Posted December 11, 2001. Health insurance, as we know it, is basically providing compensation for medical expenses incurred by the insured and generally is a very good thing to have. You may hear controversies once in a while but these, I suppose, are isolated cases. To understand the controversies, you have to get into the mindsets of the companies that provide health insurance. They are in business to make money. If you are a very sick person who sees lots of doctors and needs lots of tests, you will cost the insurance lots of money. So how do they balance this out? They may keep a tight hold on your health care and getting the compensation you deserve may not be as easy as you thought.

     This column is not intended to present another controversy but to elicit reaction. I don't intend to answer questions but to ask them. I don't intend to show my expertise, but perhaps to expose my cluelessness. I don't intend to suggest anything to you but to present something for you to think about. I don't intend to offer the viewpoint of a doctor (or as insurance companies like to refer to a physician, a 'health care provider') but the viewpoint of a patient. In other words, I'm here not to educate but to be educated.

     If you are employed, be it in the Philippines or the United States, your employer may have health insurance as part of your compensation. Since health insurance is not cheap, in cases of the unemployed or those who work for companies that don't have a health insurance package, many Filipinos don't bother to have one. If you work for the government, you may be compensated in the form of Medicare. For the really less-fortunate, the government has free services (although not totally), in the form of government hospitals and health care units.

     Lack of health insurance is not only a problem in the Philippines. Last year, according to the United States Census Bureau, 38.7 million Americans had no health insurance coverage of any kind. That's a big number even if you consider that this only represents about 14 percent of the American population. Most of the insurance are employment-based. If you are unemployed, or work on a part-time basis with minimum wage, health insurance may not be an option in your budget. God forbid, if you get extremely sick, without a health insurance is a disaster. Not on your health necessarily, but on your pocket.

     When I was in Iloilo last year, we visited a family friend at her place of work at a health insurance company near Plaza Libertad. The place is basically a laboratory that offers lab examinations for the company's clients. At the building's entrance, I saw a big board that says HMO with names of physicians (familiar names, of course) and their specialties. I never heard of an HMO plan in Iloilo before so I asked some friends. They did not really offer that much information, except that this HMO plan is not devoid of controversy. For one, a surgeon-friend said, the Philippine College of Surgeons (PCS), discourages its members to be part of HMO. My friend did not venture to offer any explanation. He also told me that a prominent Iloilo City-based surgeon attempted to block the fellowship to the PCS of another surgeon who just passed the PCS's written and oral exams because he is a member or used to be a member of this HMO. What's with this HMO? In retrospect, I should have asked.

     In my previous column, I mentioned about two health plans in the U.S. that you need to choose from, HMO and PPO. There are pros and cons to both plans. It is really up to the employer based on employee need to offer the plans that suit them best. Or in cases where the employer offers both plans to its employees, it is the employee's responsibility to understand both plans and to choose carefully and wisely.

     I've been a member of HMO for years and I love it. I've never tried a PPO so I can't really speak for it. I have heard about the HMO horror stories, but they don't seem to bother me. I know lots of jokes with HMO as punchlines, although not all of them are funny. Each company that carries an HMO may be different, and lots of people are very opinionated about them. I've come across a book recently entitled "Death By HMO: The Jennifer Gigliello Tragedy" written by the victim's mother, Dorothy Cancilla. The author has used words such as "incompetence, neglect, and greed", and blamed the HMO for her daughter's death. I did not bother to read the book because it will just boil down to one thing: malpractice. Malpractice happens everyday. An inept doctor can cause death, sure. The health plan you are in may be an accessory to your death, probably. But the doctor allowed you to die just because your health care plan tells him to, hogwash.

     Maybe I just trust doctors too much. Maybe I failed to realize that my choice of health plans may ultimately determine, God forbid, my demise. Maybe I failed to see that doctors are under the control of insurance companies. Maybe I am just being stupid.

     HMOs are very attractive to people, including myself, because they can save you lots of money (my bi-weekly paycheck may only be half-a-day to most of you, so I always consider the 'savings' part). Office visit co-payments are very low-cost and I have never filled out a single claim form (again, there are lots of HMO organizations and I may only be speaking for mine). Because of this, HMOs are usually restrictive and have lots of rules. Many consider this as the HMO's downside, because they are in business to make money, they keep a tight grip on your health by putting all these rules. I am not buying it. All insurance plans, be it health, car, life, etc., are there to make money. Period.

     What are these rules anyway? First and foremost, you can only see the doctors on your HMO list, and you must see your primary care doctor first, no matter what is wrong with you. You may have a problem with that but I don't. The list that was given to me for my primary physician (my daughter and wife, included in my plan, can have their separate primary physicians) was enormous, broken down into 'primary care' specialties, Family Medicine, Internal Medicine, Pediatrics and Obstetrics and Gynecology. As regards to seeing your primary physician first before going to a specialist, what is the problem with that, right, Jesse Ray? HMOs probably believe that some people may go to an expensive specialist when their primary care doctor, contracted by HMO, could have helped them just as well. We all don't have the ability to determine what our problem is before going to a doctor, that's why we go to the doctor's clinic in the first place. The HMO doesn't want you deciding how your health care should be handled, it wants its contracted doctor to make those decisions. If your primary care doctor is only good at hitting golf balls, then it could be a problem. That's why it is always good to have a top-rate primary care doctor. I changed primary doctor once, because I felt my first choice was only good at cooking 'Kung Pao Chicken'. I called my HMO for the change, the process took just 2 minutes, easier that ordering a pizza or, well, Kung Pao Chicken. Needless to say, when looking for a good primary care doctor, it is always good to listen to recommendations. Like Dr. Jesse Ray Consing (Class 1991) for example, one of the best in North Carolina (you owe me another Viagra pen for this :)).

     In the State of Illinois, there is a State law that allows women who have Family Medicine or Internal Medicine as primary care to go directly to an Obstetrician-Gynecologist for pre-natal, childbirth and other 'women' problems without a referral. So in the case of my wife, she has essentially two primary care doctors, an Internist and an OB-Gynecologist.

     PPOs are generally less restrictive than HMOs, because they are less structured, and there are far less restrictions. Because you can handle many aspects of your own health care, it will cost you more money. Co-payments for office visits are higher, and you need to pay a percentage of the cost of diagnostic tests and hospitalizations.

     Supporters of PPOs claim you have more control over your health care. You can go to any doctor of your choice, whether or not they are on the PPO list. (Oh, they have a list too, but if you choose a doctor on the PPO list, you pay a lower percentage of the total cost, same goes for lab exams and hospital admissions.) With PPOs, you do not need to see your primary care doctor before seeing a specialist. You do not need a referral for that, you can just pick a doctor and see them. There is an advantage to this as well as a disadvantage. An officemate once complained of lightheadedness, searched the Internet, and believed he had Diabetes. He went to a Diabetologist, and it turned out, he just skipped breakfast that day. Unfortunately, he had to pay for the whole visit.

     I will not end this piece by stating which one is better. I have not experienced both plans, never had a problem with what I have now, and others may have separate opinion altogether. I think it is safe to say that the choice depends on your individual circumstances. Whichever you choose, it is certainly better than having no health insurance at all, a sad state for many Filipinos and Americans as well.

     Finally, is it true that many HMOs and some PPOs tell their doctors to meet a patient quota each day? Is it true that doctors who see less than the recommended number of patients are often financially penalized or warned by the HMO? Is this the same reason why doctors sometimes rush you out the door? Is it true that HMOs and some PPOs tell their doctors to keep the patients hospital 'bed days' to a minimum? Is it true that HMOs and PPOs pressure some doctors to kick you out of the hospital as soon as possible? Will my doctor be ready to fight for me when it is warranted?

     I need a second opinion.

TODAY'S LAST WORDS:

• Did it ever happen to you that your self-confidence went up a notch after realizing that there are people more stupid than you are? According to a newspaper quote, a member of a review panel at MTRCB (Movie and Television Review and Classification Board) in Manila recently rated the Disney movie, Monster, Inc. 'X' because it is 'satanic'. Holy Viagra! What type of people do they hire at this government agency? This is the same rating that is normally reserved for such films as 'Live Show' or 'Scorpio Nights 2', yet these movies were shown publicly. This is the same agency that put an 'X' on 'Schindler's List' because there's a millisecond where pubic hair was shown. Steven Spielberg threatened to pull out the film and they caved in, the movie was eventually shown in the Philippines. According to sources, half of Filipinos who saw the movie did not actually see the pubic hair. The other half did not quite understand the story because they were too pre-occupied waiting for the pubic hair to show up.

  Incidentally, the main characters in Monster, Inc., Sulli (voiced by John Goodman) and Mike (voiced by Billy Crystal), were the creations of a Filipino, Rick Nierva, who works at Pixar, the same company behind Toy Story and Bug's Life.

  I've seen Monster, Inc., ok. And I still listen to 'Hotel California'. Should I burn in hell?

     E-mail the author at drgarcia@wvsumedaa.com

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