Having experienced access to care inside the Kaiser system and outside the Kaiser system I have to say that with the integrated approach that Kaiser has accessing care is easier, getting Kaiser to cover care is easier. Outside of their HMO, with standard PPO care it's a veritable morass of insurance portals, individual doctor portals, no shared medical files so you end up having to request medical records, and send them to each provider individually and for prescriptions... With Kaiser if you need it, you go to the pharmacy at the facility where your doctor is and odds are they'll have it for you. There's no need to "shop around" or wait for a prescription to be transmitted to CVS, Wal-Mart, your local grocery store, etc. It's just there. You have full access to your complete medical record and test results online at any time. My family always received top-notch care and from what I've seen now that I'm on the outside (F's for Cigna), it's just a better way to do medicine.
That said, my experience and my family's is from Kaiser Permanente Southern California (San Diego).
Second that. I was covered by Kaiser for more than 10 years. It really is a great provider. You just show up to a clinic and everything is there - all the specialists, doctors, labs all under one roof. They have all the records already, everyone in the chain can see each others notes, lab results etc.
Yeah with my plan I don't have access to outside doctors, so far however I didn't need them.
I've been with Kaiser in Northern and Southern California. But not really with other HMOs.
I think the difference is Kaiser (in most places) is really a closed system; if you're with Kaiser, you go to Kaiser facilities for everything, as long as you're in the service area. If you're not with Kaiser, you don't go to Kaiser facilities, other than the emergency room maybe. Everyone you interact with is a Kaiser employee or contractor. You don't get recommended care that won't be covered, you don't get treated by someone who isn't in network, you show up, you pay your copay, and that's it, you're done.
For HMO plans with other providers, it seems like the doctors are often independent; you have to stay in network, but you still have to deal with network BS like this office is in network, but only some of the doctors. There's not a Blue Shield medical center with doctors, specialists, and a pharmacy at one location.
My personal perspective: I am a Kaiser member (California) and I love it. It is extremely simple to deal with: if I ever feel sick, I show up at a Kaiser facility and pay a $10 co-pay. If I need tests, I walk down the hall and pay a $20 co-pay. There is no billing, no headache, no mess. Everything is in one facility and integrated. The doctors, nurses, and NPs seem competent, if somewhat busy.
That said, I've heard that people with rare and specialized conditions have a harder time navigating the Kaiser system, but I'm not sure that it's any worse with other healthcare systems.
Overall, it has made me a believer in the HMO model when properly executed. And it appears that it takes complete integration for it to work right: the joy of Kaiser is having everything in one building and managed through one system.
One reason I like the Kaiser HMO system... Everything is under one umbrella. If a doctor approves a test, the system will cover under the plan agreement. I can take 1 test or 50 and it is all covered at a small copay per visit. And specialists are within the system. Last time I needed a specialist, my doctor looked up one in the system and told me there is an open slot in a few hours so he can book me. And once you establish tie with a doctor, you can email them for advice, prescription renewal anytime. For very simple problems, I just email the doctor my concern and maybe a picture and they may prescribe something if it doesn't need an office visit. All at zero cost.
There are still a occasional billing hiccups but the big tradeoff is that I can only visit the Kaiser hospitals except if I'm traveling and have an emergency.
I have Kaiser. It's vastly simplified because the people paying for my care are the same people who are providing my care. They also seem to have a real "get you up and running so you can get back to work" kind of attitude, which meshes well with my own values.
I mean, consider for a moment how much of a pain in the ass it is to get an insurance claim on your house or your car or whatever filled. Multiply that by the complexity of medicine, and... yeah. You can see how it would get complex fast.
Maybe this is an area where horizontal integration is the order of the day?
Honestly this is why I really like having Kaiser as my insurance provider (for those who don't know, Kaiser is an HMO that is both the insurance provider AND the hospital/doctors office/pharmacy. You get all your care from them).
Some people don't like not having choices for doctors, but I would much rather just have one system to deal with. I don't have to print out medical records like I have to for my wife and kids (they are on a different plan), or call a bunch of different providers to find care, or go back and forth as two different providers say the other side is the one that has to do anything. I never have to argue with my insurance provider about paying for something, I never have to wonder if something will be covered.
It really is a comprehensive system that rewards providers based on outcomes.
When you have a medical emergency, you’re covered. It’s pretty simple.
In PPO systems, you’re always fighting to understand when you are covered, at which hospital, by which doctor, using what machine. Sure there is choice, but how often do you actually have an informed opinion on what expert can best help you with whatever is happening to you in the moment?
With an HMO you either go into any hospital in an emergency and it’s covered for emergency care, or you go to one of their hospitals if it’s not an emergency. Very simple.
In my experience the level of care is great and everyone is actually trying to make sure you have the best outcome.
It's not always like that. There are insurers like Kaiser that are vertically integrated that make the whole experience much smoother. At my last checkup, my doctor gave he an immunization, ordered blood tests and prescribed medication. The blood tests and pharmacy were both in the same building, so I just had to make two stops on my way out of the building that took an extra ~15 minutes. The immunization and checkup were covered by my insurance and I paid my copay for the blood work and prescription up-front just before having my blood taken and getting my medication. It was all very affordable, quick and easy and I never saw a total bill. I only got a receipt for my copay.
I've never needed any major health care from them, but I have a parent that has had both hips and a shoulder replaced with Kaiser who had a similarly simple experience.
But the issue is still the same: the network of doctors you can see is very much restricted. And in any event, the way Kaiser is structured (at least in Southern California, where a friend is a Kaiser doctor), the doctors are employed by separate legal entities which contract with the hospitals. So it's kind of a distinction without a difference. HMO implies vertical integration where incentives line-up differently than when providers and insurers are more at arms length.
That said, PPOs also have in-network restrictions. They're looser, but PPOs are also often significantly more expensive.
In my limited experience, it's not the network restrictions per se, but that people want to continue going to a specific doctor or to a specific hospital. My relative who is a partner at a law firm rails against Obamacare because of the ridiculous premiums her firm has to pay. But they only pay those premiums because she demanded a policy that allowed her to continue seeing the same doctor she's seen for over 20 years. She's smart and almost always votes Democratic; the cognitive dissonance in her rants would be comical if it weren't for the fact that so many people exhibit that kind of thinking.
I use Northern California Kaiser and love it. For one thing, it's ridiculously inexpensive, all things considered. And I don't expect the kind of relationship with my doctor portrayed on television. Kaiser is very technologically savvy and data driven. (Though that doesn't mean they used the latest & greatest tech). Their doctors are disciplined to attend to patients efficiently. I've never felt rushed or anything of the sort (even during the 48 hour birth of my son), but neither the doctors nor staff will linger unnecessarily.
But because Kaiser works as a holistic entity, some people may feel neglected. Kaiser dis-intermediates you from the doctor and his personal staff. Appointments are booked on the web or via a call center. For illnesses, you first contact the Kaiser nursing call center, where a nurse and on-call doctor will do a preliminary diagnosis over the phone and often even write a prescription. For common injuries like sprains, etc, you might be scheduled to see a doctor at their sports injury center or similar specialized department, which at my medical center is conveniently (and I doubt coincidentally) located across the corridor from the imaging department. Follow-ups with a doctor will often use their electronic messaging system (basically, web mail).
I _love_ that aspect of Kaiser because I appreciate the effort that goes into reducing costs and improving outcomes. For people who want to feel coddled by their doctor and his staff, or use them as an outlet for their anxiety, it's probably a nightmare.
Maybe it's because Kaiser is more integrated than most providers, but that wasn't the case for me. I might've had to check in with separate receptions, but no actual paperwork
This is how a HMO works in the US and they are very popular due to lower costs than health insurance plans that allows you to go to any doctor/hospital of your choice. My experience with Kaiser in California is that they also provide better service in general, but sometimes don't have the specialty services you might need in their system.
With a PPO I can go to whatever specialist I want. With Kaiser you are stuck with the specialists Kaiser directly employes.
So if the Kaiser clinic by you is good then sure Kaiser is great. However if you ever want a second opinion or want to use a non Kaiser doctor your out of luck.
A PPO plan offers you freedom to choose what doctors you see. It will also enable you to go straight to a specialist without your general practitioners consent.
Kaiser is the only place I’ve seen where these things are seamless (still didn’t feel enough to keep them). Even CareFirst HMO doesn’t have that level of integration.
I too like Kaiser HMO. I have had PPO plans for 20 years before Kaiser but I prefer Kaiser because their routine stuff is very quick and well organized in my opinion and paperwork was nil. Now I have medicare, they send me an online bill for $0 every month. I had a major lung surgery with a week in hospital under PPO and I had $20k out of pocket expenses and a 2 inch thick stack of paperwork to figure out. I had another one day general anaesthetic gall bladder surgery under Kaiser that was very good IMHO.
Definitely not a fan of Kaiser. They're really restrictive and extremely good at avoiding proper treatment from what I've seen. With most normal HMOs you can at least see a variety of somewhat-independent doctors and some quite-independent specialists. It's easy to move around. I hate to recommend any insurance company but Blue Shield of California did okay for me.
I currently have Kaiser insurance. As an HMO, they integrate a lot of services, which has really helped save a lot of time for us (like using email to talk to a doctor, who calls the specialist, then replies, without making a visit).
However... when we do go in for a visit, I get the distinct feeling that there is a lot of pressure to keep appointments within a specific time interval and basically get patients in and out as fast as possible.
Overall though, the integration of doctors, specialist, labs, and hospitals does create a smoother and less stressful experience.
I use Kaiser Permanente as my health care provider. For those who aren't aware, it's one of the few "integrated care" providers in the U.S., meaning they act as both the health insurance and health care provider.
Now, Kaiser is FAR from perfect - they have their share of problems.
But....this sort of nightmare is not one of them. With Kaiser, doctors are free to prescribe whatever they think is medically necessary, and if they prescribe it, it's covered, guaranteed. There's no separate claims department.
Obviously there are some exceptions, like if it's an emergency and you need to get care outside of Kaiser and then submit a claim.
But, the vast majority of the time it just works.
Now, sometimes we aren't happy with what Kaiser offers. So then we go outside of Kaiser and pay out-of-pocket.
Our friends sometimes tell us we're crazy when we do that. We just spent $1200 out-of-pocket to see a specialist because Kaiser didn't want to refer us. What they don't realize, though, is that we saved $3000/year by choosing Kaiser over the next cheapest health insurance provider from our employer. So we're still coming out ahead.
And most importantly, we have the peace of mind knowing that any time we end up in a Kaiser hospital, we'll never once see a bill.
I think we really need more integrated systems like Kaiser. Imagine if there was actually competition in that space, where you could choose between competing hospital systems that came with complete integrated coverage, no middle man.
Kaiser has no specific preventative care requirements and does not withhold care if you are not up to date on some schedule. In fact Kaiser works pretty much exactly like any other HMO with the main difference being that insurance is in-house (but a different department, so insurance screwups still happen, but at least the hospital and the insurance are not constantly fighting each other with you stuck in the middle).
Well that and with Kaiser it's a lot easier to tell who is in network (they never commingle in and out of network care).
That said, my experience and my family's is from Kaiser Permanente Southern California (San Diego).
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