It’s open enrollment time. And selecting a health plan is a decision you may need to make, perhaps leaving you baffled and confused to hear some of the frustraing and unrecognizable health care lingo. HMO, PPO, EPO—what do they really mean? How do they differ? How can you quickly select what is right for you and your family? The acronyms certainly don't help!
Comparing and contrasting the copays and monthly premiums may not necessarily be the best method of decision making. Some plan differences may be subtle and not significantly affect the care you receive or your pocket book. But other features of these plans can be actually substantial, costing hundreds to potentially thousands of dollars a year if you are not careful.
So it’s vital to learn exactly what you are selecting for you and your family. Let's learn about the most common types of health plans and how to discern what is more appropriate for you.
There are various plan types, but most plans belong to one of the following three groups:
HMOs = Health Maintenance Organizations
HMO plans are often less costly than typical PPOs, but not always. The goal here is to keep cost down for both patients and the health care organization. The physicians are encouraged to practice using evidence-based medicine and to avoid ordering unnecessary tests, especially if their costly orders would not change the doctor’s plan and outcome for the patient. .
For instance, MRIs are one of the most costly tests available. But patients sometimes request, let’s say a knee MRI to simply “know” if there’s a ligament or meniscal tear. But unless the patient is contemplating surgical options, an MRI does not provide useful information in many instances and doesn’t change the outcome. I’ve discussed the outcome of a study that showed that sham meniscal surgical repair is comparable to a real one. Check out that article to learn the details. In a nutshell, whether there’s a tear or not, surgery is not always the best or necessary option and patients seem to do just as well in the long run if they opt for conservative therapy, such as physical therapy and the tincture of time.
Hence, doctors employed by an HMO are encouraged to practice evidence-based medicine, which decreases unecessary tests and helps keep costs down for everyone.
In an HMO setting, your Primary Care Physician (PCP) becomes the most integral and central person involved in your health. You will need referrals sent by your PCP for all specialists. But patients do not always know when/if they need a particular specialist. And even if they do, they don’t always know who to go to. So this referral requirement is typically not a decision breaker. For instance, if your blood test reveals that your kidney functions are mildly diminished, patients don’t always need a specialist right away. Your PCP knows at what point you should seek specialist care. Or if you have a new rash, there’s often no need to see the dermatologist—primary care doctors are typically well-trained in dermatology and they see and treat common skin conditions every day.
HMO patients are required to stay within a network of providers, otherwise you will need to pay, often fully out-of-pocket. Therefore, if you are under a particular specialist’s care and you would like to continue to see the same doctor, if they are not part of the HMO network, you will be required to switch your care to an in-network specialist.
Sometimes a referral for some preventative services may not be required—for services like pap smears and mammograms, for instance. OB/GYN referrals are often unnecessary as well, so if you are pregnant, you can directly schedule an appointment with their department.
Doctor copays are standard within an HMO: one to see your primary care doctor and one for any specialist. And the more the patients utilize the system, the higher the expense for the medical group. Therefore, the goal with an HMO model is to keep you as healthy as possible in order to decrease the utilization of healthcare and hence keep costs down.
PPOs = Preferred Provider Organizations
PPO plans provide a little more flexibility, at least in terms of referrals, which are not required by your PCP. You can simply call to schedule an appointment with a specialist of your choosing. But be certain they accept your health plan first, because there is often still a preferred network of doctors. But patients can go outside of the network for a higher copay and/or share of cost if they choose to.
As a result, PPO’s are often more costly. Out-of-pocket costs are typically higher with PPOs, and understanding what your deductible and copays for office visits, labs, and tests are crucial. Think of it more as a “fee for service” model, in which providers and/or the medical group they are employed with get paid per procedure and office visit. More procedures and services mean higher compensation.
EPOs = Exclusive Provider Organizations
EPOs are a hybrid of a PPO and HMO, incorporating features of both. The essence of an EPO is to require patients to stay within a network of providers like an HMO, but they do not need a referral to see those doctors within that same network.
So, what should you think about when choosing between these three plans?
4 Tips to Help You Choose a Health Plan:
1. As the very first step, estimate how often you will need office visits, labs, imaging, etc. If you have chronic health conditions, like diabetes or COPD, that require more frequent visits and services, then a plan with a lower copay, but perhaps with a higher monthly premium, may be more optimal. If you are healthy and see the doctor perhaps only once or twice a year, it may be more prudent to select a plan with higher copays but lower monthly premiums.
2. Review your med list and the corresponding copays for each and compare it to the various formularies of the plan options. This one small step can save you a lot of money. Because health plans have their own "formularies," or preferred medications. Therefore, comparing and contrasting cost of each of your emdications, especially if you are on a brand rather than a generic drug, can be essential for your wallet.
3. If you have a specialist you particularly like, research if they accept the plans that available to you. This may be a deal breaker for some.
4. You can always forgo your employer’s plan and opt for an affordable care act plan instead. I am always surprised to hear that patients are not aware of this choice. Sometimes Obamacare is less costly. Go to your state’s corresponding affordable care act web site to compare—they often give you quotes after a few simple questions.
If you have a specialist you particularly like, research if they accept the plans that available to you.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
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