Healthcare Basics

Choosing a Healthcare Plan

Here are some tips for including quality in your health care decisions. Such decisions involve health plans, doctors, treatments, hospitals, and long-term care:

Look for a health plan that:

• Has been given high ratings by its members on the things that are important to you.
• Does a good job of helping people stay well and get better.
• Has the doctors and hospitals you want or need.
• Provides the benefits (covered services) you need.
• Provides services where and when you need them.

Look for a doctor who:

• Has received high ratings for quality of care.
• Has the training and experience to meet your needs.
• Takes steps to prevent illness—for example, will talk to you about getting the screening tests that are right for you.
• Can get you admitted to or treat you at the hospital of your choice.
• Is part of your health plan, unless you are willing to pay extra.
• Will work with you to make decisions about your health care.

When choosing a treatment, make sure you understand:

• Your diagnosis.
• How soon you need to be treated.
• Your treatment choices.
• Whether the treatments are based on the latest scientific evidence.
• The benefits and risks of each treatment.
• The costs of each treatment.
• How much experience your doctor has in treating your condition.

Look for a hospital that:

• Is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
• Is rated highly by the State and by consumer groups or other organizations.
• Is one where your doctor can treat you.
• Is covered by your health plan.
• Has a lot of experience and success with your condition.
• Monitors quality of care and works to improve quality.

Look for a long-term-care facility that:

Has been found by State agencies and other groups to provide quality care.
Provides a level of care, including staff and services, that will meet your needs

Five Steps to Choosing a Physician

Choosing a personal or family physician can be an overwhelming task. After all, your relationship with your physician is unique; he or she is your partner in maintaining your health and usually, the first person you turn to for information and professional advice about your medical care and general well being.


Not too long ago, most of us were able to visit any physician we chose at any time. However, with the arrival of managed care health plans, some of our choices may be limited. Before you select your health insurance, choose a doctor you trust. After all, your health plan won't diagnose or treat you -- your doctor will. To help find a doctor who is right for you, ask yourself these questions:

1) What type of physician do I need? Do I have special health concerns?

If you have an HMO plan, you must first choose your primary care physician, who will refer you for specialty care as needed. That's why it's important to work with a primary care physician you trust. Family practitioners, internists, pediatricians are all considered primary care physicians. These doctors treat general medical conditions and may have additional training in an area such as geriatrics or digestive problems. If children are covered under your plan, you may want to choose a pediatrician to provide their care.

If you have a special health concern, consider looking for a physician with in-depth training in that area. For example, if you have a sports injury, you may want to consult with a doctor who has experience in sports medicine. Some physicians have additional training in women's health issues, heart disease or other areas.

2) What criteria are most important when selecting a physician?
The most important criterion in selecting a physician is his or her background -- clinical training, experience, board certification plus interests and expertise in specialized areas -- depending on the care you need. The age and sex of your physician is a matter of personal preference. For some patients, it is also important to choose a physician whose philosophy of care is in keeping with their own.

If English is not your native language, check to see if your doctor is bilingual. Given San Diego's diverse ethnic population, many people prefer doctors who speak their native language.

3) Do I want a large group practice or a small office?
Choose the setting where you feel most comfortable, whether it is a large medical practice that offers a variety of doctors, a smaller practice or a solo practitioner's office. What is most important is that you receive excellent care and service from your physician and office staff.

4) Where is the office located?

If it is easier for you to see the doctor on your lunch hour than after work, look for a medical practice close to your job. The location and office hours should be convenient and accessible so you can easily make and keep your appointments. Allow enough time to arrive a few minutes before you appointment, relax and jot down any questions you have for the doctor.

5) If I need hospital care, where will I go?
Make sure your physician can care for you at the hospital of your choice, and that he or she would be willing to admit you to that hospital if necessary. Your options are also determined, in part, by your health plan. Before you sign up with a particular plan, check to make sure it gives you access to Scripps hospitals.

Remember, it is important to be able to be open and honest with your doctor, and to trust him or her with your concerns. If you are not satisfied with the physician you select, notify your health plan that you want to change your doctor. Many plans will allow you to switch.
 

Health insurance basics

It's a fact of life — you need health insurance — and the time to get it is before you have an accident, suffer a serious illness, or discover you're pregnant. Insurance doesn't cover health care for medical problems or conditions that start before the moment you have your policy. Finding adequate coverage might seem overwhelming, but knowing the basics can help make your search less stressful.

Your boss doesn’t have to provide health insurance

The first reality of health insurance is you do not have a right to it. There are no state or federal laws requiring private employers to offer health benefits to their workers.

“For a number of valid reasons employers are not mandated to offer or provide health insurance for their employees,” explains Peter Bigelow, CLU, employee benefits specialist with The Foresight Group. “It is common knowledge; however, that most employers though not mandated to do so offer insurance to their employees for a variety of reasons related to competition and smart business practice.”

If you have benefits through your employer, and you quit or lose your job, don't assume you will be able to pick up the identical coverage for the same price.

Similarly, don't expect your former employer to extend your benefits beyond your last day at work. There is no "grace period" during which you're still covered.

If you do lose your employer-sponsored benefits, there is a federal plan called COBRA (Consolidated Omnibus Reconciliation Act) that could provide you with a short-term safety net. For more information, see Know your COBRA rights.

Another federal law that offers some protection to workers experiencing a short-term lapse in their coverage is HIPAA (Health Insurance Portability and Accountability Act).

Individual health insurance can be costly

If you need to purchase individual health insurance, it can be expensive. Unlike group plans, in which the costs and risks associated with health care are spread among many people; individual health policies are "medically underwritten" to take into account your personal health history. Any "pre-existing" condition such as heart disease, diabetes, and even pregnancy, can nix your chances of acceptance or boost your premiums. Some states require individual health insurers to offer everyone a plan, a mandate known as "guaranteed issue."

Expect to pay more and more

Once you have a health plan, don’t expect your premiums to remain the same. Health insurance companies often seek permission to raise premiums. Additionally, some states allow health insurers to "file and use" rate increases, which means the insurers only have to submit their increases in writing and then they may immediately begin charging customers more money. Unless insurance regulators determine the rates are excessive, the insurers are allowed to keep charging the higher premiums.

North Carolina Insurance Commissioner Jim Long says even if you have group health insurance, there’s a good chance your rates will climb. “Even though you have not presented any claims, others that are insured by the same type policy have presented claims. Rates are directly affected by the claims experience of the group insured under a given plan or policy,” Long explains

Help when you can't afford an individual plan

If you're a college student and you need coverage — perhaps you're being dropped from your parents' plan — your school might offer reasonable health insurance. See Health plans for college students for more information.

No matter what your age, there are several federally sponsored programs to help you if can't afford the premiums for individual health insurance, providing you meet their eligibility guidelines:

• Medicare, a health insurance program for people age 65 or older, certain younger people with disabilities, and people with end-stage renal disease.
• Medicaid, a program for the poorest individuals and low-income families with children.
• The Children's Health Insurance Program (CHIP), a plan that provides health care to children whose parents make too much to qualify for Medicaid, but earn too little to afford individual health insurance.

Many states offer health care plans for children of parents, who don’t have health insurance through work and cannot afford individual plans. Some states have expanded the plans to cover the parents as well.

The Different Types of Managed Care Plans

Health Maintenance Organization (HMO)

This is the most controlled type of health care plan. You must use the HMO's doctors and facilities. Medical care outside the system is not covered. But while you do lose some "freedom of choice," you benefit from lower out-of-pocket costs. HMOs usually have no deductibles or plan limits. For each visit, you pay only a small fee ("co-payment"), or nothing at all. Because the HMO provides all of your care for one set monthly premium -- no matter how much care you need -- it's in their best interest to emphasize preventive services. Some HMOs still operate their own facilities, staffed with salaried doctors; others contract with individual doctors and hospitals to be part of the HMO. A few do both. An HMO can be a good choice if you don't mind the restrictions, if its facilities are convenient, and if you want to avoid most out-of-pocket expenses and paperwork

Point-of-Service Plan (POS)

This plan operates a lot like an HMO, but it allows you to choose a doctor or hospital each time you need care. To receive the plan's highest level of benefits, however, you must choose a doctor or hospital within the POS "network." If you choose a provider outside the network, you will have to pay the difference in costs. A POS plan usually requires you to select a primary care physician, who acts as a "gatekeeper" to control and direct all of your care. This doctor will refer you to specialists, if needed.

Preferred Provider Organization (PPO)

This is a network of doctors and hospitals that has agreed to accept a discounted fee for their services from the plan. When you enroll in a PPO, you can choose any doctor or hospital on the list of "preferred providers." If you select a provider who is not on the list, the plan will pay less (and you will pay more). Some PPOs require that you select a primary care physician to control and direct your care. Often, preventive services are covered. Unlike HMOs, PPO plans are likely to carry deductibles and plan limits. Many offer several different plans, ranging from the most expensive (full coverage) to the least expensive (higher deductibles). If you like the freedom of choosing your own doctor and hospital, and you're willing to pay some of the costs, a PPO may be for you.

Independent Practice Association (IPA)

This is a loosely organized network of doctors who practice out of their own offices, and treat IPA and non-IPA patients.Usually, IPA coverage is available only to groups, and there's usually a small co-payment for each visit. Under the IPA plan, some of the doctor's income may depend on the plan's success (i.e., efficiency). Participating doctors often share in any losses the plan sustains, or in any profits the plan makes.

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