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Re: HMO PPO and the american misinsurance system

Posted by yxibow on April 23, 2008, at 23:48:40

In reply to Re: True or Not About Docs And Self Pay?????, posted by undopaminergic on April 17, 2008, at 22:10:38

> What's HMO, PPO, and "network"?

An HMO is a Health Maintenance Organisation
The worst (or best depending on your belief) of the two non national and non socialised medical systems. You pay a fee per month, out of pocket or through work (deducted), and you can only use doctors that the HMO deems acceptable (i.e. that they can cheat out of money). So you have a Primary Provider (your GP), and he must refer you to specialists (that are again approved). Special procedures have to be Pre-Authorised and "off network" is considered to be non-authorised or not payed for as much.

A PPO is a Preferred Provider Organization. That means that you can go to any Primary Provider you choose, although the copay may be higher than a HMO. You also don't have to have a referral (unless the special clinic has their own referral system, but thats not part of the paying structure) to a specialist. You have a higher deductible on prescriptions (meeting an annual deduction before actually paying less for a prescription) and a deductible anually on doctor's fees and whatnot. These deductibles coalesced can run rather high. But you get the benefit of a la carte for this.

In essence, "Sicko".

But how do you provide socialised health for 300 million people, especially the undercounted and impoverished -- this country still has pockets of people living in situations that you could call "2nd world" or whatever is politically correct.

Canada has its problems with its system but it has 1/10th the people and England has 1/5th the people. Triage happens and especially in England old medication and old practices are still used in non-university areas.


And the worst of it all is that mental health coverage, though supposed to be at "parity" is not -- loopholes can make it 50,000 even if you have a 6,000,000 lifetime policy. And if you touch the mental health side, its a sticky wicket, cancellations can occur leaving people without major med (the other side of the insurance, e.g. emergency surgery) or branded with preexisting conditions -- that's the other part of insurance, preexisting conditions prohibit payment, especially with HMOs. So you fight the legal system and spend lots of money -- I could go on, but there's no free lunch.

Ultimately, people who can afford it fork out cash for therapy.

-- end soapbox --

 

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poster:yxibow thread:821395
URL: http://www.dr-bob.org/babble/20080420/msgs/825097.html