So, what about CalPERS Blue Shield EPO?

Well, that's a good question!

Between the newspapers, phone calls, and conversations with patients I think Blue Shield made real efforts to revise their way of running the EPO here to reduce costs. This was at CalPERS's request back around January. They were so far into this that they were mailing contract offers to doctors, and outlining the specific changes: mainly requiring authorization for CAT scans and more expensive tests, and requiring you to see me first before going to a specialist. The first requirement would have been a minor nuisance, the second not a problem. Heck, that's what we're for is to see you if you don't feel well!

However, I don't believe CalPERS had any intention of accepting any offer Blue Shield could reasonably make. I suspect they have a big wave of retirement coming in, and a lot of financial incentive to funnel people into cost-effective (read: cheap) HMO's. They would arouse too much complaint by simply doing away with everything but Kaiser, so they simply keep eliminating every other choice one at a time and jacking up the price on everything else.

Remember two years ago, when you could have brain or spine surgery and cancer treatment at Sutter? How about just before then when you could also choose HealthNet or PacifiCare?

So, now what?

You've got two choices; stay local, or go down the hill.

The two HMO's are Kaiser and Western Health Advantage. Kaiser is Kaiser, 'nuf said. WHA is an HMO based around UC Davis, which is a good place if you have acute leukemia or need a transplant, but otherwise is Big County in my book. I think there may still be one or two docs up here who take WHA, but maybe not.

In any event, WHA means down the hill for any X-Ray, surgery, or specialist. If you go to Marshall ER, a lot of effort will be taken to transfer you down the hill once you are medically stable because Marshall doesn't have a contract with WHA. WHA will therefore pressure them to send you to a hospital where they do have a contract.

HMO'S are cheaper, but you get what you pay for.

BTW, docs get paid by HMO's on what's called capitation. Meaning, the doc gets a dollar figure per patient per month (PMPM) whether any of them are seen or not. Problem is, that's what your insurance company is supposed to deal with; it's called managing risk. In an HMO, then the doc has to manage risk and decide whether you are too ill (expensive) to keep or take as a new patient, and whether to see you (expensive) or treat you by phone. You have to take on a lot of patients to make this risk a safe bet, which is where the stereotypic HMO experience of packed phone lines, impacted schedules, and "I'm Dr. Smith's patient, but I've never seen Dr. Smith" comes from. Do docs learn to game this system? Only if they want to live.

The remaining alternative would be with Blue Cross as a PPO: PERSChoice or PERSCare. Same as with any other cafeteria plan. The PPO means you can go just about anywhere you want (not many docs or hospitals that don't take Blue Cross), but it's more expensive. How much more? If you are a single employee not covering dependents, PERS Choice (less cost, higher deductibles than PERSCare) would cost you $1.80/day more than WHA. Naturally, it's more if you are covering dependents.

So, what to do?

If your employer is local (like City of Placerville, EID) then raise a stink! Being a local employer with local employees and sending them all down the hill every time they become ill, or need to take a sick child to the doctor is crazy and costly in terms of missed work to boot!

If you're retired, do the same! If you live over 30 miles from Sac, how can you be expected to go there for every medical need or problem?

Otherwise, it's all going to boil down to money- yours. You're going to have to look at the cost of a Blue Cross PPO compared to a cheaper down-hill HMO. I know my medical care is better than theirs, I hope you agree and find the additional cost worth the value.