Inspiration By Experience

Archive for January, 2010

One of the more annoying features of modern life is this alphabet soup. You are expected to know what all these letters stand for, iykwim. Even those who are into texting and SMSing can get caught out when it comes to insurance jargon. So here is a simple explanation of the differences between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) with guidelines to suggest which to buy. Both employers and the private health insurers offer this choice. An HMO is a network of healthcare providers that enters into a contract with insurance companies to provide medical services at a fixed price. This network will include hospitals, clinics and a range of professionals. Usually they are grouped together in a particular part of a city or rural area, offering a spread of coverage across the major medical specialties to all the people living within that area. Because the insurers can bring a guaranteed volume of business to the network, they are able to negotiate quite good prices for the different services. These savings are passed on to you as lower premiums. Even more importantly, service within the network can be free or with only low copayments. But the majority of plans have quite restrictive terms. When you sign up, you have to choose one doctor to be your primary care physician. This person must be an existing member of the network. If your current doctor is not a member, you will have to change. This physician acts as the gatekeeper and he or she must refer you on to specialists within the network. Because the insurers pay bottom dollar, the gatekeepers tend not to refer on unless the problem is really serious. Further, because the network is for-profit, it must see more patients in a day to earn a reasonable profit. You may therefore expect little opportunity to discuss your treatment or explore options. You have only a few minutes and must make the most of that limited opportunity.
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When you are buying either term or whole life, there’s a chance you will be asked to go through a medical exam. It will not be necessary for most young people who are only asking for small amounts of coverage. So, for example, a 30 year old only asking for $50,000 will usually be allowed to self-certify good health. As age and the amount to be covered increases, you will move through a simple paramedical exam to a full examination by a physician. A paramedical is licensed professional employed or hired by the insurance company. The physicians and paramedicals are independent and their only role is to make a basic assessment of your medical history and current condition. Some operate a mobile service and will come to your home or office with all the necessary equipment. Others will ask you to attend at a laboratory or clinic. The cost of all medical exams is met by the insurance company. For the record, almost all insurers insist on independent exams and refuse to accept information provided directly by your own physician.
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One of the big dilemmas for any government when it bails out a business deemed “too big to fail” is how far it should go in managing that business. There is a temptation to actually start calling the shots whenever this is seen as necessary to protect the interests of the taxpayers whose money is bailing out the company. For example, if tax dollars are propping up a bank that has lent hundreds of millions to home buyers, should the government tell the bank to take a less aggressive approach to foreclosures? You only have to look at the public anger when top executives in these businesses started awarding themselves big bonuses, claiming their performance as managers justified these rewards. Even President Obama was moved to anger and Washington has appointed a pay czar whose job it is to moderate some of the pay excesses in the boardroom. There is support from the public for curbing excessive greed and reckless risk-taking by these businesses. There is less political will in Washington where lobbyists buy votes with campaign donations and other inducements. In a sense, this moves the dynamic back to the states. If Washington has a political logjam because of the power of vested interests, can local voters force change through?
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