Conference 7.286::digital

    
    
    	I don't know what an MRI is but if the primary care physician
    	ordered one up. It would cost $2.00 under the Fallon plan.
    
    
    						Mike
    						----

    In the past two years I have had to have 1 MRI, 2 CT Scans and both an
    upper and lower GI series.  Total cost to me:  $0 under my HCHP
    (Harvard Community Health Plan).
    
    	Steve

    
    But ... you paid $700 during the past two years for membership in HCHP.
    

re Note 1245.0 by FSTTOO::BEAN:

>     My question is:  If I were enrolled in any HMO that you know about, how
>     much would this examination have cost???
  
        Or would you have been denied the test as not medically
        necessary?

        Face it folks, the HMO's are not printing money.  If they
        really cost less than "patient managed" care, then that has
        got to mean that in many cases services are just not rendered
        by the HMO which the patient would have otherwise selected.

        Of course, there is another possibility.  There may actually
        be some persons who abuse the traditional system. The base of
        non-abusers who shoulder the cost of their care has been
        steadily eroded by the movement to HMO's (presumably an
        abuser would not choose an HMO).

        This means that soon there will be only two kinds of persons
        under the traditional plans -- those who insist on managing
        their own (or their children's) health care, and abusers. 
        And increasingly, only the rich will be able to afford to be
        in that first group.

        (This would seem to foretell the eventual total collapse of
        the traditional system, as fewer and fewer people can afford
        it.)

        (Since surgery under the traditional plans is already subject
        to considerable medical review, how do the "abusers", if they
        really exist, continue to run up large but unnecessary bills? 
        Or is the problem really not the abuser, but the chronically
        ill?  What happens to them?)

        Is the "problem" just an accountant's wild imagination?

        Bob

    re: .0

>    My question is:  If I were enrolled in any HMO that you know about, how
>    much would this examination have cost???

    Tony, you need to ask at least one more question: under the given
    circumstances would the HMO even recommend the MRI?
    
    Most of a HMOs revenue comes from pre-payment for health care
    coverage.  The less they spend providing that care when it is
    needed the greater their profit.  And the HMOs are out there
    to make a profit.
    
    Physicians working for HMOs, including those in private practice
    who are affiliated with HMOs and treating HMO patients, are
    employees of the HMO and must follow HMO practice guidelines
    designed to minimize expenses.  Diagnostic tests are one major
    source of expense.  If a HMO can get away with not ordering a test,
    they won't.

    re: .4

    One major source of cost escalations in the traditional health care
    system are those who can't pay for their care.  Many hospitals are
    required by law to accept a certain "quota" of patients who cannot
    afford to pay.  Those who can pay have to make up the deficit.

    Correct me if I'm wrong, but, I seem to remember that the Digital plans
    are ADMINISTERED by John Hancock. You Don't actually have JH insurance,
    but rather DEC is the insurer. JH is contracted to run things. This may
    be the reason for the increasing employee contributions, DEC may be
    trying to ease their involvement in the insurer role while at the same
    time providing the traditional JH programs for those who really really
    want to continue with them. The point I'm making is that if you choose
    an HMO YOU pay them and they treat you and run thing with this money.
    If you chose DEC plans in the past DEC put up some of the money for
    your coverage AND payed JH to run things. It may be that in these hard
    times DEC is trying to limit their outflow of cash in this area.
    
    I hope I made sense, at least it made sense to me.
    
    
    TPV 

re .7:

Does DEC pay the HMOs a flat fee per person/family, or do they pay based
on services rendered by the HMO?

    re: .8

    Most HMOs are prepaid plans: the subscriber pays a fixed periodic
    fee plus a small co-payment for each use of the service.  This is
    why it is to the HMOs benefit to reduce expenses (physician time,
    tests, referrals to outside specialists, etc.)

    I don't believe that HMOs encourage their providers to avoid ordering
    tests for their patients. My family belongs to HCHP (in Wellesley, as a
    matter of fact), and we have never had a problem seeing a specialist or
    having tests done if the physician/provider was unable to diagnose a
    problem through a regular visit. Of course, it IS a hassle to get to
    see the specialist, as you usually have to go through the front line of
    office personnel, nurses, physician's assistants, and primary doctors
    first. But no one balked when my daughter needed orthopaedic and
    radiology work, or I needed a battery of lab and other tests during my
    pregnancy with her.
    
    On the other hand, HCHP lost a court case not too long ago where the
    family of an AIDS patient sued the plan and the doctor who failed to
    diagnose her condition until it was too late to even prolong her life.
    Overall, the possibility of lawsuits such as this should be enough for HMO
    administrators to just let their doctors/employees treat patients
    properly. After all, the plan saves a bundle of money through the
    "gatekeeping" system as it is.
    
    JMHO.
    
    Nancy-

One of the reasons the two DEC plans have gotten so expensive lately is
due to Massachusetts law.

In Massachusetts, once Blue Cross/Blue Shield has paid your doctor the
80% they pay, that's the end of it.

BC/BS members are NOT required to pay the extra 20%.

This means that health care providers in Massachusetts charge 25% more
than what they really expect to take in.  When DEC pays 100%, or pays
80% and you pay the other 20%, that's just gravy on the top of their
planned income.

/john

re: Note 1245.5  by: VMSZOO::ECKERT "Once-upon-a-time never comes again"  
    
>>> Most of a HMOs revenue comes from pre-payment for health care
>>> coverage.  The less they spend providing that care when it is
>>> needed the greater their profit.  And the HMOs are out there
>>> to make a profit.
    
	some HMO are patient cooperatives, at least the Group Health
	plan in the Seattle area used to be.  that means that the HMO 
	is owned by its members and profit in the traditional sense is 
	not an objective.  i have not heard of any HMOs in the Healthnet 
	area that are organized this way.  i believe they are all either
	doctor cooperatives, where the doctors split the profits, or some 
	other kind of profit making business.

    How much would it have cost?  (I'll reference my own 1128.140).
     Cost you out-of-pocket?  Or cost the hospital/lab which performed the
    MRI in money not paid by the HMO?..and time/staff sending out bills?
    
    This is craziness...
    
    Pat

    I didn't see anyone answer the question back at the beginning for
    whoever asked.
    
    MRI = magnetic resonance imaging, a technique for examining the human
    body without convential X-ray radiation.  Utilizes computer-assisted
    and interpreted magnetic field to derive images of soft body tissues.

    I am in an HMO, CMHC, Central Mass Health , and I have had several
    cat-scans, a MRI an several other tests.  The only cost to me has been
    the $3.00 to the administering MD. I have not paid for the tests.

RE: .5

>    Diagnostic tests are one major
>    source of expense.  If a HMO can get away with not ordering a test,
>    they won't.

I would say that if a HMO can get away with not ordering a test, they
shouldn't.  "Get away with" in my use meaning "perform proper diagnosis and
treatment without the test."

--PSW

    just today i was talking with a peer who is having surgery soon on his
    back.  he is with John Hancock.  his doctor proscribed the following
    diagnostic tests:
    
    1) an MRI... which said he had two bad disks
    
    2) a Mylogram... which said he had two bad disks,  and "by the way, since
    you are here..." a 
    
    3) CAT-scan... which said he had two bad disks.
    
    none of these tests were inexpensive, and in each case, my friend had
    to "bring a check up front" before the test.
    
    is there something wrong with this picture?
    
    
    tony

    re: .17:  Just being back from back surgery myself, I wish my doctor(s)
    had done it in that order.  My order was:  CAT scan (inconclusive),
    Myelogram/contrast-positive CAT (inconclusive), MRI (definite).  These
    three cost about $5000 in hospital/x-ray/radiologist fees.  If they had
    done the MRI first, they could have saved two CAT scans...
    
    Now, I'll likely be forced to an HMO or Healthnet, and can only hope
    that my surgeon is part of whatever plan I change to since he is
    responsible for follow-up care.

    RE: -1
    
    I to reciently had back surgery and CAT scans and xrays and EMG's were
    inconclusive but the MRI was very positive. Only the MRI showed what
    was wrong with my back and enabled the doctor and me to determine how
    to proceed with surgery. While these tests were expensive, $800 for the
    MRI only, excluding its interpratation, nothing up till then showed what
    was wrong. I had to push all my doctors (family physician, neurologist,
    and neurosurgen) to continue diagnostic testing until a cause and
    affect was determined. All my doctors were ready to give up at one
    point or another due to not getting positive answers on the tests they
    ran. I have John Hancock Plan 2 and probably will continue to keep it
    as the plan of choice. I refuse to let anyone else determine how and
    when I will proceed to seek medical care when their primary concern is
    balancing a budget and not on my or my families welfare. I have been
    with this company 19 years and have more then paid my fair share in
    medical costs and co-payments during that time. J.H. does not
    always cover everything and either by the size of deductables, second
    opinions or areas above the reasonable and customary charges which 
    are not covered have caused me to pick up a larger share of the 
    expense. There were times when I could not even talk J.H. into saving
    money by using alternate methods to control costs. My wife is a
    diabetic and has had severe foot problems. She was seeing a doctor
    every week or two for foot care and surgical procedures. The doctor
    perscribed special shoes ($230) to help control the problem and J.H.
    wanted her to continue seeing the doctor rather then pay for the shoes.
    I bought the shoes and she has not had to see the doctor for over a
    year now. These things I can handle and it has still left the final 
    decisions up to me and my doctor, which is as it should be. HMO's were
    never the answer for me due to their restrictions on who I can see and
    how I was to proceed with any particular medical care. My families
    doctors are spread out over a 30-50 mile area and cross over mutliple 
    HMO's and city bounderies. Take this and the amount of area I travel in,
    both in business (varies, 20-1800 mi. per trip) and personal milage 
    (about 20k a year), and John Hancock is still my best bet for proper 
    health care. 
    
    Regards
    AL ROOT  

    I too had a back problem that eventually required surgery.  

    In my case, I might have been a bit luckier than the last few replies.
    My brother is a pediatric emergency room doctor at a hospital in NY.  
    When I first started to have some pain in my leg(ankle) which I thought 
    was a ankle injury, I talked to my brother and he told me to go to a
    doctor and have it looked at. So I took a trip from Boston to NY and
    had my brother the doctor look at it.  (btw none of the equipment in 
    a pediatric emergency room is made for people over 4' tall)  All my
    brother did was take a simple xray of my foot and told me I had a 
    problem with my back or it was all in my head.  

    He had me see a Neurologist that day who had me get a CAT-SCAN.  He
    told me that he felt one of my disc's was pinching a nerve and since
    the pain was not very sever he would just prescribe some exercises.
    He had me take the CAT-SCAN to tell him which disc so he would know
    what type of exercises would help.  A CAT-SCAN in NY at that time cost 
    $400 while the MRI was $1000. 

    I felt better for about 6 months at which time I moved.  If you have 
    had a problem with your back don't ever try to move yourself.  It is a
    lot cheaper to pay for the move and forgo back surgery.  I went back to
    the same Neurologist in NY who told me that he would bet my bill that
    I had rupturded the disc.  He then had me get an MRI, saying that the
    surgeon would need it.  He then had me walk to the next office to see a
    Neuro-Surgeon and I had the operation the next day.  I was lucky that 
    all these doctors fit me in to their schedules due to my brother being 
    a doctor in the same hospital.  


    -Bruce_who_is_back_trying_to_playing_ice_hockey

    I have not had back surgery, and hope that I never have to, but I have
    had back pain for about 3 years.  When the time comes (numbness or pain
    I cannot tolerate), I will take every test imaginable to AVOID having
    someone take a crowbar to my back.  Think about the size of that
    scalpel blade compared to a nerve or axxon!

    Yes, the tests are expensive, but the surgery has severe risks, including
    _increasing_ the pain level and a small but measurable risk of paralysis.
    A thoughtful doctor might very well prescribe the whole battery of tests
    in the hope of learning something which will avoid the drastic surgical
    approach.  I don't see the expense of the tests as a foolish waste of
    money.  Going in with a knife before knowing all the facts is foolish,
    and can potentially cost the patient and the medical system more in the
    long run.

    We don't take apart our VAXes before running the diagnostics :-)