Tuesday, October 21, 2008

Pass it on

I've had an email forwarded to me several times and so I thought I would post the general response to the points it raises.

The responses below do not represent a comprehensive overview of the PEIP proposal, just a response to the points raised by the original email. For a comprehensive overview, I invite you to attend an informational meeting.

(Email with my points in bold and Italicised.)
1. You have to choose one clinic as your primary clinic. You have to go to only that clinic unless you have a referral from your doctor to go some where else. I know you can change what you list as your primary clinic so many times a year, but I don't know how many.

Yes, you have to choose one clinic as your primary clinic. You can change primary clinics monthly.

2. You need a referral to go to any other doctor (like a specialist of some kind) that isn't in your primary clinic. When I asked if that requires only one referral, I was told the doctor would have to list how many times you could see that other doctor. If you need to see the other doctor more times than was listed on the original referral form you would have to get another referral. It's not a blank referral that would say you could see them as many times as needed for a year. They have to list how many times that would be. I was told by Gundy at the union office that the reason referrals are required is because by doing that it cuts down on how many times people go to a specialist that usually costs more. -If you're like me, you want/need the freedom to go to doctors you choose without a referral. No one really knows when something will happen that will require a specialist or how many times they will need to go.

Actually, referrals are not needed for the 5 most commonly referred situations: chiropractic care, OB/GYN, chemical dependency care, mental health care, and vision care. Those 5 areas are self-referral. Other areas of care need a referral from a primary clinic and that referral is set for the number of times your medical doctor determines is appropriate. Actually, doctors have been trained to have the expertise to know what might happen when you experience certain symptoms and have a general idea of the method and frequency of treatments. .

Depending on the relationship your doctor has with you specialist and/or you the re-referral can happen a few different ways. The specialist calls your doctor after your last visit and says “Re-refer Patient A because I’m not done treating Medical Issue B.” The specialist sends you back to your doctor or the specialist asks you to phone your doctor and ask for the re-referral.

Whether Gundy is right or not, I can’t say. I do know the medical community is concerned with self-diagnoses. Perhaps this is a way to catch someone who believes they have one ailment soon enough to treat them successfully for the correct ailment so perhaps the referral system is intended to provide someone with the proper care.

2. The rate or tier you pay for all doctors you see (even those specialists you are referred to) depends on the rating your primary clinic has. This includes hospitals. Every place you go to you will pay according to the level/tier your primary clinic has been assigned. -The doctor I like to see for all my pre-op exams and other things is at a clinic that is rated a level 3. That means I would have to pay that rate when I go to any of my other doctors too. Currently my specialists have a lower co-pay than my regular doctor has. I'm thinking most people wouldn't want to be locked in to paying at the one level or tier that their clinic is rated. Of course, there is the option of changing doctors & naming a lower level/tier clinic as their primary clinic, but not everyone would want to change doctors.

This looks accurate for this person’s situation. Co-pays, etc. are rated by the Tier your primary clinic is in. Just over 80% of the clinics in the PEIP network are Tier 2 clinics but clearly that leaves 20% of the clinics to be Tiers 1, 3, or 4.

4. The co-pay cost for same day surgery or hospital stay surgery is higher. - Here is how it works for the Health Partners Distinction plan . Currently if I have surgery and stay in the hospital I pay nothing for a co-pay at a level 1 hospital and $250 for a level 2 hospital. On the new plan I would have to pay $450 for an inpatient surgery because my primary clinic is considered a level/tier 3 clinic. Currently if I have outpatient surgery I pay a $25 co-pay at a level 1 hospital and $50 at a level 2 hospital. On the new plan I would pay a $220 co-pay for any hospital outpatient surgery due to the classification of my primary clinic. I realize that might not be the same for everyone depending on what rating their primary care clinic is given, but it's something to think about. None of us know when we will need surgery. I had hardly been to a doctor until I retired and found out I had b.c..

These numbers are true for someone in the Distinctions plan. Here are some other numbers that would be applicable comparisons from Distinctions to Advantage as well: Chiropractic care: $30 (with Wellness Initiative) vs. $27. Ambulance: 80% coverage vs. 95% coverage. Prescription drugs: $12 for generics vs. $10, $24 for brand name vs. $16, non formulary NOT COVERED vs. $36, OutOfPocket Max: NONE vs. $800. A comprehensive comparison reveals savings and costs from both plans, which would apply differently to different people.

I do appreciate that she realizes that this is not the same for everyone. In addition to everyone’s unique set of circumstances, there are about 1,200 people who don’t take Distinctions. Ultimately everyone must do what this person did and that is study it from their own vantage point to determine how they feel about the potential of switching to PEIP from the district health insurance pool.

5. The difference in monthly cost between the Health Partners Distinction plan we currently have and the higher level of the public employee plan is $31.89 for one person, $72.02 for a single + 1 plan, and $90.51 for a family plan.
I'm wondering if you're like me and feel the advantage of going to any doctor you want without a referral is worth the small additional cost. The referral part alone makes it worth it to me. All it takes is 50% + 1 vote to switch to the public employee plan so everyone's vote really counts.

The difference in monthly costs is accurate. However, one person’s couch change is another’s college savings account. It is difficult to tell a member with an $11 pay check after health insurance expenses that $32, $72, or even $90 isn’t worth it. It is equally difficult to tell someone scared that their cancer will re-emerge that it’ll all be fine.

Clearly access to affordable and high-quality health care is important to everyone or we wouldn’t have spent so much time at so many membership meetings in the last 3 years on this subject. It is also clear that some members want access and quality so affordability isn’t an issue to them. It’s also clear that some members want quality and affordability so access is less of an issue to them.

In the aggregate, we need to work toward a balance of access, affordability and quality that meets the needs of our members. We have been trying to do that through our legislative advocacy, our bargaining team work, and through investigating the Public Employee Insurance Program (PEIP).

Every vote is important. However, this vote continues our discussion on a suitable solution to affordable, accessible, and high-quality health care, it does not finish it. Our bargaining teams' work needs to continue and our legislative advocacy needs to continue as well.

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