Confusopoly on a kaiser bun.
October 27, 2010 12:44 PM   Subscribe

Should I switch to a HMO? My company offers Kaiser Permanente's HMO, and it's a good bit cheaper than my current plan. People tell me that HMOs are evil, but the plan looks pretty good on paper. I'm in Washington, DC.

Not-particularly-special snowflake details: I'm a guy, in my mid-twenties, and have no major health problems. I can afford my current PPO plan without a problem, but wouldn't mind spending a bit less. Also, I'm not currently tied to any doctors or practitioners within my current plan.

My primary questions are:
  • How hard is it to find a good GP in the Kaiser network? I've been in DC for about 8 months, and never got around to selecting a GP, because all the good ones didn't seem to be accepting new patients. Given my (currently) unremarkable needs, Kaiser seems to have the upper hand here. Right?
  • How's the quality of care? I had an awesome/amazing/incredible GP back in my previous city. Ideally, I'd rather not have to wait in long lines, or be treated as a number. I also recall a number of vague HMO horror stories from friends and relatives.
  • How stingy are the GPs about specialist referrals? I'm not a nitpicker, but I'll be able to get a referral for anything obvious, right?
  • Given Washington DC's reputation, I'm outright paranoid about my sexual health. Will I get funny looks if I walk in, and ask for an STD test (which presumably will have to go through my GP)?
I'm sure there are other things to consider that I'm not thinking about. Any anecdotes, horror stories, and general advice would be greatly appreciated. Straightforward answers about health insurance and medical care seem to be incredibly hard to come by on the internet.
posted by schmod to Health & Fitness (21 answers total) 4 users marked this as a favorite
OK, this is strictly anecdotal. My experience with HMOs is that you get considerably less contact with actual MDs, they hire less able doctors (there are notable exceptions), it is harder to get referrals, and in general the quality of care is lower.
posted by bearwife at 12:48 PM on October 27, 2010

Really depends on what your needs are, the sacrifices you're willing/able to make and the particulars of the actual plan. In my anecdotal experience, HMOs are a pretty good bet so long as you're single and basically healthy. The SECOND you need any sort of specialist care or non-standard stuff, you wish to god you'd coughed up the higher premium for a decent plan every month. This is especially true for mental health care benefits, if you ever plan on using 'em.
posted by julthumbscrew at 12:55 PM on October 27, 2010

Kaiser is a different beast than an average HMO. If you look through the Kaiser and KaiserPermanente tags, you'll see some better descriptions of it.
posted by Zophi at 1:02 PM on October 27, 2010

I have KP, and so do a ton of people I know (we're all in California). A friend of mine was successfully treated for breast cancer there; another friend gets his HIV care there; another has had two babies via Kaiser. When I was a kid, I had to have an operation on my arm, and it cost $3. (Okay, that was the co-pay, but still - walk out of the hospital, and pay them $3? Awesome!)

Yet another friend had a complicated pregnancy and her son was born with a lot of serious problems. Kaiser was very good and swift with saying "Your son will get Most Excellent NICU care at [non-Kaiser facility]" and whoosh, it was done, with a minimum of paperwork and no hassle.

I don't know anyone who's had trouble getting referrals. No one I know who has KP has to go to a special off-site lab for bloodwork and then has to fight with the insurance company to get it covered. Etc.

You'll hear horror stories, yes. And tons of people can also tell horror stories about non-HMO systems, so keep that in mind.
posted by rtha at 1:06 PM on October 27, 2010

I've had Kaiser on and off my whole life, but only on the West Coast. I've briefly had a couple private physicians as well.

- Everything is right there - your doctor, your pharmacy, the lab, specialists are all in one building or cluster of building. This saves time and reduces mix-ups and poor communication.
- I've never had a problem seeing an appropriate specialist. In some cases you can go straight to the specialist but you do generally need to see your GP first. Specialists have plenty of time and are attentive for the most part.
- Appointment wait times for most departments have significantly improved recently, due to a change in organization-wide policy (or perhaps this only applies to Northern California? You could ask.) At this point, I always get an appointment with my GP (or my child's pediatrician) within 3 days of requesting one. Specialists can take a bit longer but not unreasonably so.
- Care is good. I did not say excellent. But it is consistently of a high caliber. Practitioners are expected to conform to certain evidence-based guidelines and protocols that are for the most part sensible. This reduces the wingnut factor of the occasional wack-o doc you might run across in the world.
- Out here at least, providers are now expected to communicate by email. They have 24 hours to get back to you and I find this a very useful service.

- Primary providers are expected to work within very short appointment times. I believe they are going for 6 minutes per routine adult health appointment. (Not sure where I heard this, but i do know from experience and speaking to docs there that the appointments are very short.) I find this insane and never get all my questions answered even when I've liked my provider.
- You have somewhat less say about who you choose as a provider.
- Maybe more importantly, the providers have less say about how they practice. Maybe a doc can chip in here and correct me if I'm not getting this right, but my feeling when I've had private docs was of getting highly individualized attention. At Kaiser, I'll be honest, I often feel like part of an assembly line. It's a very effective and fairly humane assembly line, but an assembly line none the less.

Good luck, and PS, no responsible doctor, nurse practitioner, PA, or anyone else should give you any kind of hairy eyeball for asking for STD testing.
posted by serazin at 1:06 PM on October 27, 2010

I have experience with Kaiser Permanente in Northern Virginia, so this will be with different centers, but the same system.

You have to be somewhat lucky to get a good PCP (primary care physician) and luckier still to find a good PCP that will stay with Kaiser in the long haul. I don't go see the doctor very much, and I've had my PCP changed three times in the last five years since I'm just added to the newest doctor and they don't stay very long.

The quality of the care seems overall good, but somewhat hit-and-miss how much they pay attention to you. I've had some good experiences with their nurse practitioners, whom you may see more than a MD.

Referrals aren't that big of a deal if your PCP agrees you should see a specialist. KP does have agreements with a lot of other medical orgs in the area, so if Kaiser doesn't have a specialist that fits what you need, you can go somewhere else and pay the normal Kaiser rate for covered stuff. You may have to travel some, since Kaiser has some of the more specialized equipment spread across several facilities. Like, if you need specialized imaging (very specific CT or x-rays), you may have to travel to their imaging center near the Fairfax Hospital center (which is actually in Merrifield more or less).

You have to adjust how to deal with medical care slightly if you're used to non-HMOs. KP will, even if your doctor doesn't have an appointment, be able to fit you into your PCPs "office" (which normally has 5-10 doctors and about as many nurses) within a day or two if you think it's urgent enough. If you have a condition you think is "urgent" but not emergency, you might want to visit one of their 24 urgent care centers, since it's way cheaper than visiting an actual ER. (For me, $15 co-pay normal office visit, $25 urgent co-pay vs a minimum $50 ER co-pay.)

I seriously doubt they'll blink about asking for STD tests. I wouldn't lead with the line about DC though, since that's pretty silly. Just say it's been awhile since you've tested and want to. Depending on your exact plan, they'll be any where from free to like $30.

That's the core of my experiences, I think. And what serazin said jibes with my DC area experience.
posted by skynxnex at 1:08 PM on October 27, 2010

When I worked for a doctor's office in MA. Kaiser was far and away the worst insurance company for trying to get approvals for out-of-network claims. That always stuck with me and I've been vary wary of them. I, too, live in DC and have stayed away from Kaiser for that reason. I should add that at the time Kaiser was pretty much non-existent in MA. I don't know if they have a larger presence there now (we had a lot of out-of-state patients). I haven't really noticed a large Kaiser presence in the DC area (entire Kaiser health centers for example, see below), even though they seem to be a popular choice for local insurers.

On the other hand, it seems that Kaiser/Kaiser Permanente works really well (or at least pretty well) in places like Northern California where there are huge Kaiser specific health centers. My friends in Oakland have been insured by them forever and haven't had any complaints.
posted by kaybdc at 1:12 PM on October 27, 2010

Best answer: I have Kaiser in DC and I like it a lot. Obviously one of the things that you deal with when you do an HMO rather than a PPO is the whole song-and-dance of: (1) needing to get a referral from your GP to see any specialist, rather than making an appointment directly; and (2) being totally limited to HMO docs rather than having the option of seeing someone out-of-network and paying a higher copay/coinsurance amount.

However, there's a huge difference between network HMOs, which are stand-alone insurance companies that contract with independent doctors who may or may not be accepting new patients, and group-model HMOs, which are insurance companies that actually hire doctors directly who do nothing other than see the HMO's patients. Kaiser is the latter kind, which means you're not going to have a problem finding a doctor who accepts new patients--you call up their appointment line and the appointment person just goes through and either makes the next available appointment with your GP or finds you someone who can see you immediately, if it's a "need to get in today" sort of issue. They can even look across different medical centers (e.g., my GP practices at the Foggy Bottom center but I've asked the appointment person to give me the next available appointment with a specialist either there or at any center in Northern Virginia, which usually means I can get in even quicker).

Specific pluses and minuses about Kaiser:

*They cover travel vaccinations, which is pretty rare for health insurance companies, and can save you hundreds of dollars if you're traveling somewhere that requires Hep A and typhus and yellow fever vaccinations. I try to take at least one big trip per year to those sorts of places, so this saves me lots of money compared to my boyfriend, who has "better" (more expensive) insurance that doesn't cover travel vaccs.

*You basically have to make all of your appointments through a centralized appointment center, which is a plus and minus. On the plus side, it means that if you need to come in ASAP because you're barfing your guts out for the third day in a row, you call one number and they will do all the legwork of looking through 50 doctors to figure out who can see you at a location you can get to--rather than leaving all that on you, which can happen if you're in a PPO and you don't have a current GP. On the minus side, sometimes they stonewall you a bit when you think you need to come into the doctor but the decision logic they're following doesn't agree. (Example: having a bad cough for less than a week). I had a frustrating go-around when I wanted to come in and get the second Hep A booster after I got the first for a trip to Peru, but because I didn't have a specific travel date I could give them they were like, "Well, call us back within 2 months of your next trip to a location requiring this vaccination." I eventually just e-mailed my GP and had her staff make the appointment directly, but ugh that was frustrating.

*You have to get a specialist referral from your GP, and in my experience they are swayed very little by your perception of how bad you need that referral and much more by what the current guidelines say. I think this is a plus, lots of my coworkers think this is a minus. I like that my GP will look at whatever mole is freaking me out and say, "Oh no, that mole is fine, doesn't have the signs of cancer, we'll keep an eye on it but no need to go to a dermatologist" but some people get really upset that their GP won't just refer them to a dermatologist to get it cut off for their own peace of mind. Same thing with Lyme disease--I hike a lot around here, and I kind of appreciate that the GP will look at my weird rash and reassure me it's not Lyme (while giving me a list of symptoms to look out for), but I had a coworker on Kaiser who was frantic about not being given the option of a blood test for Lyme after finding a tick on herself. If you're someone who likes a very interventionist and "let's just be sure" sort of approach, Kaiser might drive you nuts. If you're the type that prefers to not be really aggressive with testing/biopsying/whatever unless it's really necessary, you'll probably like it a lot. (For STD testing specifically, I've never had a problem with asking my gyn to run the full panel, just to check for everything, and when I mentioned my boyfriend had been counseled against STD testing because his doctor thought it was too painful for dudes, my gyn narrowed her eyes and said "well that's not really what I or most doctors would recommend", so I don't think you'd have a problem there.)

If you decide to go with Kaiser and are looking at finding a GP at their West End center, memail me and I can tell you who I've had good experiences with and the one GP I've had a bad experience with.
posted by iminurmefi at 1:14 PM on October 27, 2010

I've been with Kaiser in DC for well over 10 years. I started because they were cheap, but as I've made more money, I still haven't found a real reason to switch. I've had some not-so-great GPs, but I have a good one now (who I'll recommend to you, if you're going to go to the West End location--I wonder if iminurmefi and I have been touched by the same hands).

When my now-wife and I first started dating, we agreed to go in for STD tests. I have to say there was a bit a drama attached, as the nurses had a god damned celebration that I was in there getting an STD test. Medical privacy be damned, but no, there was no resistance to it.

I, too, had to push for a Lyme disease test. I've had to push for moles to be taken off, and for an allergist referral. I didn't have to push hard, mind you, but I did have to bring it up.

For my then-young daughter, it was fantastic to have after-hours care and someone always on call.
posted by MrMoonPie at 1:40 PM on October 27, 2010

Response by poster: Great responses so far -- thanks!

Tack-on question: Any specific experience with their North Capitol center?
posted by schmod at 1:42 PM on October 27, 2010

I was born at Kaiser (So Cal) and have never had any other insurance in my 40 years. My husband is a frequent user of medical services (HIV+) and has had a PPO in the past. He went on my Kaiser 10 years ago and freaking loves it.

A few things to know in addition to the above:

- you have to advocate for yourself. Your PCP is not going to send you a little note saying that you should come in for a yearly appointment

- Kaiser has the most advanced e-medical records I've ever seen and I work at a major university medical center. You will receive your test results on their system within hours of having your blood drawn.

- You can find an excellent doctor. My physicians and surgeons (I had a cholecystectomy and a benign breast tumor removed) have all been beyond excellent. For the excision, my surgeon herself came out to the waiting room to discuss how my surgery went with my husband. I also followed up directly with the surgeon, not some fellow or resident.

Feel free to memail me if you have any other questions.
posted by Sophie1 at 1:42 PM on October 27, 2010

I believe the North Capitol branch has recently been renovated and expanded. I'd been to the older center for dermatological issues, and it was a sad place full of poor old people.
posted by MrMoonPie at 1:48 PM on October 27, 2010 [1 favorite]

I grew up with Kaiser in the DC area and I had the same GP pediatrician until I was 18. Then I moved to a big boy doctor until I got my own healthcare.

In my experience, if you know the system, you'll receive excellent care. Call the line up, they'll get you an appointment ASAP in driving distance (most of the time on the same day or the next day), go in, explain your issues, and you'll get a referral and an appointment for a specialist within the next week.
posted by Michael Pemulis at 1:49 PM on October 27, 2010

Response by poster: I believe the North Capitol branch has recently been renovated and expanded. I'd been to the older center for dermatological issues, and it was a sad place full of poor old people.

Looks like I just partly answered my own question: The North Capitol facility will be closing in January, and reopening on 2nd St.

And, yeah. I didn't want to phrase the question that way, but the North Capitol St facility is in a poor neighborhood, while the West End is a rather posh part of town. The idealist in me wants to say that this doesn't matter, but the pragmatist says otherwise.
posted by schmod at 1:56 PM on October 27, 2010

I'd been to the older center for dermatological issues, and it was a sad place full of poor old people.

Okay, MrMoonPie, now I'm pretty sure you're stalking me. I've only ever been to the North Capitol branch for dermatology as well; the derm I saw was a very nice guy, but I think the waiting area was shared with nephrology (kidney docs) and it was indeed full of older folks with some serious health issues. Not sure what the adult/internal medicine office is like, though.

If you're looking for metro accessibility, I don't find the North Capitol branch very accessible at all (it's like a 15 minute walk if you're a brisk walker), but I think they're building a brand spankin' new building with a ton of GPs and specialists right next to the New York Avenue metro. At least KP keeps sending me flyers about it.
posted by iminurmefi at 2:03 PM on October 27, 2010

I have mid-Atlantic KP and got STD tests. No funny looks from the doc. He punched them into the computer. I went to the lab, peed, and maybe had blood drawn (don't remember for sure.) Quick and easy.

KP is large so you will be treated as a number, sorry. My GP is great and he might actually remember me, who knows. I don't find it bad to be treated as a number though. You call a central number for appointments, or you can make them through a website. It's very efficient.

No long lines. I go to the doctor very rarely but have not had to wait longer than a couple of weeks. On the one occasion I had something urgent (loss of hearing in one ear) I was seen that same day. (They cleaned my ear out. Should I admit this here?)

I grew up with KP in Denver. I moved here and did not want a PPO because I find their cost structures to be opaque. So here I had another HMO (now part of United Healthcare) for a few years. I had no good experiences with any of their docs. So I switched back to KP and have been satisfied. I like Dr Jain at West End and since I like him he probably won't mind me putting his name up here. He has never seemed hurried to me. He takes time to answer all my questions and is very professional. I got a "health assessment" and he took a complete medical history.

North Capitol is a dark place, but I was only in there once. They have also opened a new place near Union Station that might work for you.

They're not going to want you to go outside the KP network for anything. If you want to pick your own doctor from the zillions of docs out there, don't use KP. I trust my GP to know when to refer me to another doc. He went to med school, not me. I also don't feel that being able to pick from zillions of docs benefits me at all, but you might feel differently (e.g. your best friend recommends a particular doc. My friends don't seem fond of any of their docs so this makes me no difference.)

Since you are healthy I would switch. You can probably tell health plans apart better if you are a sick person. Since KP is cheaper and you won't go to the doc much anyway, I would get it.
posted by massysett at 2:12 PM on October 27, 2010

I have a DC North Capitol KP horror story. Forget them when they relocate, too.

West End might be OK.

I have two former coworkers, one with a husband and three kids, who lurrrvve KP. But they're in Virginia.

From my personal, very bad experience, avoid it like the plague!!!!
posted by jgirl at 2:46 PM on October 27, 2010

Response by poster: I have a DC North Capitol KP horror story.

Which is.........
posted by schmod at 3:47 PM on October 27, 2010

I can't speak about Kaiser DC, but I have heard nothing but awful stories in Northern California. My father, a physician (not at Kaiser), basically has the attitude that Kaiser will kill you. He called me a few weeks ago to tell me that one of his friends had passed. I asked how he died, and my dad said "Well, it's not quite clear...he went into Kaiser's ER and never came know..."

Don't do it.
posted by radioamy at 9:07 PM on October 27, 2010

Best answer: I had Kaiser in NoVA for a few years before I changed jobs. Loved it. (Actually, having to switch back to a PPO was one of the downsides of the new job, and they seemed to think it was a plus. Not for me.)

Their e-records system is slick. I mean really, really good; I've never seen anything like it actually work as advertised. You can call up their hotline (say with a bad sore throat and fever) and give your information ... they'll find someone who can see you ASAP, make the appointment, and send all the information to them. When you show up, you don't need to go through the song and dance of repeating your symptoms fifty times over to everyone who walks in the door. And having lab results available online only a few hours after you get blood drawn is slick.

Their offices are big and sterile and it's likely you won't build much of a relationship with your doctor (I get the impression they hire a lot of young doctors right out of med school), but they're also efficient and I never got the feeling like my time was being wasted.

I do know some people who seem to have a pathologic, angry aversion to Kaiser, but ... they're, well, um, I'd say in general they tend to be the people who want a lot of hand-holding and greater than recommended levels of intervention (cf. iminurmefi's comment about Lyme disease testing above) and are always sending themselves to specialists, etc. The whole reason that Kaiser works (and is cheap for the quality of care / outcomes) is also why people like that are going to be unhappy.

To be fair, it's entirely possible that if you have a chronic disease condition that you have done a lot of research into and that you know and understand really well, better than the average GP, then the whole Kaiser thing might not be a good fit. But for the average person I think it works pretty well. It's certainly something to factor into your decision though.

Since being forced to leave Kaiser for a "better" PPO, I've been constantly irritated by the whole process, and I've pretty much resigned myself to going in for checkups less often. If my company offered it, I'd switch back tomorrow.
posted by Kadin2048 at 10:09 PM on October 27, 2010

Lots of great detail above. I'll just add my personal experience with HMO vs. PPO plans.

Two years ago my company at the time offered an HMO plan that was cheaper AND had a lower deductible than the PPO plan, so I, and lots of my colleagues, jumped on it. Without exception we regretted the decision.

HMO pains in the ass:
* You have to see your Personal Physician FIRST, EVERY TIME. This is a huge pain in the butt if you're an athlete in particular, since you often know from experience what kind of specialist you need to see for sports problems.
* I tried to find a counselor during the time I was on the HMO, and lots of doctors simply don't take the HMO plans, since they have to be in the network. PPO gives you much more flexibility, and for some types of medicine (psychiatry in this case, but sports medicine, cardiology, and lots of other specialties) you really, really want the flexibility to be able to use someone that is recommended by a friend, as opposed to just whoever happens to take the coverage.
* If you're young chances are you're not going to reach the deductible limit either way, even if it's lower. If you do it'll be because of a serious accident (I broke my leg, for example), and, at that point, a couple hundred bucks extra isn't that big a deal.

I'll never go HMO again. Ever.
posted by kryptonik at 7:32 AM on October 28, 2010

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