayment.
    
    			Steve

    re: .284
    
    Steve, there is a limit on how long a supply PCS will pay for.  I think
    it is limited to a 100 day supply.  For medications to be taken longer
    than that, you are encouraged to use the mail-order supplier.  However,
    the difference in the co-pay ($2 vs. $6) isn't enough incentive for me
    to go thru the paperwork hassle and hope my refill arrives before I run
    out.
    
    Bob

    The Harvard Community drug benefit covers prescription drugs prescribed
    by their physicians or dentists.  Under the benefit, oral
    contraceptives and diaphragms are covered.  Also, the following
    diabetic drugs and supplies are covered as prescription drugs: insulin,
    syringes and blood and urine testing products.

    The exceptions are vitamins, experimental drugs, drugs or supplies
    which can be purchased without prescriptions (except as mentioned
    above), and drugs or supplies prescribed or purchased outside the HMO
    area unless authorized in advanced.

    The charge is $3 per 30 day supply or fraction thereof, including
    refills.  If you belong to one of their "health centers" then you must
    use the health center's pharmacy.  If you belong to a "medical group"
    you must use a CVS pharmacy or one of the few other pharmacies on their
    list.

    	rep .277-.280  I'm confused.  Maybe it's a state-by-state
    variation, but insulin is NOT a prescription drug here in 
    Colorado.  You must ASK for it at the pharmacy because they
    keep it refrigerated, but technically it's an over the counter
    (OTC) drug, so hence no "prescription drug benefit".  (it's also
    relatively inexpensive).  Obviously, you would want your doctor
    to spec the amount and type of insulin, but the pharmacy does
    not need to see any sort of prescription.
    
    	You also just ask to purchase the disposable syringes here--
    and tell them what size (40 units/100 units/etc.)  Is this a
    state-regulated type of thing, or does this possibly explain
    the rules around coverage?
    
    	Just a note to folks who mention specific co-payments:  They're
    different for almost every HMO, so be careful in making assumptions
    about least cost paths--everyone should be sure to check for their
    own health plan and community.

    up to 30 days at local pharmacy for $6.
    
    up to 90 days by mail for $2.
    
    so a 90 day supply has mail cost of $2 vs. local cost of $18
    
    
    re: 287
    
    Yes, local laws differ a LOT about purchase of needles and
    syringes, whether it be for human insulin or veterinary
    vaccinations.  Good ol' war on drugs has everyone nervous.

re: .288

I just refilled a prescription of 100 tablets to be taken once a day using my
PCS card.  I know they checked it with PCS because I was told that the PCS
computer was running slow and it would take 20 minutes to get my prescription,
eventhough the pharmacist had already put it in the bottle for me.

Bob

Just a note on generics vs. brand name drugs....

Some drugs do not come in all dosages from all manufacturers.
Your doctor may be familiar with the dosages for one maker and prescribe
on that basis.  Your pharmacist may not be able to substitute (say)
200 tablets of a 125 microgram dosage of a generic drug to fill a prescription
written for 100 tablets of a 250 microgram brand-name drug.
Ask your doctor to check before he writes the prescription,
or ask your pharmacy what substitutions might be available if you do get
a brand-name drug when a generic might be available.

- tom]

    In Vermont the CHP plan allows you to purchase your prescription 
    from the CHP Pharmacy or, if they don't supply it, from Kinney Drug.
    You are supposed to get it for half-price (it used to be for a much 
    lower fee such a a dollar or two).  
    
    But we had to pay $18+ for a 2-week supply of a recent prescription. 
    'Makes me wonder if the price didn't get jacked-up so the half-price 
    would be closer to full-price at the outside contracted pharmacy. 
    
    N

    re: .291
    
    You could call another pharmacy and ask for the price for the
    medication (include strength, number of tablets, and whether
    it was generic or brand name) and ask what *they* would charge
    for it.
    
    Then you know approx. what you are really saving.

     U.S. News                                                LIVE WIRE
                                                              April 4, 1991

                     Open Enrollment results are in 

  Open Enrollment for the Digital Health Care Choices and Health and 
  Dependent Care Reimbursement Account Programs is complete for 1991. 
  The chart below shows the health care choices employees made:

                          1991 Health Care Choices 
       Digital HealthNet Area             Non-HealthNet Areas
                        Percent                            Percent
  Health Care Choice    Enrolled     Health Care Choice    Enrolled

 Digital Medical Plan 1    13%      Digital Medical Plan 1     26%
 Digital Medical Plan 2    19%      Digital Medical Plan 2     42%
 HMOs                      48%      HMOs                       27%
 Digital HealthNet         11%      HealthNet Not Offered      N/A
 Opt-Out                    9%      Opt-Out                     5%

 In HealthNet areas, a majority of employees made the choice to receive 
 their medical care primarily through Digital's two managed care programs, 
 Health Maintenance Organizations (HMOs), and the new Digital HealthNet program.
 In Non-HealthNet Areas, there was little change in enrollment percentages 
 when compared to last year's employee enrollment of 72% in the Digital 
 Medical Plans and 28% in HMOs.  Employees are participating in the new Opt-
 Out program in both HealthNet and Non-HealthNet areas.

 Also, during Open Enrollment, 5,475 employees opened a Health Care 
 Reimbursement Account.  Dependent Care Reimbursement Account participation 
 increased from 1,624 in 1990 to 1,665 participating in 1991.

 Digital expects to expand the Digital HealthNet program to approximately 
 16 new locations in 1992 and eventually throughout the United States where 
 HMOs are found to meet Digital's quality, access, data, financial and mental 
 health standards.  

 The objectives of these standards are to:  1) assure access to a quality 
 program in each HMO at an acceptable level; 2) assure adequate access to 
 employees for medically appropriate care; 3) obtain complete and reliable 
 data on a timely basis; 4) assure the continued financial stability of the 
 HMO and 5) assure that the HMO's mental health programs offer effective and 
 efficient quality care to employees and their dependents.  

 These standards have been established to help Digital in deciding which 
 HMOs to offer in the new Digital HealthNet program locations.  The standards 
 also assist the company in its ongoing management of HMOs that currently offer
 the HealthNet program, as well as other traditional HMOs with larger Digital 
 memberships.  

    Does anyone know which department in Digital will be working the
    proposed standards?  I understand that most HMO's do not cover
    therapist visits over $500.00 per year and some do not cover at all.  I
    went back to JH because they still cover treatment centers for
    alcohol abuse and while I had a HMO, my husband was denied quality care
    for his addiction. 
    
    Marie
    RE: 293
    
    Hi Mark.

As far as I know, *no* HMO provides a level of psychological services that's
adequate for treatment of long-term problems.  I think the most that any of
the HMOs in my area offers is 20 visits.

That's one reason that HMOs are cheaper.

    
    Re: .295
    
    If you need therapy or substance abuse help then HMOs are not
    a lot of help.  Their psychological services tend to treat
    the symptom rather than the cause i.e. if you're feeling like
    you're going to commit suicide today then they can fit you in,
    but if you need long term help to get over what is causing you
    to feel suicidal then you're out of luck.
    
    Steve
    

    re: last few
    
    If it matters, HMO coverage for psychological service in Massachusetts
    is **FAR** better than in many other states. It may be that
    Massachusetts regulates HMO's and requires them to offer the level of 
    service they do. In Illinois, none of the HMOs available offer anything
    beyond "crisis intervention" type services.

    Or maybe people who live in Massachusetts _need_ more in the way of
    psychological services.  :-)
        John Sauter