March 01, 2015

GP Mentor: Beyond Immortality: Basic Choices in American Health Care

Elio F. Martinez Jr.

I am immortal. That is what I told my doctor when he asked why I waited 20 years after graduating law school before scheduling my first checkup. The fallacy of my self-diagnosis was evidenced by the test results—while I was in reasonably good health, better diet, more exercise, and cholesterol control would become part of my everyday life.

I was lucky. Had something been seriously amiss, my long delay could have created significant issues.

My sole excuse for neglecting health care was age. As a young lawyer, I felt strong and energetic. I did not wish to waste time visiting doctors who would tell me what I already knew: I was healthy. Neither did I wish to dwell in the alphabet city of the American health care system (HMO, EPO, POS, PPO), a world akin to acronyms on steroids. My time was better spent at work or at home, the two places that framed and defined my life. It was only as my kids grew older and I began to experience some of the inevitable challenges of age that I decided to incorporate health care into my everyday life. In retrospect, I should not have waited.

Neither should I have remained enrolled in an expensive PPO (preferred provider organization) during my period of inactivity. PPOs are all about choice, which comes at a price, while HMOs (health maintenance organizations) strictly limit users to in-network providers and pay nothing if users visit doctors or hospitals outside the network. I was, effectively, paying more not to choose. I would have been significantly better off enrolled in an HMO or similar plan with lower premiums accompanying sporadic visits to doctors.

Users today are not limited to HMOs and PPOs. They may also enroll in EPOs (exclusive provider organizations) or POSs (point of service plans), effectively blends of the HMO and PPO business models, with varying degrees of choice given to users. A POS is similar to an HMO in that it requires primary care physician approval before a specialist may be consulted. Unlike an HMO, however, a POS will allow and pay for visits to out-of-network providers. An EPO, like a PPO, will not require primary care physician approval for a specialist visit. Unlike a PPO, however, the EPO enrollee will be limited to in-network specialists.

In addition to cost (and paperwork when using out-of-network providers), the main differences among these four principal types of health plans in the United States can be categorized as follows:

  • whether or not the user must have a primary care physician (yes for HMOs and POSs);
  • whether specialist visits require primary care physician referrals (again, yes for HMOs and POSs);
  • whether health care services must be pre-authorized by the insurer (generally yes for EPOs and PPOs); and
  • whether the plan will pay for out-of-network care (only POSs and PPOs).

Regardless of the type of plan selected, the American health care system works best when it is used for prevention rather than correction. Insurers will pay for regular checkups because they will ultimately save money dealing with medical conditions that are diagnosed early. By delaying my checkups for 20 years, I not only played Russian roulette with my health, I also failed to derive even minimal benefit from the health care funds taken out of my regular paychecks.

Of course, I did not know much of this back when I graduated law school and embarked on my chosen profession. Knowledge has come with experience, particularly in my role as administrative partner of a boutique litigation firm.

If my 25-year-old self came to me for advice on navigating the American health care system, this is what I would tell him:

  • If you are young and healthy, there is no need to enroll in an expensive plan. HMOs and POSs will suffice at this stage of your life.
  • More important than the type of plan selected is the directory of doctors and facilities participating in the plan. Make sure the principal hospitals in your geographic area are included in the network.
  • Go for regular checkups. Nothing good ever comes from delaying the inevitable.
  • Use your plan. Why pay for something that you ignore?

Following this advice may not ensure immortality, but it will help maintain health at a reasonable price.

Elio F. Martinez Jr.

Elio F. Martinez Jr. is a partner with Concepción Martinez & Puente in Coral Gables, Florida.