How to decide between a bad PPO and unknown HMO health plan?

November 2, 2012 3:33 PM

It's health benefits selection time at work! I'm fed up with the PPO I have now, but the only other choice I can afford is an HMO. Is switching a good idea or a bad idea? (I'm looking at Aetna HMO specifically, but I'd value more general input too.)

At work (New York City government) I'm currently with the cheapest option, the GHI CBP plan. The problem is that while there seem to be a fair number of doctors in the network, I've had the experience of calling up eight or nine in a row and found that all of them were no longer taking new patients, or no longer taking new patients on GHI, or just plain not answering their phones. The doctors I have seen have... not always been that competent.

Among the health plans I can choose between, the only other one I can afford is the Aetna HMO. There seem to be a lot more doctors who take it, and in theory it doesn't seem like it would be that bad to have to get a referral to a specialist if I need one, but I've heard such horror stories about HMOs that I'm just not sure. (Alternately, is GHI better than I think, and I just need some tips and tricks for finding a doctor?)

Other possibly relevant information: I am 30 and generally healthy. I don't currently have a primary care physician because it's been such an enormous hassle to get a doctor's appointment at all. Both plans provide pretty similar levels of coverage, and I'm part of a union that provides prescription benefits so I don't have to worry about that part.

posted by Jeanne to health & fitness (11 answers total)

I don't have experience with Aetna, but I personally like HMOs a lot (I am with Kaiser). My experience has been that when you make contact with the system, though whatever way (maybe using your online account to find/choose a doctor, or calling the scheduling number) there'll be a way to route you to someone who is taking patients, or who can get you the referral. At Kaiser I've loved the OB/GYN experience I had, including all the prenatal stuff and my hospital delivery, and I thought the staff and doctors and nurses I encountered were all excellent. When I've dealt with the GP side of things I find my doctor slightly less fantastic, but I'm generally healthy and don't have a lot of contact. As far as PPOs go I never liked having to call around, or figure out what is covered/what is not covered, while with my HMO I love that I have a co-pay and then pretty much everything is in network and covered and I don't have to worry about all that stuff as much.
posted by handful of rain at 3:47 PM on November 2, 2012 [1 favorite]

I agree with handful of rain. I've been on very nice PPOs and now I'm on an HMO. I come from a family of hypochondriacs and we're all overly medicated and have gotten way too much testing done (in other words, we like having control over our health options), so I used to think that HMOs were the root of all evil. Then I actually put in the effort to learn more about them, and they make a lot more sense to me now.

I never really had a Primary Care Provider (PCP) until I switched to an HMO and it really has put my mind at ease. Before, when I had sinus problems, I'd scramble around and try to find the best ENT doctor I could find. I'd wait a few weeks until they had an opening, then I'd visit them once or twice and then never again. Then when I had a rash, I'd scramble again and try to find the best dermatologist. I'd see them once or twice, then never again. And the thing is...even though these were doctors who were supposedly the best in their fields, I didn't feel particularly more cared for by them or that I was receiving better treatment.
I got the same predictable prescriptions and treatments each time. Antibiotics here, steroid cream there.

Now I have a PCP who I go to for everything, and I have never once felt like I was being cut off from specialists (which was my biggest fear). In fact, she's offered me so many referrals I've actually turned them down. It's very nice to have the chance to get to know a doctor and a doctor's office, have one number to call and be able to sneak in the same day I ask for an appointment since they are familiar with my health history.

I can definitely see why PPOs are better for some, but if you're young and relatively healthy I think HMOs are a great option.
posted by dede at 4:04 PM on November 2, 2012 [2 favorites]

My family has swapped back and forth between HMOs and PPOs in the past few years (changing options, changing coverage requiring us to try new plans). We've been pleased with HMO coverage in recent years. Yes, you still have to have a primary care physician and going to a specialist requires a referral -- but what I've found is that most specialists prefer a referral from your main doc anyway to schedule an appointment. And I think it makes sense to see a GP to rule out the usual suspects before getting in line for a specialist.

I can't help w/doctor's offices, other than to say I've become a fan of large offices w/multiple docs and at least one or two nurse practitioners or PAs. I see my primary doc about once a year for checkup stuff, and if I get the odd illness I'm happy to see whoever else is available. If I need a specialist they're happy to refer out.
posted by hms71 at 4:12 PM on November 2, 2012 [1 favorite]

HMO horror stories are just that: horror stories. As in, not necessarily representative. I liked my HMO back when I had one better than I like my current PPO.
posted by Tehhund at 4:25 PM on November 2, 2012

When you're looking at HMOs, it's important to note the distinction between staff-model HMOs (where all the doctors are employees of the HMO, and do nothing other than see the HMO's patients) and a network-model HMO (which operates almost exactly like a PPO, where the doctors have contracts with lots of insurance companies and see lots of different types of patients).

I've been a member of a staff-model HMO--Kaiser Permanente--and I loved it. Like handful of rain mentions above, this type of insurance plan generally encourages the HMO to be really active in "managing" your care, which generally means they'll figure out a way to get you in to a doctor if you need one, and all you really have to do on your end is call a single number and let them figure it out. Network-model HMOs, on the other hand, don't tend to be all that active in managing your care and have all the same problems that PPOs sometimes have with finding a doctor to actually SEE you. For this type of HMO, it's all about how big their network is in your area, and how busy / booked the physicians in-network are. I am not positive, but I'm pretty sure Aetna's HMO is a network model.

All of which is to say: you really need to get some Aetna HMO-specific information for your area, because people's experience with other HMOs or other areas might not have too much bearing on how much you'll like this particular plan. New York does put out consumer guides for HMOs that give you some information about how well current members rate their plan; you can find the one for New York City here. As you can see, Aetna is kind of average in how well its members rate their ability to get needed care and overall satisfaction. Not the worst, but definitely not the best either among HMOs. In comparison, GHI's PPO has a slightly higher overall rating (64% versus 55%) but you can see it's low compared to other PPOs.

If it were me, I'd probably ask other people at my work if they had Aetna and if they liked it, and were satisfied with their ability to find a PCP. Barring that, based just on the information from surveys of patients (which obviously don't represent everyone's experience), I'd probably not change, just because it doesn't seem like Aetna's HMO members rate their ability to find a doctor any better than GHI's PPO members.
posted by iminurmefi at 4:43 PM on November 2, 2012 [4 favorites]

I have no idea if it's just my area or what, but I have Aetna PPO and I had a very hard time finding a doctor who both took Aetna at all and was taking new patients. I would ensure you can get in to see a doctor of your choosing before switching. Many of the doctors listed as taking Aetna on Aetna's website do not, in fact, take Aetna. Frustrating experience, but admittedly you may end up with a different outcome.

I live on the west coast in an area that has a lot of doctors for what it's worth.
posted by cecic at 4:58 PM on November 2, 2012

I was on an Aetna HMO for two years in NYC and in my experience their network was not quite as extensive as United Healthcare/Oxford's but still with plenty of good choices. No real issues getting referrals. It's unfortunately a fact of life that in New York it can be quite difficult to find ANY primary care physician taking new patients. (When I left, I was seeing Dr. Binsol at http://www.downtownmds.com/index.php, and I was quite happy with her; very worth checking if she's still taking new patients.)
posted by psycheslamp at 4:59 PM on November 2, 2012

I've had Aetna HMO in NYC as well, and my experience matches psycheslamp's. MeMail me if you want specific PCP or OBGYN advice.
posted by snickerdoodle at 5:20 PM on November 2, 2012

Another satisfied Kaiser HMO user here. I switched from a PPO about two years ago and I can say my experience has been excellent so far. While I have been very pleased with the medical care (and currently getting a lot of that now at 38 weeks pregnant with some complications early on) what I actually have liked best is the organization of it all and the "one stop shop" aspect.

Whether I see a dermatologist, OB-GYN, primary, etc. it all gets logged into their same system. This includes a pretty decent online interface that I get to use to communicate with my doctors, track prescriptions, and my general health record like test results and the like. So regardless of what type of appointment I need or what medical concern I am calling about ALL my medical history, preferences, allergies, recent issues, etc. is just all right there at the fingertips of whomever I am speaking with, and they can help me more efficiently and effectively because of it.

Maybe other (more organized) people might not care about this but for me who had a random primary doctor picked out of the phone book and an unrelated OB-GYN across town and a therapist I saw irregularly, this has been helpful and makes my total care more comprehensive and holistic-y.

I did have to get a referral to see a specialist once and it was sorta a pain because I had to go in to see my primary first. But this was pretty minor. My co-pay and overall HMO expenses (including monthly premiums) are pretty minimal so the extra trip was not made at a big expense to me.

In terms of actual medical care, I have been really pleased. All the doctors I have seen have been more than competent and have taken the time to address my (many) concerns, questions, etc. When I expressed concern over anesthesia used for an upcoming procedure they even made a quick phone call and sent me over to the actual anesthesiologist that same day who spent about a half hour with me answering my questions and explaining everything to me.

What kind of horror story HMO stories have you heard? Perhaps myself or others can chime in with more specifics addressing those concerns.
posted by click at 5:26 PM on November 2, 2012

FWIW, my wife has an Aetna HMO and she seems fine with it.
posted by Dansaman at 11:15 PM on November 2, 2012

I think that the medical group you join for your HMO is the most important thing. Here in Illinois my husband and I use Dreyer through BCBS Blue Advantage HMO, and although we do have a PCP, we can self-refer to any Dreyer specialist. When I wanted to see an allergist, I just called up and made an appointment. I saw him twice, paid a $40 co-pay each time, and got extensive allergy testing at no additional cost. My flu shots are free, my cholesterol tests are free. I don't know if I'd be as happy with a different medical group.
posted by Joleta at 3:28 PM on November 3, 2012