Conference 7.286::digital

I am in an HMO elect plan and like it.  It costs more than a regular HMO but
not nearly what it would cost for JH.

You can go outside the plan without the HMO's approval.  If you do, you are
subject to a deductible (I think its currently $300) and they only pay 70% of
the charges.  The maximum deductible for each individual and for family
coverages, if you have it, are also higher than JH.

The reason I have it is that you can use it cover chiropractic care, which the 
HMO doesn't cover.

Whenever you use the regular HMO doctor's, you revert back to whatever the HMO
provisions are for co-payment (mine is currently $5).

Larry

    Ed
    
    Someone may have a different experience but I have always had HMO elect
    because my doctor does not participate in any HMO's.
    
    What this means is that:
    
    If you go to the hospital for something (emergency), you submit the
    forms to your HMO choice.  When you have HMO elect they make you select
    an HMO even if you never use it.  I chose HAP but I've never been to a
    HAP doctor.
    
    The HMO which receives the forms and bills for your treatment will
    evaluate the situation.  If they choose not to pay, which is typical,
    because their physician didn't tell you to go to the hospital, even
    though you may be bleeding to death...
    
    ANYWAY...if they reject it then the hospital is to bill John Hancock
    who will pick up the tab.
    
    If your doctor is not a member of an HMO, which mine isn't, then the
    bills are submitted directly to John Hancock and they pick up 70% of
    office visits, etc, as outlined in the medical plan.
    
    If you are wondering if it is worth the extra bucks, these are things
    to consider:
    
    Do you have any conditions which require you to see specific doctors at
    specific times?  
    
    HMO's typically work so that the primary care doctor is paid to keep
    tests to a minimum, to try and care for you and only refer you to a
    specialist as a last resort, and in my opinion, can jeopardize the
    health of the patient.  I know a little girl who is now deaf in one ear
    because her doctor kept treating her ear infections instead of sending
    her to an ENT specialist.
    
    If you want to be able to see any doctor at any time, get any test when
    your doctor feels it is necessary, and be able to go to any specialist
    when they are best for the job, then it's worth paying the extra money.
    
    I have this plan and it's always been worth the extra cost to me.
    
    

    I also belong to HMO Elect.
    
    My wife ( who is a Reg. Nurse ) would not go for treatment for her or
    my daughter if hell froze over.
    
    Therefore, by selecting HMO Elect I am taking a gamble that my total
    out-of-pocket expenses for medical care recieved outside the HMO will
    be less than the difference in premiums between HMO Elect and the
    Digital Medical Plans administered by John Hancock.
    
    With 10 + months gone in 1993 I am in good shape to win the bet this
    year. In 1994 the gap in cost between HMO Elect and the Digital Medical
    Plan will be much greater and therefore much easier to win by selecting
    HMO Elect.
    
    Unless you can be totally satisfied by a straight HMO plan, HMO Elect
    is the way to go.

    .2
    
    We also have a friend who's child is deaf now due to a doctor who
    kept treating ear infections and not putting tubes in her ears...
    
    Guess What????
    
    It was Blue Cross/Blue Shield and it was Children's Hospital in
    Boston!!!!  (Are they an HMO???)

    That sounds like one cocky doctor, not an HMO!  
    Sounded like his incentive was his ego and not money saved in not
    sending her to a specialist!
    
    

    re .2
    
    I am saddened to hear that you haven't made any effort to work with the
    system to your advantage. I am part of an HMO. I have a primary care
    physician. If I am in an emergency situation, I go to the first
    hospital available, I tell them the name of my HMO, and my primary care
    person, and I have them work out the details.
    
    I've never had a problem getting an emergency covered by my HMO. I
    think your anger toward your HMO is costing you unnecessary dollars.
    We're talking about $3-5 just to give them some record of your medical
    history.
    
    I realize that, for many people, there is a great deal of energy and
    emotion involved in deciding who is allowed to poke and pry in your
    orifices, much less render medical opinions about them. But in this day
    and age, if YOU know what's wrong with you, I would think it's worth
    the $3-5 investment to let your HMO in on the "secret"!

    The hospitals here in Michigan all have computer databases with medical
    records.  Afer you've been treated in emergency, the send a card that
    looks like a credit card with your number on it.  That way they can
    bring up your history by entering your number.
    
    As for working with an HMO, I don't call having a primary care doctor
    refusing to send you to a specialist when you need it, not working with
    them.  It's a doctor making the decision he or she can take care of all
    your problems.
    
    Having had an aneurysm in my youth, I have to be able to go to a
    specialist at any time if they think it necessary, not if the primary
    care doctor decides my condition is "over his head" of knowledge.
    
    With the case I mentioned in .2, the little girl kept getting repeated
    infections and the guy kept just giving her anti-biotics which weren't
    doing the trick.  Her parents repeatedly suggested they get referred to
    a specialist at Children's hospital in Detroit, and he said no, he
    could take care of it.
    
    She has been deaf in her right ear for a few years now, all because Mr.
    "I'm a smart man" doctor thought he could "take care of it"
    
    no, I don't have a good impression of HMO's
    
    

    
    Does the "Elect" coverage also cover Psychiatric care from someone not
    in the HMO?
    
    -Ed
    

    I am in the HMO elect. I have not gone outside the HMO yet, but I
    still count the price difference as pretty cheap insurance for those
    things that the HMO doesn't do and those things I might not want them
    to do.
    
    Examples - 1) My HMO (Lovelace in New Mexico) doesn't cover Kidney
    transplants.  2) If I need open heart surgery I want to go to a
    hospital and doctors who are the world's best, not the HMO's best.

    Yes
    

    I've been in the Harvard Elect plan for over a year now.  I use the
    Elect for a chiropractor and allergist for me and my daughter.  No
    problems--you just go.  I pay the uncovered portion at the time of the
    visit--I pay the allergist $13.50 and they take care of the rest.
    
    So far, I've had no problems.  My husband was attacked by bees and when
    I came home I found him out cold on the back porch.  I just called 911
    and the next day let the HMO know what was going on....no problems.  If
    one of us ends up with some terrible affliction, I want the ability to
    go to another physician or hospital without waiting for the go ahead
    from my primary care person (not that I wouldn't get it) or being sent 
    to the local hospital for a headectomy.  I don't want to leave any of
    this to chance.
    
    So far, so good...
    headectomy.

I was very skeptical about the HMO-elect.  Having been in the Harvard Community 
HMO-elect for a year I must say I am quite pleased.

The advantage of the HMO-elect in my mind is that you get to choose which way
to go and you have the best of both worlds.  For example:

	1. Go to HMO primary care physician.  Get one that is open
	   minded and willing to be flexible.  You can keep your regular
	   doctor as well.  For a given affliction, if it is cheaper under
	   HMO way, go the primary care physician.  If he doesn't do what
	   you want or it is not covered go insurance way.

	   For example, go to the HMO primary care physician for checkups,
	   routine physicals, shots, kids stuff where you don't perhaps have
	   a long history of care.  This stuff costs almost 0.

	   Go to outside person for long term pyschiatric, chiropractic,
	   hearing aids etc.  It's only a 10% reduction in coverage over
	   the Digital Medical Plan.

	2. If you need to go to an emergency room go.  After the emergency
	   send the stuff to the HMO, they will pay all of it. (vs. 80%)

	3. The premiums are MUCH cheaper.  If you go nowhere you save lots.
	   If you go only for preventative you save lots over Digital Medical
	   Plan.  If you get admitted to the Hospital through an HMO doctor
	   you save lots.  If you have costs for things outside the HMO it
	   costs you a little more than John Hancock.

	4. Prescriptions have to be prescribed by the HMO to be filled by
	   the HMO, but I believe if it is cheaper to fill outside the
	   HMO you can take that prescription outside.

I have had NO problems getting my primary care physician to send me to tests,
specialists etc.  In fact, since it is all done in the one facility he seems
MORE eager to do that that my regular doctor was.  My doctor seems very willing
to let me go to any specialist I wish to as long as there is a credible reason
to.  AND some specialists you can get an appointment with WITHOUT a primary
care physicians involvement.

My biggest concern with HMOs is a little item that is in the small print.
That is, you will find that most HMOs reserve the right to REFUSE to treat
you or REFUSE to PAY for your treatment if you REFUSE to follow their treatment
plan.  This, to me, seems to throw the principle of informed consent (you get
to say what treatment you will and won't have) out the window or at least
put it in serious jeopardy.  In most HMOs this is left up to the primary care
physician.  If you get a doctor that supports your right to decide it is
probably OK, if you don't the HMO could hold you hostage by threatening to
refuse payment.  UNLESS you have HMO-elect.  They could still without payment
BUT you have an out.  This makes choosing the right primary care physician very
important.

This is an issue I think Digital should look long and hard at when they choose
an HMO to partner with.

It is also why the -elect option is the ONLY one for me.

	Kim Mains

You might ask, how does out-of-plan treatment in HMO Elect compare with
Digital Medical Plan 1?  The HMO Elect premiums are lower, of course,
and the co-payment is higher (30% vs. 20% for most things, 60% vs. 50%
for outpatient psychiatric care after the first $2000).  The co-payment
for prescriptions can be significantly higher -- 30% vs. $8.  The out-of-
pocket maxima are also considerably higher -- $3000 vs. $1800 for an
individual and $9000 vs. $5400 for a family.

    I have been with a straight HMO (Kaiser) for the past 5 years and have
    nothing but good words for them. I have two young children (8 and 3)
    and as such we have used their pediatric services. No complaints there.
    I have yet to come across a doctor that has the type of ego mentioned
    in one of the previous notes ( the one that was treating the little
    girl for an ear infection and refused to consult an expert). My second
    child was born while we were part of the HMO. The local center did not
    have an OB on staff so they let us choose a doctor that belonged to the
    HMO (but was not on their staff) and was close to our residence versus 
    sending us 15 miles away to another center that had an OB on staff. 
    They are affiliated with the best hospitals in Atlanta. Both my wife
    and I are also pleased with their Adult care. In the Atlanta area
    Digital has done an excellent job in selecting a quality HMO care
    provider.
    
    chandan
    

    I'm in the Harvard Community Health Plan.  The weekly cost is $18.24 a
    week for my family, o  $948.48 a year.
    
    The HMO Elect Harvard Community Health Plan costs $26.52 a week or
    $1113.84
    
    There is a $900 deductible before the HMO Elect plan starts to cover
    70%.  So, for it to make sense for me to choose HMO Elect over the
    standard HMO I have to assume that I will spend $1065.36 on medical
    care not normally covered by the HMO. (1065.36 = 900 + (1113.84-948.48))
    
                                August G. Reinig

    I'm in the Matthew Thornton HMO and I only have good words for them
    too.  We had HMO Elect last year, but I didn't have anywhere near the
    outside expenses to meet the deductible.  Also, our family physician is
    fantastic and has sent my husband to a specialist when he needed it. 
    They are quite aggressive about treating breast lumps early (48 hours
    to 2 weeks at most for mammogram and biopsy) from when lump is
    detected.  No matter what age (most of the bad things I've read about
    HMOs have been about women having spreading breast cancer because the HMO
    wasn't aggressive about treating a lump if you were under 40, since the
    chances were it wasn't cancerous).  Also, our Dr. assured us that she
    has *never* been refused by Matthew Thornton in ordering a test or
    medical procedure done, if it was in her best medical judgement.  She
    also told me that several times when she didn't think anything needed
    to be done, she had patients tested, more to put their mind at ease
    than anything else. 
                                               

    re .15:
    
    >There is a $900 deductible before the HMO Elect plan starts to cover
    >70%.  So, for it to make sense for me to choose HMO Elect over the
    >standard HMO I have to assume that I will spend $1065.36 on medical
    >care not normally covered by the HMO. (1065.36 = 900 + (1113.84-948.48))
    
    Not true! For yourself, there is a $300 deductible before they start to
    cover for 70%. Separately, for you wife, there is a $300 deductible.
    Separately, for each child, there is a $300 deductible. That much I
    know. I believe that the $900 means that after you've paid $900 in
    any combination of deductibles, they start to pay 70% of costs.
    
    Example: One member of your family has health problems which require
    several trips to a physician (outside the HMO). No other member of your
    family ever visits a physician. Once the single family member's medical
    bills have exceeded $300, the plan starts to pay 70%, even though no
    other member of the family has any medical costs.

re .15

>    The HMO Elect Harvard Community Health Plan costs $26.52 a week or
>    $1113.84

    $26.52 x 52 = $1379.04, not $1113.84

    Somehow I grabbed the number $21.42 as the weekly cost, not $26.52.
    
    So the numbers are
    
        HMO:    $948.48     + all outside costs
        HMOE:  $1379.04     + 30% outside costs over deductible
    
    HMOE cost $430.56 more per year.  For it to have any benefit, I must
    pay somewhere between $300 and $900 in deductibles.  So, for it to 
    make sense, I have to assume that I will spend at least $730.56 in
    on medical care not normally covered by the HMO.  I might have to pay
    as much as $1330.56.  
    
                                August 

    Here in NY I have U.S. Healthcare. So far I been pleased with thier
    performance. I selected HMO Elect because my son is in Forida at
    college and need coverage beyond the geographic boundaries that all
    healthcare systems seem to impose on the participants. 
    Another benefit has been a lowering of the weekly contribution from
    $35.94 to $26.71 for 1994.
     If given all possible options, I would elected to stay with the JH Med
    Plan1. However this seems a reasonable alternative.
    

    The HMO-Elect plan fits me nicely.  MY kids live with their mother in
    Texas... and when I was on the JH coverage, everything was fine.  Until
    DEC decided to price us out her in New England (and a few other places,
    but NOT in Texas).  Result:  I went to the elect plan, my kids remain
    covered by JH and my wife and I are on the HMO.  
    
    tony