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I disagree, HMOs can be severely limiting especially as medical practioners (and medical groups) change or cancel insurance groups (HMO providers) they partner with. Further, getting access to specialists can be daunting - in network may be over loaded/over booked (appointment in 6-9 months); out of network providers can take significant hoops to jump through.

The same is true for PPOs, you just pay more for them. And a bigger problem is healthcare deserts. If you're in a rural area your options are limited by default.

I'll pay more for faster wait time and approching specialists from the "customer frame" as opposed to a "referral frame/shuffling through the system".

> And a bigger problem is healthcare deserts. If you're in a rural area your options are limited by default

i don't care about that. unlike the last healthcare debat, i think i'll keep my doctor this time.

Perhaps rare in the general population, but the entire military is functionally an HMO (as are the dependents, unless specifically opted into the PPO option, which is rare).

I just swapped to the PPO version after retiring because the cost isn't any different, and I'm no longer in the area of the easy HMO's for them (Military Treatment Facilities).

I guess I can't fathom not having a PCP. As far as finding a Primary, what is your actual method for finding a good one if not by people who have experience with them?

I loved my previous HMO because I was in a union and the (huge) premium was mostly covered by the company however it's really never that simple. Changing jobs and insurance companies means all of a sudden all of my previous doctors are out of network and now I have to pick and choose which ones are worth sticking with while eating the out-of-network costs and which are replaceable. Multiply that by several family members and it's a nightmare.

Continuing the counterexample, recently my daughter had to be hospitalized literally a month after changing to a PPO. Amazingly, our $175,000 bill ended up costing me just $300 because she was admitted to inpatient care. If I had been on my previous HMO, it likely would have either cost $50k for the out-of-network, out-of-pocket maximum (assuming nothing exempt from that even...) or worse, delayed getting care while attempting to figure out any of that on the spot.

Was there some limitation listed with your HMO coverage, or are you just speculating? All insurance plans have emergency coverage regardless of if the hospital is in your network.

I would have to dig through the old plan details again but they had a pretty similar example to our situation where they estimated you would owe essentially the entire bill minus some copay amounts, i.e. $100k - $300, which is funny but depressing. Their version of emergency coverage would have come in to play perhaps if one of us had been hit by a car and were bleeding out on the street.

My conclusion was that if you're young/healthy, HMO vs PPO may not matter as much. That said, I went with a PPO because in my case: (1) it's faster to see a specialist, since a referral is not required; and (2) in my area, it has vastly more in-network doctors who are highly-rated.

One gotcha I've run into is that most plans (both HMO & PPO) are only valid in a single US state. The one exception is "emergencies," but when I asked it seems this is basically only the ER (and I was told only if it turns out it's actually an emergency, whatever that means).

I believe you can get out-of-state covered via out-of-network. But as mentioned, the out-of-pocket max on my plan is shockingly ~6x more for out-of-network than in-network. So you won't pay 90% of $200k, but it will still end up a very substantial amount. But maybe that could still be worth it to see an out-of-state specialist?

> I believe you can get out-of-state covered via out-of-network. But as mentioned, the out-of-pocket max on my plan is shockingly ~6x more for out-of-network than in-network. So you won't pay 90% of $200k, but it will still end up a very substantial amount. But maybe that could still be worth it to see an out-of-state specialist?

See, this would be the expected, plain reading of out-of-network vs. in-network deductibles and coverage.

But be very, very careful with out-of-network: the truth is that your insurance only covers whatever percentage they claim they cover of the "usual and customary" charges for out-of-network care, not the the actual charges you receive. Because out-of-network providers are by definition not contracted with the insurance carrier, they can (and do!) charge you whatever they want. And then your insurance only pays for 10% of that, because they then claim that the "usual and customary" charge for whatever care you received is only 10% of what your provider charged you. (And, of course, the out-of-pocket max for out-of-network care is only for "usual and customary", not any charges beyond that—so it offers basically no protection.)

...which leaves you with a bill for 90% of $200k that you're not particularly in a position to negotiate—neither with your insurance company, which has no incentive to cover it, nor with your care provider, which has already billed you and will happily send your bill to collections (most of the time, though not all the time) and take XX% of it rather than give you a 90% discount.

So: on the one hand, you have zero price transparency before you receive care; on the other hand, your insurance contract has terminology that implies one thing but hides the reality behind reasonable-sounding legalese. One would be hard-pressed to design a worse system.

I’ve always thought the whole “in-network” “out-of-network” thing is such a scam—a booby trap set to trip you up so you end up owing a fortune. You carefully went to an in-network hospital to see an in-network doctor, but SURPRISE a non-network doctor happened to stop by to draw blood and boom, you now owe 90%! Sucker! I don’t know why it is the way it is but it sucks. What even is this in/out distinction if not a conspiracy to fleece the public? I’d be in favor of regulation that simply makes all doctors in-network for all insurances, period. Get rid of the unnecessary complexity minefield.

This particular surprise (out-of-network provider in an in-network facility) is getting addressed, albeit slowly -- surprise bills like these are not allowed in many states.

But it wouldn't surprise me if they were still coming in under the assumption that most people don't know they're disallowed.

This feels all well and good but in reality it might work out differently. Your hmo argument feels like centering the lower quartile folks at the cost of the average middle class man that wants agency in his healthcare journey. the reason i chose a ppo instead of an hmo is with a ppo i can go visit a psyciatrist directly, tell them i had adhd symptoms, get diagnosed and get prescribed adderall pretty much immediately. With an hmo that would take at least months. Why pay full price for a canadian/uk style wait/referral system?

HMOs don't prevent you from choosing a psychiatrist as far as I know, you just need to find one in network.

And yes, if want a pill pusher or crooked doctor who gives you what you think you need without following evidence based medicine, a PPO is better for that. Those are going to be more rare on HMOs because the doctors in HMO networks are more connected.

In my experience, psychiatrists will often require a referral even with a PPO - not for insurance reasons, but for their own reasons.

yep, i was able to shop around till i found one that wasn't old school (ie we need to talk to your second grade teacher to diagnose you). exactly due to being on a ppo plan.

//Most people choose doctors based on friend/family referrals and Yelp reviews, meaning they don't know how to choose a doctor. Reviews/referrals have no relation to health outcomes.

People don't have access to doctors' health outcome data.

Are there any useful proxies for that ?

Whenever an employer has offered a choice of PPO or HMO, they’ve been identical in price. If HMOs are supposed to be cheaper, then I guess I’d be overpaying for the supposed benefits versus a PPO.

If I contribute a certain amount to my hsa, my company kicks in about $1k per family member which takes a big bite out of the deductible.

Not sure how many companies do that. But I believe it may be quite common.