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Good health care. You want it. Where, how, do you get it? The question is puzzling because so many changes are taking place in medicine and medical insurance. www.mccormacks.com
The “operations” of a few years ago are the “procedures” of today, done in the office not the surgery, completed in minutes not hours, requiring home care, not hospitalization.
Large insurance companies, through their health maintenance plans, are setting limits on what doctors and hospitals can charge, and — critics contend — interfering with the ability of doctors to prescribe what they see fit. The companies deny this, arguing they are bringing reforms to a profession long in need of reforming. Many hospitals have merged, the better to avoid unnecessary duplication and to save money by purchasing supplies and medicine in large amounts.
Universal health insurance having failed to clear congress, about 45 million Americans are not covered by any medical plan. Unable to afford medical bills, many ignore ailments and illnesses.
Recently, however, for the elderly, the feds passed partial funding for drugs. www.mccormacks.com
This chapter will give you an overview of Northern California health care and although it won’t answer all your questions — too complex a business for that — we hope that it will point you in the right directions.
Napa has two “community” medical centers, Queen of the Valley in Napa City and St. Helena at Deer Park. Just over the south border, in Vallejo, are two medical centers that serve many Napa residents, Kaiser and Sutter.
The Napa County government runs a clinic and contracts with Queen of Valley and possibly other medical centers for care for the poor and low-income. For information about county clinics and services, (707) 253-4227.
Napa has two other medical centers that offer special care not available to the general public: the Veterans Home in Yountville (for elderly veterans) and the state hospital at Napa, (psychiatric).
For most people, health care is twined with insurance, in systems that are called “managed care.” But many individuals, for a variety of reasons, do not have insurance. www.mccormacks.com
This is a good place to start: with nothing, all options open. Let’s use as our seeker for the best of all health care worlds — on a tight budget — a young woman, married, one child. Her choices:
No Insurance — Cash Care
The woman is self-employed or works at a small business that does not offer health benefits.
She comes down with the flu. When she goes into the doctor’s office, she will be asked by the receptionist, how do you intend to pay? With no insurance, she pays cash (or credit card), usually right there. She takes her prescription, goes to the pharmacy and pays full cost.
If her child or husband gets sick and needs to see a doctor, the same procedure holds. Also, the same for treatment of a serious illness, to secure X-rays or hospitalization. It’s a cash system. www.mccormacks.com
Medi-Cal
If an illness strikes that impoverishes the family or if the woman, through job loss or simply low wages, cannot afford cash care, the county-state health system will step in.
The woman fills out papers to qualify for Medi-Cal, the name of the system (it’s known elsewhere as Medicaid), and tries to find a doctor that will treat Medi-Cal patients.
If unable to find an acceptable doctor, the woman could turn to a county hospital or clinic, if one is available. There she will be treated free or at very low cost.
Drawbacks-Pluses of Medi-Cal
County hospitals and clinics, in the personal experience of one of the editors — who has relatives who work at or use county facilities — have competent doctors and medical personnel. If you keep appointments promptly, often you will be seen with little wait. If you want immediate treatment for, say, a cold, you register and you wait until an urgent-care doctor is free. www.mccormacks.com
If you need a specialist, often the county facility will have one on staff, or will be able to find one at a teaching hospital or other facility. You don’t choose the specialist; the county physician does.
County facilities are underfunded and, often, inconveniently located — a major drawback. Some counties, lacking clinics and hospitals, contract with adjoining counties that are equipped. You have to drive some distance for treatment.
County hospitals and clinics are not 100 percent free. If you have money or an adequate income, you will be billed for service. Some county hospitals run medical plans designed for people who can pay. These people can ask for a “family” doctor and receive a higher (usually more convenient) level of care. www.mccormacks.com
Let’s say the woman lacks money but doesn’t want to hassle with a long drive and, possibly, a long wait for treatment of a minor ailment. She can sign up for Medi-Cal to cover treatment of serious illnesses, and for the colds, etc., go to a private doctor for treatment and pay in cash, ignoring Medi-Cal.
There are many ways to skin the cat, and much depends on circumstances. For the poor and low-income, Medi-Cal is meant to be a system of last resort.
Medicare— Veterans Hospital
If our woman were elderly, she would be eligible for Medicare, the federal insurance system, which covers 80 percent, with limitations, of medical costs or allowable charges. Many people purchase supplemental insurance to bring coverage up to 100 percent (long-term illnesses requiring hospitalization may exhaust some benefits.) Medicare is picking up more drug bills.
If the woman were a military veteran with a service-related illness, she could seek care at a Veteran’s Administration clinic or hospital. www.mccormacks.com
Indemnity Care
Usually the most expensive kind of insurance, this approach allows complete freedom of choice. The woman picks the doctor she wants. If her regular doctor recommends a specialist, she can decide which one, and if she needs hospital treatment, she can pick the institution. In reality, the choice of hospital and specialist will often be strongly influenced by her regular doctor but the patient retains control. Many indemnity plans have deductibles and some may limit how much they pay out in a year or lifetime. Paperwork may be annoying. www.mccormacks.com
Managed Care
This divides into two systems, Preferred Provider Organizations (PPO) and Health Maintenance Organizations (HMO). Both are popular in California and, if your employer provides health insurance, chances are almost 100 percent you will be pointed toward, or given a choice of, one or the other.
PPOs and HMOs differ among themselves. It is beyond the scope of this book to detail the differences but you should ask if coverage can be revoked or rates increased in the event of serious illness. Also, ask what is covered, what is not. Cosmetic surgery might not be covered. Psychiatric visits or care might be limited. Ask about drug costs and how emergency or immediate care is provided. www.mccormacks.com
HMOs have a spinoff: called Point of Service (POS).
Preferred Provider
The insurance company approaches certain doctors, clinics, medical facilities and hospitals and tells them: We will send patients to you but you must agree to our prices — a method of controlling costs — and our rules. The young woman chooses her doctor from the list, often extensive, provided by the PPO.
The physician will have practicing privileges at certain local hospitals. The young woman’s child contracts pneumonia and must be hospitalized. Dr. X is affiliated with XYZ hospital, which is also signed up with the PPO plan. The child is treated at XYZ hospital.
If the woman used an “outside” doctor or hospital, she would pay extra — the amount depending on the nature of the plan. It is important to know the doctor’s affiliations because you may want your hospital care at a certain institution. www.mccormacks.com
Hospitals differ. A children’s hospital, for instance, will specialize in children’s illnesses and load up on children’s medical equipment. A general hospital will have a more rounded program. For convenience, you may want the hospital closest to your home.
If you need specialized treatment, you must, to avoid extra costs, use the PPO-affiliated specialists. The doctor will often guide your choice.
Besides the basic cost for the policy, PPO insurance might charge fees, co-payments or deductibles. www.mccormacks.com
Deductible example: The woman pays the first $250 or the first $2,000 of any medical costs within a year, and the insurer pays bills above $250 or $2,000. With deductibles, the higher the deductible the lower the cost of the policy. The $2,000 deductible is really a form of catastrophic insurance.
Conversely, the higher the premium the more the policy covers. Some policies cover everything. (Dental care is usually provided through a separate insurer.) The same for prescription medicines. You may pay for all, part, or nothing, depending on the type plan.
The PPO doctor functions as your personal physician. Often the doctor will have his or her own practice and office, conveniently located. If you need to squeeze in an appointment, the doctor usually will try to be accommodating. www.mccormacks.com
Drawback: PPOs restrict choice.
Health Maintenance Organization (HMO)
Very big in California because Kaiser Permanente, one of the most popular medical-hospital groups, is run as an HMO. The insurance company and medical provider are one and the same. All or almost all medical care is given by the HMO. The woman catches the flu. She sees the HMO doctor at the HMO clinic or hospital. If she becomes pregnant, she sees an HMO obstetrician at the HMO hospital or clinic and delivers her baby there.
With HMOs you pay the complete bill if you go outside the system (with obvious exceptions; e.g., emergency care). www.mccormacks.com
HMOs encourage you to pick a personal physician. The young woman wants a woman doctor; she picks one from the staff. She wants a pediatrician as her child’s personal doctor; the HMO, usually, can provide one. HMO clinics and hospitals bring many specialists and services together under one roof. You can get your eyes examined, your hearing tested, your prescriptions filled, your X-rays taken within a HMO facility (this varies), and much more.
If you need an operation or treatment beyond the capability of your immediate HMO hospital, the surgery will be done at another HMO hospital within the system or at a hospital under contract with the HMO. Kaiser recently started contracting with other facilities to provide some of the services that it used to do in its own hospitals or clinics.
HMO payment plans vary but many HMO clients pay a monthly fee and a small per visit fee. Often the plan includes low-cost or reduced-cost or free prescriptions. Drawback: Freedom of choice limited. If HMO facility is not close, the woman will have to drive to another town.
Point of Service (POS)
Essentially, an HMO with the flexibility to use outside doctors and facilities for an extra fee or a higher deductible. POS systems seem to be popular with people who don't feel comfortable limiting themselves to an HMO. They pay extra but possibly not as much as other alternatives. www.mccormacks.com
Tiered Plans
Because hospital stays make up a large part of insurance bills, insurers are shifting some of these costs onto employers and consumers. This approach divides hospitals, based on their costs, into three tiers or price levels. When a patient is admitted to a hospital, he or his plan pays extra, the amount depending on the tier rating.
Choices, more information
If you are receiving medical insurance through your employer, you will be limited to the choices offered. In large groups, unions often have a say in what providers are chosen.
Some individuals will base their choice on price, some on convenience of facilities, others on what’s covered, and so on.
Many private hospitals offer Physician Referral Services. You call the hospital, ask for the service and get a list of doctors to choose from. The doctors will be affiliated with the hospital providing the referral. Hospitals and doctors will also tell you what insurance plans they accept for payment and will send you brochures describing the services the hospital offers.
For Kaiser and other HMOs, call the local hospital or clinic.
A PPO will give you a list of its member doctors and facilities.
Ask plenty of questions. Shop carefully.
Here's some advice from a pro on picking a health plan: Make a chart with a list of prospective health plans in columns across the top.
Down the left side of the chart, list the services or attributes that you think are important. Review the health plans and check off the "important" services in each plan. Choose or investigate further those plans that have the most check marks. www.mccormacks.com
Common Questions
The young woman is injured in a car accident and is unconscious. Where will she be taken?
Generally, to the closest emergency room or trauma center, where her condition will be stabilized. Her doctor will then have her admitted into a hospital. Or she will be transferred to her HMO hospital or, if indigent, to a county facility.
If her injuries are severe, she most likely will be rushed to a regional trauma center, if one has been established. In Napa County, Queen of the Valley is the designated trauma center.
Trauma centers have specialists and special equipment to treat serious injuries. Both PPOs and HMOs offer urgent care and emergency care.
The young woman breaks her leg. Her personal doctor is an internist and does not set fractures. What happens?
The personal doctor refers the case to a specialist. Insurance pays the specialist’s fee.
In PPO, the woman would generally see a specialist affiliated with the PPO. In an HMO, the specialist would be employed by the HMO.
The young woman signs up for an HMO then contracts a rare disease or suffers an injury that requires treatment beyond the capability of the HMO. Will she be treated?
Often yes, but it pays to read the fine print. The HMO will contract treatment out to a facility that specializes in the needed treatment.
The young woman becomes despondent and takes to drink. Will insurance pay for her rehabilitation?
Depends on her insurance. And often her employer. Some may have drug and alcohol rehab plans. Some plans cover psychiatry. St. Helena Hospital specializes in treating smokers and alcoholics.
The woman becomes pregnant. Her doctor, who has delivered many babies, wants her to deliver at X hospital. All the woman’s friends say, Y Hospital is much better, nicer, etc. The doctor is not cleared to practice at Y Hospital. Is the woman out of luck?
With a PPO, the woman must deliver at a hospital affiliated with the PPO — or pay the extra cost. If her doctor is not affiliated with that hospital, sometimes a doctor may be given courtesy practicing privileges at a hospital where he or she does not have staff membership. Check with the doctor. With HMOs, the woman must deliver within the HMO system. www.mccormacks.com
The young woman goes in for minor surgery, which turns into major surgery when the doctor forgets to remove a sponge before sewing up. Upon reviving, she does what?
Some medical plans require clients to submit complaints to a panel of arbitrators, which decides damages, if any. The courts are starting to take a skeptical look at this requirement. Read the policy.
The woman’s child reaches age 18. Is she covered by family insurance?
All depends on the insurance. Some policies will cover the children while they attend college or up to age 25 if the young person is still claimed as a tax exemption (But attendance may be defined in a certain way, full-time as opposed to part-time.) To protect your coverage, you should read the plan thoroughly.
At work, the woman gets her hand caught in a revolving door and is told she will need six months of therapy during which she can’t work. Who pays?
Insurance will usually pay for the medical costs. Workers Compensation, a state plan that includes many but not all people, may compensate the woman for time lost off the job and may pay for medical costs. If you injure yourself on the job, your employer must file a report with Workers Comp. www.mccormacks.com
The woman comes down with a sore throat and headache. She feels bad but not bad enough to drive to a hospital or emergency room. She should:
Call the 24-hour advice line, if it is offered by your hospital or medical plan. This is something you should check on when you sign up for a plan.
The woman wins a vacation to Switzerland where she falls off a mountain, breaks a leg, and spends three days in a Swiss hospital. Her HMO or PPO is 7,000 miles away. Who pays?
Usually the insurance company, but it is wise to check out how to obtain medical services before going on vacation. The woman may have to pay out-of-pocket and then file for reimbursement on her return home. www.mccormacks.com
While working in her kitchen, the woman slips, bangs her head against the stove, gets a nasty cut and becomes woozy. She should:
Call 9-1-1, which will send an ambulance. 9-1-1 is managed by police dispatch. It’s the fastest way to get an ambulance.
What’s the difference between a hospital, a clinic, an urgent-care center and a doctor’s office?
The hospital has the most services and equipment. The center or clinic has several services and a fair amount of equipment. The office, usually, has the fewest services and the smallest amount of equipment but in some places “clinic-office” means about the same. www.mccormacks.com
Hospitals have beds. If a person must have a serious operation, she goes to a hospital. Hospitals have coronary-care and intensive-care units, emergency care and other specialized, costly treatment units. Many hospitals also run clinics for minor ailments and provide the same services as medical centers.
Urgent care or medical centers are sometimes located in neighborhoods, which makes them more convenient for some people. The doctors treat the minor, and often not-so-minor, ailments of patients and send them to hospitals for major surgery and serious sicknesses. Some doctors form themselves into groups to offer the public a variety of services.
Some hospitals have opened neighborhood clinics or centers to attract patients. Kaiser has hospitals in some towns and clinic-offices in other towns. The doctor in his or her office treats patients for minor ailments and uses the hospital for surgeries, major illnesses. Many illnesses that required hospitalization years ago are now treated in the office or clinic.
Some hospitals offer programs outside the typical doctor-patient relationships. For example, wellness plans — advice on how to stay healthy or control stress or quit smoking. www.mccormacks.com
