Don’t Follow Me, I’m Lost (in a PPO)

Since relocating to New Mexico from California, I’ve experienced many changes, including not working for the first time in my life, being pregnant, and the challenge of being so far from friends and family while being pregnant. But one of the biggest changes, and challenges, has been switching my health insurance from an HMO (Kaiser) to a PPO (Blue Cross Blue Shield).

Image courtesy of http://www.stibroker.com

Kaiser & HMOs

If you live in California, you understand just how omnipresent healthcare giant Kaiser Permanente is. If you’ve never heard of Kaiser, then you might mispronounce the name much like the receptionist at the office of my new OBGYN: “Is it…Kay-zer?” No, it’s not, dumbass. Kaiser is a one-stop shop; everything you need is generally located inside of one building. Gotta doctor’s appointment? Third floor. Need some lab work? First floor. Gotta fill a prescription? First or second floor–your choice. All of your medical records are computerized, meaning that all of your doctors–whether they be your primary physician, your OB, your rheumatologist, etc.–can easily access your most current information. People have their complaints about Kaiser: It’s bureaucratic, slow, imperfect. But overall, if you belong to Kaiser, you’re enjoying the convenience of having everything in one place.

But Kaiser is an HMO, meaning there are a enough people in the region to pay into this insurance in order to make Kaiser’s existence feasible. The nice thing about this is that an HMO’s main goal is to save as much money as possible, which means Kaiser focuses on preventive care because they don’t make any money off of treating you; instead, they save money by preventing you from having health issues in the first place.

PPOs

A PPO, on the other hand, operates from the opposite side of the playing field. They make their money from the services rendered. The more services (i.e., labs, procedures, etc.) that they provide to you, the more money they bring in. The result is two-fold: (1) You may receive services that aren’t absolutely necessary and that may cost you lots of money. (2) Your doctor isn’t bound by a strict budget, and thus can order a litany of tests, thereby gaining a much more complete picture of your health.

Now, in New Mexico, the population is much, much smaller than in California, so there are no high population-dependant HMOs like Kaiser. What the sparsely populated state of New Mexico does have is a litany of PPOs, so I now belong to Blue Cross Blue Shield. I’ve gotten a fairly good understanding of the differences between the two healthcare insurance companies’ business models, but their differences go down to the marrow. How do you pick a doctor that’s in the covered “network”? How do you get your medical records to that doctor? How do you get a specialist, such as a rheumatologist or a perinatologist? Where do you go for labs? Where do you get your prescriptions filled? How much is all this going to cost, anyway?

Happy Ending?

Well, long story short, I found an OB, a lovely woman with a great sense of humor who had more than Kaiser’s allotted five-minute max (it’s true) to get to know me and answer my questions so I could get to know her. She referred me to a perinatologist, who ordered so many labs plus an EKG (seemingly on a whim), that I felt compelled to call Blue Cross Blue Shield to find out my financial responsibility for this laundry list of lab work. It turns out, thanks to our HSA, it’s not too bad.

I figured out which hospital I’ll be delivering at and will take a tour of the facilities shortly. I’ve signed up for free prenatal yoga classes and fee-based classes for birthing, breastfeeding, and basic infant care. I was able to get a rheumatologist; although, I can’t get in to see him until the end of September. Now all I need to do is find a primary physician, and I’m good!

Overall, initially I felt very nervous about switching from an HMO to a PPO, but while vastly different, the change itself hasn’t been too bad. I’m still anxious about the fact that the first test of this PPO is going to be the successful delivery of my baby, but as my new OB pointed out, New Mexico has a much lower rate of C-sections than does California. Sometimes change is scary, but it can also be good.

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