Conference 7.286::digital

    I am a member of the Cigna HMO.  They too have severe limitations.  I
    once spoke with a Digital benefits person about the poor service and
    the limitations, that person just told me that I made the choice to go
    with the HMO.  Digital does not care.  I feel that I really had no or
    very little choice since the HMO is about $32 per week, where the other
    option was about $120 per week.
    

>    I feel that I really had no or
>    very little choice since the HMO is about $32 per week, where the other
>    option was about $120 per week.
    
As the base noter metioned, there is an 'elect' option where you pay more and
then get the option of 'going out of plan' to any doctor/hospital you want to.
the only gottcha is you have to pay the first n dollars and then the HMO covers
around 80% of the balance.  Not as cheap of going with exclusive HMO services,
but as the base note again said, it was a great safety net which made a very
expensive procedure a lot less expensive.

-mark

    re: .-1 
    
    There is an 'elect' option if you've been lucky enough for Digital to
    finally get around to offerring it in your are; I'm still waiting...
    
    re: .-?
    
    I have not yet found a way to get a _complete_ explanation of benefits
    write-up from an HMO until after you actually sign up. (I was given the
    option of driving to their main offices and inspecting it on premises.)
    
    Dave

    RE: .3
    
    Recently my wife that told that Matthew Thorton Health Plan (our HMO
    here in NH) they stopped covering bunion preventive care.  She asked
    if they would cover the foot surgury if the bunion goes uncared for.
    They said yes.
    
    Likewise with my orthopedic shoe inserts.  They didn't cover those,
    but they'd cover the ankle problems I was experiencing due to high
    arches.
    
    Can't these people learn that a little preventive care upfront has
    got to be cheaper in the long run? (I guess that they are hoping 
    that we would move before then...)
    
    				-John
    

    The type of restriction in .0 is just plain cruel.  I'd like to believe
    that Dec will continue to offer the Elect option (it covers for me
    about $280 a quarter in prescriptions that TakeCare doesn't cover even
    though they are HMO-doctor prescribed and FDA-approved), but I
    wouldn't be surprised to see the Elect option removed in another
    cost cutting event.
    
    The good news is that, at least in California, the legislature is
    starting to make various coverages mandatory for HMOs.
    

It is not just the HMOs you have to watch for but I was on the BEST Digital
Health plan 7 years ago, had 2 opinions before my double mastectomy and 
reconstruction surgery which then was supposed to be pay for the 2 surgeries
100%.  After the reconstructive surgery was done, insurance would not pay for 
the "Z-plasty" procedure that was done in my armpit to allow full extension 
of my arm.  This surgery was required to give me full use of my arm, it wasn't 
to make to look pretty.  But would they pay for it?  No.  Lucky for me it was 
only $700 out of my pocket.

Judy

>   Can't these people learn that a little preventive care upfront has
>   got to be cheaper in the long run? (I guess that they are hoping 
>   that we would move before then...)
    

I thought that was the idea behind HMOs in the first place!  And didn't they
start in California?  Now they are making certain coverage mandatory.

2c

	mikeP    

    
    
    	HMO's are into making money , period..........!!!!!!!!!!!!!!!!!
    

    In addition to the expenses which are not paid, I had encountered an 
    experience last week which I believe is equally disheartening, and 
    life threatening.....
    
    While having coffee with a friend in a restaraunt I fainted and had 
    to be taken to the hospital.  The hospital was not my "designated" 
    hospital, as it was a 45 mile trip.  I was taken to a hospital 4 blocks
    away from the restaraunt, also a member of my RUSH-PRUDENTIAL HMO plan
     
    
       I awoke only to discover that:
    
                   The hospital could not admit me, even though it was 
    apparent to them that I needed a cardiologist to do some immediate
    testing for heart attack.   The reason they could not admit me was due 
    to the fact that all of the doctors under my hospital plan had left 
    the HMO plan.  (This was first time news to me)  
    
                    It took the "designated and non-designated" hospital 
    3 1/2 hours to locate a doctor from the plan in order for the "non-
    designated" hospital to admit me and begin running tests.  
    
      
    I did not have a heart attack, they tested me extensively and now the 
    big question is, will RUSH-PRUDENTIAL pay the bill.  So far they have 
    looped themselves out of every medical claim I have ever made, which 
    doesn't amount to alot, but all were needed.  The program was followed, 
    the requirements met and I'm still waiting for payment for something 
    which I paid 1 1/2 years ago.  To say the least, I have no trust in the 
    plan at all and the price seems much to high.  Human life????
    

    re .9
    
    I honestly have serious difficulty believing this story. As I read it,
    you were an emergency case and the first thing they checked was your
    wallet. In my book, any practising doctor who does not treat an emergency 
    case at once is guilty of malpractice and should be struck off. 
    They would also be liable for damages. Are you sure you did not recieve a 
    preliminary examination and were then referred on for further treatment, 
    after the doctor examining you satisfied himself that no emergency 
    treatment was required ? 

    That's correct, no preliminary exam was done.  

    So let me get this straight:
    
    You were lying unconscious on a streacher or in some obviously sick
    condition and the doctor who you were presented to left you there
    like a hunk of meat because you could not pay the bill ?  There must be
    something about the legal situation in the USA I don't understand.
    Would the doctor have been covered by his liability insurance if he had
    treated you? Do doctors really have the right to refuse to treat
    emergencies if they feel like it or were you insisting on treatment
    under your insurance plan, which they could not provide? I don't get it.  

In a past life I was an X-ray tech. I've seen ambulances with very
sick patients turned away from an ER that had already treated the
required number of DPW patients. If the patient can speak the first
question asked is "do you have insurance?". A public hospital can't
do this but a private one can. 

One of our contractors just told me she had to drop pregnancy coverage.
She just couldn't afford the extra premiums. Pretty soon you will only
be able to get coverage for things you couldn't possibly collect on.
liesl

>                    <<< Note 4701.12 by ESSC::KMANNERINGS >>>
>                              -< still confused >-

>   So let me get this straight:
    
>   You were lying unconscious on a streacher or in some obviously sick
>   condition and the doctor who you were presented to left you there
>   like a hunk of meat because you could not pay the bill ?  There must be
>   something about the legal situation in the USA I don't understand.

  There are lots of things that can happen re medical care in the U.S. that
would be unthinkable in most European countries. Something for European readers
of this file to think about if you are thinking of traveling to the U.S.

>    Do doctors really have the right to refuse to treat
>    emergencies if they feel like it or were you insisting on treatment
>    under your insurance plan, which they could not provide? I don't get it.  

  The key here is what constitutes an emergency. Harvard Community Health Plan,
which is typical of most HMOs, has three levels of emergency: "life-threatening
emergency", "emergency", and "urgent care". A possible heart attack (which the
case several replies back is) is "supposed" to be considered a "life-
threatening emergency", for which the ER doctors are supposed to give im-
mediate care, regardless of the patient's insurance status. However, doctors 
have wide discretion to decide whether a case is a real emergency. And the case
described several replies back is quite plausible to me.

Required reading for this thread: "Gladiator at Law", by Frederick Pohl and
Cyril Kornbluth.

___Pete

    okay, point taken. A number of friends of mine are doctors, and one who
    works in London told me a story about a couple who arrived in London
    from the USA with a blue baby, that is to say, a baby with a heart
    condition needing urgent treatment. My friend had to check whether the
    couple qualified for help under the NHS, which fortunately they did, as
    one of the couple was a UK citizen. But the intersting thing for me is
    that this doctor was concerned that she was obliged to do a "wallet
    check" by her employer. She took the view that such a check is of
    questionable ethics. As a doctor, her primary duty was to the baby, who
    was clearly sick and in need of immediate treatment, which she was able
    to provide. So she was worried about having to tell her employer to go
    stuff the "wallet check", she had an ethical duty as a doctor to treat
    the patient, it was late in the evening and a jaunt round London
    looking for another unit with the required facilities could have been
    fatal. 
    
    Are there no doctors in the USA who take a similar ethical position ?
    It is quite common in Europe for doctors to insist on proper emergency
    care.  Indeed the doctors at my nearest casualty unit in Galway
    recently took industrial action to demand increased staffing at the
    Accident and Emergency Dept. They won, the action enjoyed the support
    of the entire hospital staff and the community, so that the health
    minister had to back down.
    
    Kevin  
    

just to balance.....

I am a member of a New Hampshire based HOM (Matthew Thornton).

After an ambulance trip to a "non-public" hospital in Chicago, my wife was
rolled into the emergency room where administration began immediately.  She was
suffering from severe food poisoning; unknown at the time.  I was escorted to
the "business desk" where, after a bit of a wait, financial information was
requested.  A sign on the wall stated CLEARLY that the hospital DOES NOT HAVE
THE RIGHT to refuse treatment.  They were hard at work on my wife trying to
stabilize her and figure out what went wrong long before I was ever asked about
insurance. 

I never called the HMO to ask "permission", the hospital called them to tell 
them that they were treeating and would likely be admitting my wife.  I found 
out, a month or so later, that the HMO had no formal agreement with the 
hospital nor any intermediary "brokerage".  Did not matter, although 
straightening out the bills was interesting.  Treatment came first, financial
considerations came much later. 

FWIW, from a relative in the medical billing industry, if they delay or refuse 
treatment, sue their collective butts off; HMO, Hospital, and any DRs you can 
get the names of.

Later

    
    I also had to take my wife to the Emergency room while travelling. 
    The hospital's first concern was getting her examined while I completed
    the paperwork.  I notified Matthew Thornton the next day that treatment
    was underway and they said everything would be taken care of.  They
    also expressed their wish that her recovery would go well.  As bad as
    an emergency situation can, both the hospital (Newburgh, NY) and MTHP
    made it as painless as possible.

    thank you for that .17. That is how it should be and I quite agree with
    
   >>>> FWIW, from a relative in the medical billing industry, if they delay or
    refuse treatment, sue their collective butts off; HMO, Hospital, and any DRs
    you can get the names of.

    I took U.S. Healtcare HMO Elect when Digital Plan 1 raised my premium
    by ~$125 per WEEK. I took it because the were few providers in my area
    and the primary care folks for my wife, stepdaughter and myself were
    not and would not participate.
    
    I appealed. I was told, no, John Hancock was commissioned to do the
    survey and make the recommendations to Digital. Those were the choices.
    There are better plans closer to my home but because they are across
    the state line, not available because of Zip Code Service limits.
    
    Some providers also service only some Zip Codes inside a small city and
    not others. Real interesting to look at the demographics of the
    support!
    
    I have been to the ER twice in 6 weeks while on the road [more than 40
    miles from home] for blood pressure related mediaction reaction issues.
    To this point both hospitals have been treat first [while someone sat
    at the admissions desk with my health card card and my drivers lisence.
    The second ER Physician forced my primary care HMO doc to change my
    meds AT ONCE. This is after I had called and plea with the office to
    let me change/reduce/stop the meds because of a different reaction.
    
    No I am not happy.
    
    What really scares me is that my stepdaughter will be in London
    starting at the end of August until mid-December and then based out of
    London while travelling the continent for the following 6 weeks. What
    happens if she, a university student, needs care? [Let alone how do I
    deal with her mother at home miles away in the States!
    
    Howard

    Well, I have positive experience(S) with Tufts HMO. My wife and infant
    son were travelling overseas and my son caught some kind of stomach
    virus. I called up Tufts, and they said just to hang onto the receipts
    and send them in when they got back. We did exactly that and got
    reimbursed. This happened not once, not twice, but thrice. (For various
    infections/viruses)
    [Just goes to show how susceptible babies are to changes in the environment.]

.9:

Nice example of "wallet biopsy."  Sorry you had to go through that.

    I have to say I've had similar experience as others with Matthew
    Thornton.  Once while visiting family in Georgia I ended up taking my
    husband and daughter into the urgent care clinic for ear infections and
    bronchitis.  I was told to notify them within 48 hours after the visit,
    hang onto receipts from the care facility and pharmacy.  When I
    submitted them later I got a refund (minus my co-pay) within a few
    weeks.
    
    Irene
    

    re: .20
    
    ASK BEFOREHAND whether your health coverage applies while out of the
    country. A few years ago, my fee-for-service coverage (I'm on contract,
    so I carry my own policy) changed WITHOUT NOTICE to CANCEL MY POLICY
    if I was outside the USA more than 30 days. At the time, I spent
    several weeks each year, split into two trips, working in Europe on
    behalf of a client. I always confirmed coverage before I left, so at
    least I found out in time to make sure I didn't trigger cancellation.
    
    There are companies which sell health insurance for people abroad.
    Several companies sell short-term policies for travelers. For longer
    term (e.g. if I take a year-long contract overseas), there are fewer
    carriers. I believe I noticed one a while back by looking for obvious
    names like "Global whatever" at
    
        http://lattanze.loyola.edu/users/cwebbe/hotlist.html
    
    The policies are not terribly expensive, all things considered, and may
    be necessary if your normal carrier limits foreign coverage badly.
    
    If you are one of those very rare people who carry an American Express
    Platinum card, the Card will pay for emergency air ambulance service to
    get you back to the USA if you have a medical emergency abroad that can
    only be treated satisfactorily here. Should I ever spend an awful lot
    of time in developing countries, I'd consider the $275 annual fee for
    the Card as "insurance" for the $15,000 air ambulance. (Just a tidbit
    for anyone in that situation.)
    
    I hope the Web site helps you make suitable arrangements.
    
    Bonnie D. Huval

Thank heaven we Americans aren't saddled with good universal health
insurance.  People would just abuse it.

___Pete

We're moving from MA to southern NH.  However, in our town in NH
HMO Blue isn't listed as a choice.  We definately wanted to keep HMO Blue
since they had good care and my wife needs to see a specialist at
Childrens in Boston.

I called Benefits Express and the People Support Network.  They
said that we could keep our HMO Blue coverage IF HMO Blue
operates in the area (they do).

We haven't moved yet so we'll see what really happens when we move.

I was at DECworld 88 in France staying on the DECruiseShip when I had what
appeared to be an allergic reaction (to escargot???) and went to the ship's
doctor for treatment.  The billing situation never even occurred to me.

When I got the final bill from the ship, I was in for a surprise!

Anyway, I did not think to call MTHP for a week or so after I got home, so by
then it was at least 2 or 3 weeks in the past, but there was no trouble at all
getting reimbursed.  I think if it were in the country they would have expected
me to call, but outside the country it was just "Send the bill to us."

Burns

> ... outside the country it was just "Send the bill to us."

You raise an interesting point.

Because I'm an international relocatee (on the American books but working
for Digital in Europe) I'm limited by Digital to a specific kind of health
insurance, which never in hell would I buy if I were in America.  For many
kinds of care, like dental prophylaxis, that insurance covers the entirety
of reasonable costs for care delivered in Europe -- good, in a sense, since
because France doesn't recognize the profession of "dental hygienist",
dental prophylaxy is carried out by dentists, expensively.

If I'm on a trip to the US I can sometimes make an appointment to see my
old hygienist at only a fraction of the cost of seeing a dentist in France
for prophylaxy.  But by policy the insurance covers only a fraction of the
cost of care delivered in the USA, so it costs me more even though it would
be less expensive for the payer.

Black and white: in the purely economic sense, this model of insurance
encourages me to get more expensive, lower-quality care.  Stupid.

___Pete

    ___Pete (-.1)
    
    Are you on "local hire" status, or international relocation? The
    situations differ, and what's "stupid" in one context is rather
    different in another. 
    
    IMHO, "insurance" in the "American" context has become equated with
    company funding of typical, planned needs, rather than "insurance"
    against catastrophic, unforeseen happenings. This has escalated the
    costs, especially as people do not "shop" services as they do for
    things they pay for themselves. In my own view, we'd be able to cover
    many more "expensive" and unusual problems if we'd push the costs of
    basic and "typical" services back onto ourselves (or at least above
    some minimum salary level). The entire concept of "insurance" seems to
    have been corrupted, similarly to what's happened to the concept of
    "rights" in the US of A.
    
    As a "local hire" in both Singapore and Australia, I can assure you
    that the qualtiy of healthcare in the US is without peer. The major
    issue I see is that people generally compare things relative to their
    previous experience, rather than some "absolute" scale. My own
    experience with HMO's (in NH) has been excellent, albeit requiring more
    effort on my/our part than a pay-per-view private Doctor. I don't know
    about France, but I've not been required to be "stupid" to receive
    adequate-->excellent healthcare in these countries, especially as I
    don't look at "insurance" to be the sole determinant of how I choose to
    be treated (e.g., in Australia, I've been advised NOT to use
    "bulk-billing" clinics, as they're like the prototypical HMO in the US
    -- thereby increasing my cost, but improving the probability that I'll
    get the treatment I'm paying for).
    
    If I find the energy I'll respond to some of your and Steve Elmore's
    comments in this NOTES conference, as I inherited the Cost Center
    and SYSCON group you once led. Interesting challenge to fix the fiscal
    and "relationship" issues you left behind. And BTW, Miles Ripley went 
    to Perot Sytems, not EDS (to work at MCI), but has since left (don't 
    remember where-to); Carl Burmeister I've lost touch with; ditto George
    Brother, but Mike Breen is still in San Fran (and married if you've not
    heard). Dan Riordan would probably say ?
    
    Cheers from down-under,
    Bill

Health Insurance = the biggest scam in American culture.


Ask yourself:

	How did my parents ever cope?

	Where do all those premiums go?

	Why are service providers and carriers vigoursly marketing?


Build an actuarial table to see what $550.00/mo (starting at age 21)
would build for you in 19years (figure 8% annual growth)

Imagine the competitive position of American products WITHOUT the
allocated costs of "health care".

Think about typical "health related" behavior when its not "real"
money.

    re .25,.30
    
   > People would just abuse it.
    
    ? or is it those who make a profit out of medicare who are the abusers
    ?
    
    Well, I'd like to start a discussion on the merits of free universal
    health care, but knowing how the moderators (understandably) react to
    people wandering off the subject, could we ajourn to the MEDICAL notes
    conference and thrash it out there ? I'll post the reference in a few
    minutes ...
    
    Kevin
    
     

    VMSZOO::MEDICAL Note 1982.0 "FREE HEALTHCARE FOR ALL!" See you there.
    
    Kevin 

Re 4701.29: from the $ point of view it's quite simple: I'm required to
have this insurance whose coverage and payment policies encourage waste,
which I'm forced to pay for.  This sure isn't how I'd choose to do it!

You're right that there's a confusion of terminology in the USA in talking
about catastrophic-event insurance versus funding of planned needs.  So
what's new?  Over a large enough population -- N.B. Atlant's remark about
single-payer systems -- catastrophic events can be planned for.

___Pete

    ___Pete (-1),
    
    I don't think I understand. Was what you are "required" to have
    different than what you were told prior to your relo? If you're a local
    hire as I, then you're subject to the "whims" of the local situation.
    If you're an expat, then I suggest you're simply in the same situation
    as US-based personel. And "waste" is in the eyes of the beholder.
    "Forced" is hard for me to understand; either you didn't understand
    what you were getting into (your "problem"), or you didn't anticipate
    changes in your home country policy (but you're no better or worse
    off than there).
    
    Atlant's remarks I'm not prepared to search for. But perhaps I
    mis-stated what I intended. "Insurance"  for the unexpected,
    unforeseen, etc. is what I meant to infer; I should also have included
    forecastasble events in the list of what I suggest "insurance" should
    cover: i.e., "insurance" to me is a "revenue-transfer" system from
    those who wish to join the pool from which payments for nonforecastable
    AND catastrophic events get covered (with some TBD return for the risk 
    of payment, augmented by the risk that Govt's will change laws to change 
    the liability for payment from what was agreed to something else -- one of
    the current problems IMHO with today's situation).
    
    Bill          

    I just used my HMO Prudential Health Care in Maryland and found that
    my primary care provider says "they werent taking any "new" patients".I 
    explained to the receptionist over the phone that I signed up 4 years
    ago and havent used it til now.The reply was the same.
    
    After being somewhat puzzled I called Prudential and explained what had
    happened. They put me on hold for a brief time and then told me to call my
    primary care provider again and ask for someone in particular.Prudential
    called the PCP ,then I was able to make an appointment.
    
    Later the next day..........
    
    While I was at the receptionist window. Someone had called and from the
    jist of the conversation the lady in the doctors office was giving the
    same line I got. Apparently the person on the other end of the phone
    just signed up. The lady in reception told the person on the phone that
    they werent taking any new patients since March 1996 and that they would
    have to call Prudential to get assigned a new Primary Care Provider.
    
    I guess the next time they log a call at the computer site. Ill get
    the call and tell them yes youve paid your monthly fee but agast we
    have not the resources to fulfill our contract. I wonder what their
    reply would be.
    
    
    Miketurro
    Baltimore Maryland
    

Glad to see my note caused so much discussion.  I hope someone who makes 
decisions about Health Care at Digital is reading.  Does HR read the notes 
file?

Anyway as far as Prudential HMO I have a complaint hearing with them on Aug 
5th about the coverage for my plastic surgeon fees, their whole treatment of 
my case as well as their lack of a plan for covering Breast Reconstruction 
Surgery after Breast Cancer.

As it turns out Prudential did pay completely for my hospital fees which was 
over $10,000,  although they had told me they weren't going to pay for it.  
They claim the only reason they paid for it because there was no way of 
separating the costs for the mastectomy versus the reconstruction surgery.  I 
guess it was easier than fighting with John Hancock, the elect coverage.  
In fact I never would have known they paid it if I hadn't asked and the fact 
that the letters from the Hospital complaining about not being paid stopped 
coming.  Yet they wouldn't pay for the Plastic Surgeon who was also on their 
plan.  Maybe complaining and writing letters to everyone you know helps!   
So fortunately I'm only out $2550... and I had really good medical care!      

    FYI - The latest issue of Consumer Reports (I received it last week)
    has a report on HMO's.  I haven't had a chance to read it yet so I
    can't provide any info.  Perhaps someone who has read the article can
    post some of the findings (although, CR tends to be pretty fussy about
    publishing their results).  OK, perhaps someone can summarize the
    results.

    Ron