Most people are faced with the choice of HMOs, PPOs, or individual coverage. Can the choice you make have a direct impact on your health? The sad truth is, “Yes, it can.” That’s why it’s so important you understand your choices. And that’s why we want you to understand the choices we’ve made at Diagnostic Clinic.
We have not jumped on the “managed care” bandwagon. Unlike many others, we still think of our medical professionals as doctors and nurses and not “providers.” Even more important, we treat patients like people and not “plan participants” or “covered lives.”
Does this distinguish us in today’s health care environment? Yes, and it is a distinction we are committed to maintaining. Managed care — in many of its forms — is in direct conflict with our beliefs and practices.
The most restrictive form of managed care is Health Maintenance Organizations, or HMOs. HMOs encourage “providers” to see a large volume of patients, severely shortening the time a doctor can spend with each one. HMO cost-saving practices such as limiting specialty referrals, tests, hospitalizations, as well as the delays patients often encounter in HMO systems, may have serious health consequences.
We share a practice philosophy, which includes spending ample time with each patient and performing all necessary tests as soon as possible. We also share the belief that financial deals should not influence medical care. For these reasons, Diagnostic Clinic has chosen not to participate in any HMOs.
A second, less restrictive form of managed care is PPOs, or Preferred Provider Organizations. PPOs allow patients to see certain physicians at a reduced cost. Diagnostic Clinic does participate in a limited number of PPOs based on their flexibility and freedom to provide care in a manner consistent with our beliefs. We review these plans yearly as the rules and participants seem to change. Based on that review we decide whether to stay on as members of that plan.
At Diagnostic Clinic, the most important choice we’ve made is to always provide attentive, comprehensive, quality health care to patients who choose to walk through our doors.
Current List of Insurance Plans
Our physicians participate in the following plans:
- Aetna Healthcare
- Blue Cross/Blue Shield of Texas – Blue Choice and Par Plans
- Cigna
- Great-West Healthcare – PPO, HMO, & POS
- Humana ChoiceCare
- Humana Preferred
- Louisiana State Office of Group Benefits PPO
- Medicare (Original)
- Multiplan PPO (includes Up&Up)
- PHCS (Private Healthcare Systems)*
- PPONext
- Railroad Medicare
- United Healthcare (except Methodist Hospital Group)
An In-Depth Discussion of Managed Care
How does all this impact you, the patient?
- You may have a medical condition that is more serious than can be realized during a rushed office visit.
- You may wish to see your PCP, but the wait is very long. Typically, you cannot see another PCP, just the one designated as yours.
- You may be limited to seeing a nurse or physician’s assistant.
- Your PCP would like to refer you to a specialist, but the system results in prolonged waits or delays.
- Your PCP or specialist determine that further diagnosis/testing is needed, but the HMO may refuse. (You have limited ability to appeal this decision.) And, in most states, the HMO is not liable for this decision.
- Your doctors agree you need ongoing treatment, but it may not be allowed due to costs.
- Because you cannot get in to see your PCP when illness or injury occurs, you may go to an emergency room for something that is considered a non-emergency–and end up with an additional bill.
Some HMOs have responded to patient complaints by introducing a POS (Point of Service) option. Plan participants can opt to pay increased fees to see any physician without PCP approval. Patients may be responsible for increased costs for tests and hospitalization not recommended or ordered by the PCP.
Diagnostic Clinic does not participate in HMOs because they conflict with everything we believe about putting patients first. We are ethically opposed to allowing financial arrangements to influence medical care.
Another form of managed care is the PPO, preferred provider organization. In PPOs, patients may see physicians included on a set list for a set price. These physicians are considered “in network”. This is different from the traditional deductible and copayment arrangements on visits to physicians of your choice, or “out of network”.
Physicians agree with PPOs to accept a preset discount from their usual charges or agree to a predetermined rate schedule. Some physicians see more patients to offset the discounted rate. However, if physicians participate in too many PPOs and patient loads get too high, they may spend less time with patients, possibly compromising the level of patient care.
Diagnostic and Interventional Nephrology of Houston does participate in a limited number of PPOs–but only those which allow us to provide care that is consistent with our core philosophy. Because PPOs constantly change their fee schedules and ownership changes are not unusual, Diagnostic and Interventional Nephrology of Houston regularly evaluates these plans and our association with them. The needs of our patients will never be compromised and will always take priority in any decisions we make.
Managed Care Glossary
Bonus Pool
Extra money provided to physicians who spend less on his/her assigned patients’ health needs than a preset target.
Capitation
The practice of paying a fixed sum per assigned patient per month to a physician who is expected to provide all required care for that patient.
Gatekeeper
see P.C.P.
H.M.O.
Health Maintenance Organization
Nurse Practioner
A trained nurse who evaluates and treats patients.
In Network
See P.P.O.
Out of Network
See P.P.O.
P.C.P.
Primary Care Physician: The physician responsible for coordinating all of the care of his/her assigned patients. This physician typically receives a capitated payment and is subject to withholds for exceeding projected expenses.
Physician Assistant
A trained person used to evaluate and treat patients.
P.O.S.
Point of Service Option: An insurance plan option utilized by some HMOs to allow patients to see physicians outside of the HMO for an increased cost.
P.P.O.
Preferred Provider Organization
Withhold
Money withheld by an insurance company from a physician’s fee to cover exceeding preset cost targets. Withholds can be for several different targets and may be based upon pharmacy costs, laboratory or xray testing, emergency room visits, hospitalizations, surgeries, or consultations to name just a few.