Would you pay an extra $1K/yr to be able to choose your own doctors?
June 19, 2014 8:33 PM   Subscribe

How much is it worth to you to have (relative) freedom of choice? Enrolling in health insurance and I'm debating between an HMO and a PPO (both under Blue Shield of CA). The difference in cost is roughly $1,000. I'm a 26 year old female but I'm not exactly "healthy". I have mysterious, debilitating, chronic joint pain all over (undiagnosed as of yet), a couple car accident-related injuries that flare up every now and then, and I need to get a pap smear every 3 months due to a recent scare. So acupuncturists, chiropractors, internists, rheumatologists, and gynecologists must all be within easy reach for me.

- How much would you pay to have the choice of seeing a doctor or specialist directly (granted s/he is within network) instead of being restricted to managed care partners?

- Do you have experience with Blue Shield in Los Angeles? Have you found differences in quality of care between their HMOs vs PPOs?

- Lastly, do you have Blue Shield HMO/PPO in Los Angeles and love your primary care physician, rheumatologist, internist, acupuncturist, chiropractor, gynecologist, etc.? Please do share!

I'm currently on a HealthNet HMO and recently, the pain of going back to my Primary Care Provider (PCP) to get a referral for a specialist every time and hopping from laboratory to imaging center and back for diagnostics has been agonizing -- but it might've been agitated by a long commute and the fact that multiple issues compounded at once.

I'm electing healthcare on my own for the first time as a young professional (just aged out of my parents' plan -- big ups to Obama for a good, extended run) and confronting the paradox of choice. I'd appreciate ANY advice. Thanks so much!
posted by doctordrey to Health & Fitness (23 answers total)
If I had debilitating pain with no known cause, it would be worth the $1000 to have the PPO.
posted by superfille at 8:35 PM on June 19, 2014 [10 favorites]

I would go with the PPO in your case. In my experience it's more flexible and easier to deal with. Even if it's more money, you get what you pay for.
posted by bleep at 8:36 PM on June 19, 2014

I have two chronic illnesses and I actually made the decision to go entirely off my company's health insurance and pay for it myself because (in no small part) of the lack of choices on my company's available plans. It costs me more in some ways but less in others (believe it or not, my medications on my company's plan cost me more than my premiums on my own), so I'd say pay the extra for your piece of mind.
posted by xingcat at 8:37 PM on June 19, 2014

I gotta say, as an Angeleno, that Blue Shield in LA really seems to be easy. (Caveat: did they resolve their issues with UCLA?) There are a lot of providers to choose from here. I'd go HMO.
posted by BlahLaLa at 8:39 PM on June 19, 2014

Chronic illness or weird stuff that has yet to be diagnosed says suck it up and pay the extra money, imo. If you can afford the PPO, do it.
posted by MeghanC at 8:40 PM on June 19, 2014 [3 favorites]

I've got metastatic breast cancer. Before it was diagnosed properly, there were about 5 different doctors involved - my primary doctor who is also a pulmonologist, an allergist, two different ENTs, a liver specialist, and my oncologist. If I had had to get a referral for every new doctor I had to see I would have gone out of my mind. If you are symptomatic with no diagnosis yet, pay the extra money - the reduced hassle will be worth it. Hope you're feeling better soon.
posted by deliciae at 8:41 PM on June 19, 2014

I had practically no health issues before age 35, but the one time my employer (who changed insurance providers and plans annually) switched us to an HMO, I was miserable, because my primary care and OB/GYN weren't in the plan. Since 35, I've had oodles of medical issues, and the comfort of continuity of care with physicians who I knew, liked and valued could not be overestimated.

Instead of thinking of this as $1000, can you think of this as $83/month? Is this an affordable monthly expense for your peace of mind?
posted by The Wrong Kind of Cheese at 9:09 PM on June 19, 2014 [1 favorite]

Not having to get referrals for a specialist every time I go is worth way more than $1,000 to me personally.
posted by elizardbits at 9:12 PM on June 19, 2014 [2 favorites]

Definitely PPO. Mysterious, debilitating, chronic pain could be difficult to unmystify and treat. You will need a good doctor, who you trust and (maybe) whose comfortable going out on a limb to order non-standard tests or treatment. You might get this with an HMO, but the more choices you have (PPO) the more likely you'll find this.
posted by pennypiper at 9:18 PM on June 19, 2014 [1 favorite]

I say this as a very cheap person--go PPO, all the way. I recently switched to HMO and I am sorry I did. It is a pain in the butt to get referrals. My relationship with my PCP has fallen through due to their lack of competence with regards to some pressing health issues, which means right now I'm stuck in between-doctor limbo because old PCP is out but I can't get treatment until my new PCP has time to see me. If you have any kind of chronic health issues you will definitely want the flexibility. After my HMO experience I will never choose it again.
posted by schroedinger at 9:53 PM on June 19, 2014

Yes I would absolutely pay an extra 1k for PPO. Even in LA.

I am Blue Shield ish but I'm pretty new to LA and it's actually the Utah Insurance Exchange version of California-friendly coverage, so it's weird and I don't know much except that I'm 42 and I have always regretted the years I've been on HMOs.
posted by Lyn Never at 10:03 PM on June 19, 2014

Yes. I'm on anthem blue cross in Los Angeles, and I was on the HMO, but switched to the PPO and I'm much happier. It can be hard to find specialists who are in-network sometimes, especially well-reviewed specialists. Plus not having to get a referral from my PCP (who is great but can be a 2 week wait for appointments) is a relief. If you can manage the extra cost then definitely pay for it. A friend who was on the same insurance as me needed a rheumatologist and there was almost no choice for her on the HMO.
posted by Joh at 10:27 PM on June 19, 2014

doctordrey: "I have mysterious, debilitating, chronic joint pain all over (undiagnosed as of yet), a couple car accident-related injuries that flare up every now and then, and I need to get a pap smear every 3 months due to a recent scare. So acupuncturists, chiropractors, internists, rheumatologists, and gynecologists must all be within easy reach for me."

The stress and timesuck of getting referrals when you know you'll need to be a regular patient of "specialists" for known issues would have me screaming. I pay the extra without blinking, because I've got a few non-optional extra docs in my stable right now.

Add in a yet-undiagnosed situation...I think you'd be crazy to not pay the extra if you can possibly afford it.
posted by desuetude at 10:28 PM on June 19, 2014

Yes, I would pay it if I could afford it. BTW, I had severe joint pain for many years. Turned out to be a peanut allergy. Once I stopped eating peanut butter every single day, the pain slowly went away. It took going to a doctor of my choosing, who I had heard about from a friend, to get the test that I needed.
posted by myselfasme at 10:47 PM on June 19, 2014

In your case the PPO is probably worth it so you can continue to work with the doctors that you already have an ongoing relationship with, and know you.

For an average 26-year-old, the HMO would probably be preferable. That's because the average 26-year-old probably doesn't have a doctor, and, at least if they're anything like me, won't be assed to find one either, so being assigned one isn't losing anything -- hell, it's a service. But it doesn't sound like that's you.

I'd go with the PPO and cross your fingers that your providers are all in-network so you can continue to use them.
posted by Kadin2048 at 11:12 PM on June 19, 2014

I have chronic health issues and have to see a specialist a lot, as does my husband. We are on an HMO because it has no deductible, whereas our PPO options all had deductibles, and with our health issues, we would have to pay that deductible every January. In other words, for us, the difference in cost between the HMO and PPO wasn't just the difference in premiums, but also that $500 deductible on the PPO that we don't pay on the HMO. So that's another thing to consider when comparing plans.
posted by hydropsyche at 5:01 AM on June 20, 2014 [1 favorite]

Thanks to Obamacare, I was able to switch from a HMO to a PPO and am so glad I did. It's so much easier to see specialists and get minor but nagging issues looked at rather than having to beg my PCP for a referral and then wait and wait.
posted by Rosie M. Banks at 6:00 AM on June 20, 2014 [1 favorite]

I used to work for a major med center for a scheduler at a top notch university. This individual is solely devoted to bringing a group of physicians and their attendants together at one time to work on a patient. It's a grueling job, let me tell you. One key element in the process, after all the coordination was mine. After all the diagnosing and coordination, the task fell to me to call the patient's insurance to secure approval for the procedure. I had to call someone in another city who had never seen the patient, who worked for the insurance company, get them to review the file, and secure approval. Many times, the insurance employee would relegate the procedure to "cosmetic" or "not essential". It was terrifying to me that an advocate of the insurance company could execute this kind of long distance power of the patient's health, really, without the patient realizing it. If the insurance company employee denied it, the whole process stopped. Let me just say that Blue Cross PPO was the best at supporting the patient's needs in my experience. I hope this is helpful.
posted by effluvia at 7:06 AM on June 20, 2014 [1 favorite]

When you say $1000 more are you only referring to the increase in premiums or are you also taking into account the deductible and the co-insurance?

One of the bonuses of an HMO is that care is pretty much 100% covered usually. If UCLA is considered in-network on your HMO (and it was when I was on a southern California blue cross HMO plan) then you will have access to some amazing doctors and care in all specialties so I wouldn't discount the HMO too quickly.
posted by magnetsphere at 7:10 AM on June 20, 2014

Check to see if your doctors are on the cheaper plan. If they are, then it might be just fine.
posted by theora55 at 7:20 AM on June 20, 2014

Are you new to LA, or new to this particular insurance?

If you're new to LA and trying to find the best doctors to treat your various conditions, I would go with the PPO, until you feel like things are a bit better under control, and maybe consider switching to HMO at your next open enrollment.

If you're new to this insurance, I would poll my existing doctors and find out who is taking HMO and who isn't. Then decide if the extra cost (remember, that's $1K/year, PLUS higher co-pays and higher out-of-pocket for bigger procedures) is worth sticking with that particular doctor.

We have Blue Shield of CA HMO (acutally, we have POS but try to use HMO when we can); for well-checks and general sick visits (like an ear infection) HMO is just fine, but not better than that. For larger issues, like hubby's chronic back pain, the HMO sucks in that they've made him jump through some hoops in terms of needing to see his primary in order to get referred to an orthopedic specialist and a surgeon (who then were sucky doctors and he didn't pursue getting care from). We've ended up going PPO and even straight out-of-pocket, but at least we had the chance to start with the cheaper option.
posted by vignettist at 9:48 AM on June 20, 2014

I would pay an extra $1000/year for a health plan which just told me what to do and didn't make me pick from a list of hundreds of indistinguishable doctor choices, none of whom I have any meaningful way of evaluating. If I'm sick or in pain the last thing I want in the way of getting help is a big complex research problem.
posted by Mars Saxman at 1:08 PM on June 20, 2014

PPO for sure. After being diagnosed with some pretty rare health stuff and spending hours pouring over the PPO and HMO booklets, I discovered that there are a lot of health conditions that HMO's SIMPLY WILL NOT COVER. Which is really sneaky because you only find out if you read the 50+ pages of footnotes.

Also, because I am able to search for in-network providers on both HMO and PPO, I discovered that HMO options suck. I.e. searching for physical therapists within a 10 mile radius gives me 20 on the PPO, but just 2 on the HMO.
posted by puertosurf at 4:27 PM on June 20, 2014

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