CalPERS AND BLUE SHIELD EPO-THE FINAL DEAL

By this time (8/16/07) you have received written notification from CalPERS that the Blue Shield EPO is not an option and reviews your options for the upcoming open enrollment period for 2008.

We are now at the point CalPERS has been moving towards for the past half a decade- you have two HMO choices, and two PPO choices and you are in the unfortunate position of assigning a dollar value to being able to get any medical care outside of the Sacramento- Folsom area.

For those who are not insurance/medical industry professionals,

• HMO (Health Maintenance Organization)
• Usually, but not always, lower monthly cost.
• You have to pick a primary care doctor, whose name has to appear on your card.
• You cannot see a specialist unless your primary care doctor makes a referral to one.
• Medications largely covered, but formulary (list of covered drugs) can be very limited.
• Doctors are salaried (as with Kaiser), or paid a certain amount per patient per month (as with other HMO’s) whether they see you or not. This creates an incentive to avoid seeing you whenever possible, and as quickly as possible otherwise. This pressure in some ways relates to the method of doctor payment, and also because doctors have to take on a lot of patients to offset the costs of sick patients

• PPO (Preferred Provider Organization)
• Usually, but not always, higher monthly cost.
• You may see any doctor that accepts your insurance.
• Formulary of medicines usually less restrictive than HMO’s.

So, this is the deal: you can either choose an HMO (Kaiser or Blue Shield HMO) and go down the hill, or pick a PPO (Blue Cross PERS Choice or PERS Care) and keep your medical care here.

• Your HMO Choices:
• Kaiser
• Well, it’s Kaiser. ‘Nuf said.
• Blue Shield HMO
• I think there are two offices up here that take this HMO, but Lots of Luck.
• You still have to go down the hill for any X-Rays or specialists.
• If you have to go to Marshall ER, your doc will have to work very hard to get you sent down the hill as soon as you are stable.
• You still cannot use Sutter hospitals, which I suppose is fine as long as you never need spine or brain surgery, or never get cancer.
• Your PPO Choices:
• Blue Cross
• PERS offers two flavors called PERS Choice and PERS Care.
• They are pretty much the usual PPO type coverage, but vary between the two of them in premiums, deductibles and co-payments.
• We already have patients with these two insurances, and have had no problems with either.

The bottom line:

If you want to continue to be able to have a doctor where you and your family live, to have a choice about getting blood tests and x-rays (also CT scans, MRI and heart tests) done here and see specialists or use your local hospital it is going to cost more than Kaiser or another HMO. It may not be much more than your current Blue Shield.

We think it’s important to base your family’s medical care where you live, and we hope you will continue to do so since we enjoy having you as our patients. If you were ever unhappy with our care we would want to know about it, but we think it stinks if you have to change doctors because of insurance.

For retirees:

MediCare already covers doctor visits, ER visits, hospitalization labs and tests.

Look very carefully at what you want any secondary insurance to cover such as medicines, long-term care and so forth. It may be that PERS Choice or PERS Care may do this perfectly well, or you may want to investigate the various MediCare supplements such as Part D which covers drugs/medicines or other ones which cover long-term care and other aspects of medical care.