"The Heart of the Matter"

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Week: 550.3 Guest: Mike Donio, People's Medical Society, Allentown, PA Topic: Making a good choice on health care coverage Producer/Host: Steve Girard

NEMA: You're in a situation where you have the chance to choose your health are provider...what do you look for? The benefits, the doctors, the price, the choice? We're with Mike Donio of the People's Medical Society in Allentown, Pennsylvania. Mike, what are the big questions to consider when making a choice about health care coverage...?

DONIO: One, is my primary care physician part of the managed care plan? Two, what additional benefits am I getting from my premium dollar? And three, what is the effect on my out of pocket expenses for the entire plan versus the new, managed care plan.

NEMA: Tell me about the physician being part of the plan....

DONIO: As a member of the plan, you would have to see this physician, the primary care physician, or the gatekeeper' as it is called. And this physician makes decisions about what type of additional medical care or services you are going to require. And it's very important that you have a very good relationship with this physician because he or she will be making most of the decisions that could ultimately affect your health and the health of your family members.

NEMA: Being part of the plan also means doctors are sometimes in a difficult situation....because they sometimes are part of the business...

NEMA: I think what it does - it sort of puts the physician and the patient/ consumer at odds. Because at one time, under the old fee-for-service' plan, when a patient crossed the threshold, the doctor could say, "Well, there's another meal on the table". Today, with managed care, it's very possible that when the physician sees the patient crossing the threshold, he or she is thinking, "..there's one less meal on the table, because I may need to refer them to another provider, which means that my, the amount of money I'm paid is going to be reduced, or my bonus at the end of the year won't be as great". So, I think we do raise a very serious ethical situation, where you have to ask, is the provider...the physician in this case...working in the patient/consumer, or in the best interest of the managed care organization?

NEMA: How about the benefits of managed care?

DONIO: One of the biggest ones is prescription plans. Many traditional insurance plans do not have a prescription benefit. Another thing that is attractive, it may cover some dental services, or maybe a full dental plan. In addition, it may provide coverage for eyeglasses. It may also provide hearing aid coverage These are the things that people need to look at and see how does it stack up with their existing coverage? And what additional benefits are they going to get if they join the managed care company?

NEMA: What are the differences in out of pocket expenses when using the different types of health care plans?

DONIO: I think the biggest delineation would be that under a fee-for-service plan, you might have a 20% co-pay on certain types of out-patient services, or in certain types of services provided by specialists. Under an HMO and a PPO...as long as you stay within the network, you may not have those out of pocket expenses. However, some of the HMO's and PPO's have added what's known as a point of service' option...which means that you may be able to go outside of the network to get a particular specialist. However, the plan may only pay what it would pay if you stayed in that network, and it may also impose a deductible. So you would have to determine if it is worth the additional, out of pocket expense to go to the specialist that you choose under the point of service' option, or stay within the network, and not incur that expense.

NEMA: There's a lot to consider when choosing a health care plan for you and your family....though the monthly subscriber fees may be comparable, make sure you check those out of pocket expenses, and think about how important it is for you have freedom of choice, before you choose. Thanks to Mike Donio of the People's Medical Society...I'm Steve Girard.


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