HMO vs PPO

Question

I understand the differences between PPO and HMO coversage. However, what is the real "scoop" from HIV patients. Is HMO really that bad from your experiences in this area?

How about PPO?

Can you give a recomendation based on your experiences(blue shield, blue cross, which is best from the HMO perspective?)

Thank you very much

Answer

All insurance can be problematic. It's a money making venture. The managed care philosophy invades both plans and its goal is to keep costs down to save the carrier money. However, my experience is that HIV is being treated successfully by both. I've also heard horror stories with both. The major battles over treatment coverage have been fought and won. While new battles arise, the industry is more receptive to our concerns and needs.

The HMO system can be complicated and frustrating, but it is the cheapest for the patient. Most employers only provide HMO coverage, so it is what most patients have to deal with. In my experience, there are no really bad HMOs in terms of HIV treatment. They are all provide comparable coverage. It's the contracted medical groups and Primary Care Physician (PCP) that are the real issue. They hold the initial level of power to approve or deny treatment/referrals to specialists. The most important factor with an HMO is having an experienced HIV doctor who can work through the system hurdles for the patient. It's best to consult your physician as to which s/he prefers working with in terms of B+ versus BS. Often this comes down to rates and payment processing times.

PPO's provide the most flexibility and potentially wider access to HIV experienced doctors. The out of pocket expense can be high, but having the freedom to go to any doctor can be worth it. Again, it's your HIV doctor that is the main issue in working through this system as well. Usually, this system is less complicated for your doctor and he receives a higher payment.

Unfortunately, this decision is not easy and often the financial considerations are the deciding factor. Regardless of the plan, my happiest clients are those with good doctors who know how to work the system.