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Getting the most from HMOs

Health maintenance plans require you to be an activist about health

The age of the health maintenance organization, or HMO, is well upon us, but savvy information on how to use one is hard to come by. Alan Raymond, vice-president of the Harvard Community Health Plan, a large HMO based in Boston, and the author of The HMO Health Care Companion (Harper Perennial, a division of Harper Collins, 1994), answers some critical questions for consumers:

How should one go about picking an HMO?

The first step is to understand your needs and expectations. What is it that you want from your health care and health insurance plan? Whether it's physician choice, benefits, access to specific doctors, hospitals, or specialists, or the cost, you need to know what's important to you.

The second step is to understand how an HMO works. What rules and procedures are different from what you may be used to? Then you have to find a plan that meets your needs and expectations.

Finally, you have to find a physician whom you trust. As with any other type of health care, it's the personal relationship of the physician or physicians that will likely determine how you feel about your HMO.

What questions should I ask of an HMO before I join?

How do you get care on a routine basis, how do you get care in an emergency, how do you get a referral when you need specialty care, how do you get hospitalized if you need it, and what should you do when you're away from home and need care? These are the fundamental issues that most people have to deal with.

Is an HMO suitable for someone with special medical needs or problems?

If there are specific types of benefits that are important to you, make sure you know what is covered, and perhaps more important, what is not. Usually the benefits are pretty similar. But there are some areas such as mental health, chronic care, substance abuse, and home care where there may be important differences between HMOs.

It's important, too, to know what hospitals the HMO is affiliated with. If you have a specific hospital in mind, you have to make sure you'll be able to go to that hospital if you want. If you have a special language need, or want a physician of a particular race or sex, you should consider those factors also.

Should my HMO be accredited?

There are only a limited number of HMOs that have gone through an accreditation process so far. A couple of years from now, when all health plans have gone through the process, you'll be able to make a better comparison. But it's certainly a useful piece of information. So is some of the information being published in health plan report cards by employers and consumer groups. They compare health plans based on the performance in preventive care - Pap smears, prenatal care, immunization. Those types of measures are a good indication of whether the health plan has an organized approach to prevention and improving quality.

What is the difference between a high-option or low-option plan?

There are usually two types of HMOs. One that requires you to stay within a network of HMO physicians, hospitals, and specialists in order to be covered. And then there's the point-of-service plan that allows you to choose a physician or hospital or practice outside the HMO network, but requires you to pay more out of pocket and has higher premiums.

How much more do point-of-service plans usually cost?

It's very difficult to say. Generally, the difference is that most HMOs only charge 5 or 10 dollars per doctor visit. If you go to a physician outside the HMO network, you might have to pay a deductible, which might be several hundred dollars, and then a co-insurance payment similar to what you have in traditional insurance. So your out- of-pocket expense can be significantly higher, although there is usually a limit on how much you have to pay out of pocket on an annual basis.

Premiums vary a good deal, from 5 to 10 percent or more. A lot depends on whether your employer contributes to the premium, and if so, by how much.

Will high-option plans always allow me to go outside an HMO network?

Not necessarily if you're joining through an employer. Your employer may have the choice of a traditional HMO or a point-of-service HMO available but may not always make that option available to you. Most people who join point-of-service plans get 80 to 90 percent of their care inside the network. So people see the point-of-service plans as a kind of safety valve. It may be a way of making a transition into an HMO from fees-for-service health care. It gives people that added assurance that they will be able to choose outside the network, even though most people who belong to those plans use the HMO network with very few exceptions.

Once I've picked an HMO, how can I make sure that I'm getting the most out of it?

There are some fundamental questions people need to ask. The first is, how do you choose a primary care doctor and what role will he or she play in your care? You may find that your current doctor participates in one or more HMOs. If so, ask if he or she will have to treat you differently if you're in an HMO. Is there going to be anything about the benefits or rules of coverage that will affect the way in which you'll be treated?

If you're required to choose a new doctor, find out how the HMO chooses its doctors and who is available to you within a convenient distance to where you work or live. If you require specialty care or have an ongoing illness, find out when a primary care doctor will take care of you and when you would be referred to a specialist. Most HMOs have member service or consumer relations departments that can answer such questions. If you're joining through an employer, your employer can often inform you. And in some cases there is comparative information that might be available from state regulators or employer coalitions or consumer magazines.

What drawbacks are there to HMOs?

You are more limited in your choice of physicians and hospitals than in a traditional insurance plan. The way to compensate is to establish a strong trusting relationship with your HMO physician. Most HMOs have ample resources available to them, but if you're used to making all of your own decisions about your health care, you are going to have to adjust to a situation where you're making your decisions in concert with your HMO doctor or HMO. Some people end up feeling that the HMO is putting up barriers and standing in the way of getting the care they feel they need.


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