Wyoming Valley West 
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Acc Struggles 
Continue For 
Sura, 'noles 
Florida State Falls To Maryland

By LEANORA MINAI; Times Leader Consumer Reporter
 Thursday, January 13, 1994 &nbsp;&nbsp;&nbsp;&nbsp;Page: 7A QUICK WORDS: HMOS, FEE-FOR-SERVICE
PLANS OFFER VARYING STYLES 





Dan and Nancy Drowne could save money without sacrificing health coverage
if they changed from their current insurance plan to a health maintenance
organization (HMO). But the Drownes are so confused about HMOs that they're
not changing anything. &nbsp;&nbsp;&nbsp; 
 The Drownes are not alone. There are more health insurance alternatives
than ever, making it difficult to decide what's right for you. And it's
getting harder every day. More plans pop up as employers strive to save money
and the health-care industry works to cut costs. &nbsp;&nbsp;&nbsp; Health insurers are battling for customers, offering all types of plans
that they say will provide quality care at a reasonable price. &nbsp;&nbsp;&nbsp; 
 Meanwhile, individuals and families struggle to understand the medical
coverage options already proposed to them. &nbsp;&nbsp;&nbsp; 
 The biggest choice these days is between HMOs and traditional
fee-for-service plans such as Blue Cross/Blue Shield. The choices usually
don't end after selecting a plan. There are decisions to be made about family
doctors, specialists, hospitals, payment plans and second opinions. &nbsp;&nbsp;&nbsp; 
 The HMO system, which is considered the granddaddy of managed care, limits
many of those decisions for the consumer. &nbsp;&nbsp;&nbsp; 
 HMOs are designed to be simpler and cheaper than traditional health
insurance. They act as gatekeepers, telling members which doctors they can see
and which hospitals they can go to for treatment. &nbsp;&nbsp;&nbsp; 
 Geisinger Health Plan, for example, gives members a choice of 300 primary
care doctors, 950 specialists and 14 hospitals. The area's other health
maintenance giant, HMO of Northeastern Pennsylvania (HMO-NEPA), offers 330
primary care doctors, 900 specialists and 21 hospitals. &nbsp;&nbsp;&nbsp; 
 Geisinger Health Plan is offered through the Geisinger health system.
HMO-NEPA is a division of Blue Cross of Northeastern Pennsylvania. &nbsp;&nbsp;&nbsp; 
 Choice differences &nbsp;&nbsp;&nbsp; 
 During the last 10 years, the number of people across the country enrolled
in HMOs has jumped from 9 million to 40 million. Blue Cross/Blue Shield, a
fee-for-service plan with 80 million members, is the nation's largest health
insurance system. &nbsp;&nbsp;&nbsp; 
 With Blue Cross/Blue Shield, you have freedom and flexibility. You can go
anywhere and see any doctor because Blue Cross/Blue Shield is accepted in
every state. If you want to send your child to an ear, nose and throat doctor,
you flip through the Yellow Pages, then pick up the telephone for an
appointment. &nbsp;&nbsp;&nbsp; 
 Not so in an HMO, which requires that you pick a "primary care physician"
when you sign up for the plan. Unless it's an emergency, that's the first
doctor you must see for anything. If that doctor says you need a specialist,
he or she will refer you to one within the same HMO plan. &nbsp;&nbsp;&nbsp; 
 "If the (HMO) patient says `I don't like any of those choices,' the patient
has a right to see who they want, but it wouldn't be covered by insurance,"
said Dr. Leo W. Landau, a Plains Township pediatrician and a participating
physician in HMO-NEPA. &nbsp;&nbsp;&nbsp; 
 Sometimes you'll find that your first choice for an HMO doctor is not
accepting new patients, forcing you to select a doctor who practices farther
away from your home. &nbsp;&nbsp;&nbsp; 
 "Look around and see what's there -- what works best for you," said Lisa
Hartman, spokeswoman for Geisinger Health Plan in Danville. &nbsp;&nbsp;&nbsp; 
 Although the fee-for-service plan offers more freedom, there are some
constraints. If you visit a non-participating doctor, you're responsible for
the bill. Your reimbursement from the insurance company depends on your plan
and a "fee schedule" established by the company for routine care. &nbsp;&nbsp;&nbsp; 
 Both HMOs and fee-for-service plans usually ask members to pay a monthly
premium, which varies according to coverage and your health. The premium is a
monthly fee often shared by employer and employee. The Times Leader, for
example, pays 80 percent of total monthly group premiums and employees kick in
the rest. &nbsp;&nbsp;&nbsp; 
 Regardless of the premiums, a fee-for-service plan offers more freedom of
choice than an HMO. That freedom to visit any doctor or hospital prompted Judy
Granick to trade the simplicity of an HMO plan for a fee-for-service plan.
Granick, 34, was enrolled in an HMO in Philadelphia, where she lived before
moving to Kingston two years ago. &nbsp;&nbsp;&nbsp; 
 "God forbid someone in my family came down with cancer," said Granick, a
nurse at Hahnemann University Hospital in Philadelphia. "I want the freedom to
go to Sloan-Kettering. With managed health care, you don't have the options." &nbsp;&nbsp;&nbsp; 
 But for others, a simple plan is more important than one with many choices. &nbsp;&nbsp;&nbsp; 
 John Styczen, a 37-year-old Hanover Township resident, switched four years
ago from a fee-for-service plan to an HMO. &nbsp;&nbsp;&nbsp; 
 He doesn't miss the paperwork. &nbsp;&nbsp;&nbsp; 
 "Whenever you went someplace for a prescription, you had to pay, then send
the receipts, then wait five or six weeks to get your money back," said
Styczen, a service man for Pennsylvania Gas and Water Co. "Now you just walk
up to the counter, show the card and pay $4 and you're done." &nbsp;&nbsp;&nbsp; 
 That simplicity is by design, according to Geisinger's HMO spokeswoman
Hartman. "It's a more convenient system. It helps guide you through the health
care system," she said. &nbsp;&nbsp;&nbsp; 
 Simple billing &nbsp;&nbsp;&nbsp; 
 In addition to simplicity, HMOs offer lower out-of-pocket expenses. &nbsp;&nbsp;&nbsp; 
 "The idea is an HMO should be less expensive," said Bill Bachman, spokesman
for HMO-NEPA and Blue Cross of Northeastern Pennsylvania. "An HMO attempts to
clearly manage and contain the cost of someone's health care." &nbsp;&nbsp;&nbsp; 
 Hartman said, "A lot of people are selecting managed care. They get to keep
a lid on rising cost." &nbsp;&nbsp;&nbsp; 
 The $4 fee Styczen paid for his prescription is called a co-payment.
Co-payments vary according to service and from HMO to HMO. &nbsp;&nbsp;&nbsp; 
 Another lower out-of-pocket expense under an HMO than traditional insurance
is the charge for an office visit. &nbsp;&nbsp;&nbsp; 
 Office visits cost HMO members $5 to $10 for each visit, regardless of how
many times he or she sees the doctor. "We keep the office visit co-pay low to
encourage people to go," Hartman said. "Otherwise, people might put off going
to see a doctor for a little thing." &nbsp;&nbsp;&nbsp; 
 Under a fee-for-service plan such as Blue Cross/Blue Shield, you pay the
full fee for doctor visits until you meet a "deductible." The deductible is
the total pre-determined amount you'll pay for care during one calendar year
before insurance kicks in. &nbsp;&nbsp;&nbsp; 
 The Drownes, of West Pittston, are covered under a fee-for-service
insurance plan through Delta Airlines, where 27-year-old Dan Drowne works as a
customer service representative. But Nancy said, "I think we are paying too
much out-of-pocket." &nbsp;&nbsp;&nbsp; 
 The family's insurance is typical of most fee-for-service plans. They pay
for health care until reaching a $500 deductible. Then the Drownes pay 20
percent of their medical bills, while the insurer covers the rest. If the
Drownes' expenses reach $1,500, their insurer pays the whole bill. &nbsp;&nbsp;&nbsp; 
 "Since I had a baby last year, it cost us out-of-pocket $1,000," Nancy
said. &nbsp;&nbsp;&nbsp; 
 The Drownes' considered an HMO offered by Delta, but were scared away by
its complexity. &nbsp;&nbsp;&nbsp; 
 "We really don't understand it...we just thought we'd go with what we have
now," said Nancy, 30. &nbsp;&nbsp;&nbsp; 
 The coverage the Drownes have now doesn't focus as much on preventive
health care as HMOs do. Pre-natal care and baby immunizations, as well as
regular checkups, are all covered by HMOs. Under a fee-for-service, these
services usually fall under a deductible. &nbsp;&nbsp;&nbsp; 
 "If you can keep people healthier from the start, you can impact and cut
down on the number of medical services -- less cost," said HMO-NEPA spokesman
Bachman. &nbsp;&nbsp;&nbsp; 
 In an HMO, doctors are not paid for each procedure performed, as they are
in a fee-for-service plan. Instead, HMO doctors are paid a flat-rate each
month for every HMO member that lists them as their primary care physician. &nbsp;&nbsp;&nbsp; 
 At least one doctor said HMOs compromise the quality of health care. &nbsp;&nbsp;&nbsp; 
 "Instead of being paid to do the tests and the operations, you're being
paid for how efficiently you can get patients in and out," said Dr. John
Carey, a family doctor in Kingston. "What cut costs translates into is reduced
services." &nbsp;&nbsp;&nbsp; 
 Hartman doesn't agree. &nbsp;&nbsp;&nbsp; 
 "Patients aren't being shortchanged, but their care is appropriate," she
said. "You wouldn't get unnecessary tests in an HMO. You don't get things you
don't need." &nbsp;&nbsp;&nbsp; 
 She said HMOs are regulated by state insurance and health departments. The
state requires HMOs to survey all members to check if they're satisfied with
care, something fee-for-service plans don't do. Patients can also complain
directly to the state. &nbsp;&nbsp;&nbsp; 
 "With an HMO, people enroll in it by choice," Hartman added. "If they're
not happy, they're going to go somewhere else, so our job is to keep members
happy." &nbsp;&nbsp;&nbsp; 
 TIMES LEADER/FRED ADAMS &nbsp;&nbsp;&nbsp; 
 Nancy Drowne reviews health insurance papers while her husband, Dan, holds
their 8-week-old daughter, Taylor, in their West Pittston home. The Drownes'
2-year-old son, Patrick, looks on. &nbsp;&nbsp;&nbsp; 
 Choosing plan can be confusing &nbsp;&nbsp;&nbsp; 
 -- Page 7A

Hmos, Fee-for-service Plans Offer Varying Styles 
Decisions And More Decisions Are Being Called For As People Confront The 
Ever-growing Number Of Health-care Alternatives

Hmos, Fee-for-service Plans Offer Varying Styles Decisions And More Decisions Are Being Called For As People Confront The Ever-growing Number Of Health-care Alternatives