Amy’s Tour of Health Plans, aka Mr. Toad’s Wild Ride in Slo-Mo

If I learned anything since my diagnosis, it’s that American health plans are pretty much all the same if you don’t have any special needs. That is, we bounced around a fair bit between various HMOs and PPOs and POS’s over the years. Some had higher co-pays, others had higher deductibles. It didn’t make that much difference, and even though I have three kids, I never looked into it very carefully.

Then I got diabetes. I had to see an endocrinologist regularly. I had to see a diabetes educator and a nutritionist regularly. Since the diabetes affects everything, I had to see an ophthalmologist, allergist, gynecologist, podiatrist, and sometimes orthopedic surgeon. My life became a nightmare of pre-authorizations and referrals. Who was in my network? How much would I have to pay if they weren’t? Why does my local “Medical Group” have the right to restrict me from seeing the world-class diabetes specialists at my local university?

What I found out is summarized below. Note that this highly condensed info took me a goodMr_toad half-year to work out, and with every agency sending me off in another direction, getting there was a bit like taking Mr. Toad’s Wild Ride in very slow motion. (The details of your plan options may differ, of course!) And note that just as I’ve figured this all out, my husband’s company is CHANGING PLANS AGAIN!! Am I covered for Exploding Head?! Anyway, here goes:

Cheapest option, but everything goes through your primary care physician. This means you need a referral from your “family doctor” for every other doctor or treatment. A pain in the @#$!! for most diabetics, who generally only see their general practitioner at the point of diagnosis, and then move on to real diabetes care. Luckily, you can usually call in for a referral, and a single referral can often provide for a long-term treatment. Standard copays for doctor visits are just $10. BUT you are locked in to choosing providers within the local network, or Medical Group, contracted with your health care plan. This includes hospital care. You need to go to the Medical Group’s specified hospital, except for out-of-town emergencies, which are supposedly covered at 100% (in my experience, you still get billed for various treatments). The HMO is also the only plan option that offers “non-critical” medical services like education and training. (Hello, 18 M diabetics in America need this stuff!)

If you choose to go out-of-network (outside the Medical Group), you pay a percentage of the provider’s regular fees for each treatment. The stinger is that your health plan will not cover any percentage of an out-of-network service that your Medical Group claims to offer itself.

Most expensive, with a significant annual deductible, because you can see any doctor including specialists without referrals. Still, they make a distinction between “preferred” and “non-preferred” providers. Preferred have signed billing agreements with your health plan, so you as the patient pay just a 20% copay versus a 40% copay for providers who have no relationship with your plan and can charge whatever they like. With our provider, the PPO plan does not cover any “special programs” like nutritional counseling or diabetes education.

The POS (Point of Service) option doesn’t cost much more than an HMO, and lets the patient choose for each medical service whether to use HMO or PPO benefits. So you can use your HMO option, and get a referral for an in-network doctor at a $10 copay, or you can go the PPO route and see a preferred provider at 20% cost or a non-preferred provider at 40% cost. Here’s the rub: these choices have caused a great deal of billing confusion, so much so that many POS plans have been cut altogether. It’s up to YOU, as the patient, to tell your doctor which option you’re using, or they’ll probably bill you incorrectly. Naturally, you’ll want to go the HMO route if your doctor’s in the local Medical Group, because it will cost you less.

With services like counseling and diabetes education, you often have no choice really. For example, under our plan, since these services are covered only by the HMO, you’re locked in to whatever your Medical Group happens to offer (unless that group grants you an exception). No matter that a nearby university has a world-class diabetes center! If your Medical Group offers “equivalent services,” they won’t be granting any exceptions — so you get whatever they’ve got, unless you want to pay full price out of your own pocket to upgrade your care. In my case, a half-hour visit with my wonderful educator at UCSF put me back $380 without the insurance. I haven’t seen her for a year.

All the diabetics I know have had similar troubles, discovering their plan doesn’t cover some critical portion of their care.

I know I’ve said this before, but I still don’t get it: Why are US health plans so restrictive on services that have the potential to ward off the big bills? Why shouldn’t patients have the freedom to take advantage of the best educational resources in their area, even if these resources aren’t the health plan’s devoted business partners? Happily, diabetes is very manageable with good training and education. If not properly managed, diabetes complications are going to cost the health plans a hell of a lot more than university counseling sessions would (!)


10 Responses

  1. Kirk
    Kirk September 11, 2005 at 9:12 pm | | Reply


    You answered your question up front; US insurers know you will probably be gone before complications arise. You should see the average before companies changes plans. Fortunately we live in a society where socialized health is not yet pervasive (of course we have medicare and medicaid). Just look at Germany, France and Great Britain; Great Britains healthcare SUCKS and France and Germany are broke.

    I’ll take our system over all the others none are perfect but ours is still the best.

    Moving towards year 48 and still comp free…….

  2. AmyT
    AmyT September 11, 2005 at 10:31 pm | | Reply

    I think I’d have to disagree. I lived in Germany for many years and found their health care system excellent — at least from patient’s perspective, since everything is covered!

    Whether they can continue to finance such a system is another story…

  3. kym
    kym September 12, 2005 at 8:53 pm | | Reply

    I’m not sure. I think that the POS is on the way out and the other options address the situation pretty well. Each time I accelerate my request within my “group” to see a specialist or my university area (sometimes I can even combine it with participation in a study like at Stanford which is local to me) I have been able to get the visit covered with a higher copay that is not excessive. It takes longer to navigate it this way and you have to be diligent but it works if you have a good relationship with your doc and it sounds like you do.

    I forget the carriers you mentioned but Blue Shield is pretty good for that. Personally I find when employers switch to be the most frustrating since although there should be no preexisting conditions. Pregnant, diabetic and my co switched during my birth month! Talk about a headache to navigate.

    You can call your local research hospital or TrialNet to see if they are doing a study in your area. One I did was looking at insulin resistance and fed me for 6 weeks with really yummy premade meals. :)

  4. Kirk
    Kirk September 13, 2005 at 7:59 am | | Reply

    That is my point Amy they cannot AFFORD to keep it up they are going down the economic toilet. Unfortunately we all have to live in the real world.

    I am sure the patients love it; have you looked at the tax rates over there recently?

  5. Dr. Roosevelt
    Dr. Roosevelt September 13, 2005 at 11:08 am | | Reply

    Amy asks:
    “Why are US health plans so restrictive on services that have the potential to ward off the big bills? Why shouldn’t patients have the freedom to take advantage of the best educational resources in their area, even if these resources aren’t the health plan’s devoted business partners?”

    My answer, you cost them money. They want you to either leave or die. There is no incentive for private companies to reduce end-organ complication costs since the government (i.e., the taxpayer) is the insurer for these costs. Insurance companies are not your friend. Here is the model to remember: 1. Collect premiums. 2. Invest them to generate additional income. 3. Deny claims. 4. Result = net profit. The horizon of an insurance company is quarterly, yours is lifelong.

  6. hypnoid
    hypnoid September 13, 2005 at 3:38 pm | | Reply

    Thanks for the interesting review-I have to confess I bit my tongue when you said”…most diabetics, who generally only see their general practitioner at the point of diagnosis, and then move on to real diabetes care.” I found it interesting that you were describing HMO plans, which seem closest to the system in Canada-you see a GP, and if needed they refer you to a specialist. However, I don’t know of any GP in Canada who wouldn’t be competent to provide “real care” for a patient with diabetes.

  7. AmyT
    AmyT September 13, 2005 at 4:19 pm | | Reply

    Hi hypnoid,
    Interesting… I don’t know any diabetics (at least Type 1′s) in the US who don’t see an endocrinologist rather than a GP. The endos know so much more about this disorder.

  8. Alice H
    Alice H September 14, 2005 at 8:51 am | | Reply

    I guess I can consider myself lucky – it seems like practically every doctor affiliated with the hospital I prefer is part of the same medical partnership. I have seen an otolaryngologist, an OBGYN, and have used excellent urgent care services without any hassle from my insurance company because they’re all part of a large medical group – which means no referrals are required, although I usually touch base with my PCP to see if I am overreacting first.

    My son’s pediatrician is also in the same group, so if multiple family members are sick with the same thing, we just go to an adult doctor and are able to get treated from the same doc on the same visit, and the pediatrician is aware of the diagnosis.

  9. Kirk
    Kirk September 14, 2005 at 1:01 pm | | Reply

    Amy if Germany is so great why are you here? (just kidding)

    I will again attempt to explain why insurers here do not do much for treating for the long term. People in the US switch providers so regularly that the patient statiscally will leave before they have complications.

    The reasons and discussions you are having are exactly why I am the primary doctor for myself. Education and all these years of D have provided me with more information than most of the specialists I have known. I take full and total responsibility for my care. After all no one else can care for my diabetes, only I can do that.

    We do have socialized insurance in the US they are called Medicare and Medicaid. Anyone who needs health care can be covered by these governmental programs.

    By the way Doc R in Germany your income would be somewhat different.

  10. crislyn
    crislyn February 18, 2006 at 7:42 pm | | Reply

    need assistance, i am the director of nursing and want to combine inpatient and outpatient diabetic education, please share articles that support the change

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