Guest Blog: A Simple Guide to a Complicated Health Care System

This article was written by Jodi Smith of, an online resource for those seeking the best health insurance quotes.

HMO, PPO, POS… Huh? If you look at these commonly used acronyms and are completely clueless as to what they mean, you’re not alone. Millions of intelligent, competent individuals are at a complete loss when it comes to translating health care jargon. And it is by no fault of their own: most health insurance providers provide little to no education when it comes to the ins and outs of the United States’ health care system, and just want you to go online and get health insurance quotes from them without asking any questions. Well, that’s where we are going to come in and attempt to provide you with a simple guide to a health care system that has been described as complicated, ambiguous, and clustered at best.

There are Basically Four Ways to Go

For all the complications and intricacies of our nation’s health care system, there are essentially four types of health plans you can utilize for your health care needs:

  1. Indemnity Insurance (AKA Fee-For-Service Insurance) The most traditional insurance coverage, indemnity insurance pays for most of your health problems, but generally won’t pay for routine physicals or preventative health care like booster shots and vaccinations. It usually has a high premium cost (monthly out of pocket cost you must pay to the insurance company), but does not limit you to any specific network of doctors or health care providers.
  2. HMO: Health Maintenance Organization An HMO will cover most of your health care needs, including yearly physicals and vaccinations, for a small co-payment which is paid to the medical service provider. However, an HMO will limit you to a list of affiliated doctors and hospitals, or they will not cover your care.
  3. PPO: Preferred Provider Organization A PPO will cover most of your health care needs for a small per-visit fee. Your fee will be less if you choose to see a doctor that is on the list of “preferred providers,” and more if you venture outside of this list.
  4. POS: Point of Service Point of service plans offer you two options for using them, both of which are similar to other types of insurance:
    i.) You can use the POS plan like an HMO, choosing physicians from a list and paying a small co-payment per visit.
    ii.) You can use the POS plan like an indemnity plan, choosing your own provider while being responsible for a percentage of your bill.

Time to Choose One

Now that you know the four types of health plans, it’s time to choose one now, before you’re actually sick and need one. Many people who are young, healthy, and don’t often use medical services are under the mistaken impression that they do not need health care coverage. However, all it takes is one car accident or mild to moderate illness to empty a significant amount of money out of your bank account in medical bills and service fees. Best to purchase some type of health care plan now to avoid financial ruin.

The first step in choosing a health plan is to choose a doctor that is right for you. If you already have a primary physician that you wish to keep, find out which type(s) of plan(s) they participate in. Second, consider your medical needs; are there specialists you regularly see that require you to be able to quickly get an appointment with them without a referral? Certain plans will accommodate this, and certain plans will not. Finally, are there specific hospitals or facilities you like, or that specialize in specific medical services that you routinely utilize? Choosing a plan that is affiliated with these providers will be particularly important to you.

Some Simple Questions to Ask

Once you have narrowed down to a few plans and have obtained health insurance quotes from their respective companies, there are several questions you must ask to finalize your decision:

  • Can I keep my primary care physician(s)?
  • Will maternity care be covered?
  • How will an ongoing, chronic condition be handled?
  • Will I be required to fill out claim forms?
  • Will vaccinations and preventative care be covered?

Finding a plan that minimizes out of pocket expenses while maximizing coverage is the goal of anyone who is trying to navigate our health care system. Following these steps will make things easier on you and your family in the coming year.

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Pellucid Goes Live

Back in 2002 I was asked to make a hospital-level report card for a couple dozen hospitals in New York on some Pneumonia measures. Seemed like a fun project, and it went off without a hitch. Since then I have descended into the seven levels of hell* known as the United States health care data universe. I’ve waded through claims data, gotten mired in discharges, homed in on HMO quality, unearthed mountains and mountains of data and made not a few people unhappy with a relentless pursuit to find some commonality and standard by which we can store and publish health care performance data.

All along the way, my sole goal has been to commoditise the data. It shouldn’t be this hard, it shouldn’t be this complicated, and it shouldn’t cost a million dollars every time someone wants to do some research.

IPRO has stuck by me the whole way, and we’ve built an amazing, dedicated team along the road. Last week, at the NAHDO annual meeting we finally got to show off the very beginning of the fruits of our labours: Pellucid.

Pellucid is a concept of data that allows us to store any measure from any facility or provider in the same way. It allows us to cross-reference providers from different payer sources. It hopefully catapults public reporting and research efforts by months – maybe years – for any given project.

So far we have acquired and analysed 11 million rows of data on the US health care system, and the bulk of it is now publicly available at

Let me say that again.

We have acquired and analysed 11 million rows of data on the US health care system, and the bulk of it is now publicly available at

Man, that feels good. More data is coming (if you have some, please let us know), and coupled with our HIT efforts we stand ready to process the coming flood of data from electronic health records for up-to-the-minute performance reporting.

I will probably be blogging a lot less here, and will be switching to the Pellucid blog at least until it’s steady on it’s feet, so please join me there. And stay tuned for this summer’s work load to be released publicly: we have an amazing interactive flash app covering a whole bunch of data in Illinois; an atlas of US health care about to hit; a new HAF report card – and of course more data on more providers.

If you feel like funding us, please give us a call…

*Technically it’s seven layers of purgatory – hell has nine levels.

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Partners in Health

My boss – Dr Anthony Shih – is co-author of the chapter “Achieving the Vision: Payment Reform” in the recently published book “Partners in Health”, available in Hardcover and Kindle.

“The combination of visionary leadership, knowledge, and superb timing makes this book a winner. Health care is evolving toward collaboration and integration, and this book is essential reading for anyone wishing to change the relationships between hospitals and physicians.”—Donald W. Fisher, PhD, president and CEO, the American Medical Group Association

“This book is a must-read for anyone committed to a high-performance health system. It spells out the practical steps that will move us toward an accessible, coordinated, patient-centered system of care. Its recommendations for payment and regulatory reform underscore the urgency of comprehensive health reform if the current misaligned incentives are to be changed to support those on the frontlines in providing the best care with prudent stewardship of resources.”—Karen Davis, PhD, president, The Commonwealth Fund

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Should Paul Levy be More Transparent?

As many of you already know, health care transparency evangelist Paul Levy, CEO of BIDMC in Boston, is having a bit of of trouble with his professional life apparently colliding with his personal life. Details are unknown, but include an inappropriate relationship with a subordinate. Mr Levy apologised to his staff via e-mail for his lapse in judgement, and little else is known.

The Boston Herald has run a few pieces about this, and sent a reporter down to Ohio where Mr Levy was speaking about health care transparency at a conference. The Herald is having a grand old time asking a transparency leader to be transparent about this particular incident, basically flogging the story as “Mr Transparency has something to hide” while Mr Levy ducks the reporter and tells everyone at the conference not to talk to the media.

So the question is probably a valid one. If you are a thought leader and public speaker on transparency in the hitherto opaque world of health care business and outcomes, shouldn’t you tell us all who you’re having sex with and when?

Hmm, now that I say it out loud, it doesn’t sound so valid. But let’s examine it a little more. Continue reading

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I Bet They Ain’t Moving to Canada

ATLANTA, Georgia, March 19, 2010 ( – A new poll reveals that President Barack Obama’s health care reform may push as many as a third of the nation’s practicing doctors into shuttering their offices and getting out of the medical business entirely.

In other words, the doctor may not be in to see you shortly.

According to a survey conducted by The Medicus Firm, a nationally retained physician search firm, “nearly one-third of physicians responding to the survey indicated that they will want to leave medical practice after health reform is implemented.”

Sounds like a quick fix for bringing down the national spend. Would less doctors per capita be a good thing?

Dennis Cauchon, USA TODAY -Others worry that more physicians will drive up the cost of medical care, not make it cheaper and more accessible. Physicians will order more tests, more procedures and more drugs — without improving the nation’s health, they say.

“Doctors create their own demand,” says physician Don Detmer, co-chairman of an Institute of Medicine committee that, in 1996, recommended cuts in funding for medical residents. “If we produce an abundance of doctors, there’s little incentive for the system to become more efficient.” The Institute of Medicine is an independent group created by Congress for advice on medical issues.

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Field Trips are Fun! Random Op-Ed is Fun Too!

I received a link this morning to a cutesy video wherein Doctor Marshall advocates for Congress to come visit a hospital on a field trip and truly learn what’s broken in health care. Obviously, a day late for me, but nonetheless it sparked a few thoughts which I’ve jotted down below. Continue reading

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About Health Satisfaction Two Point Oh!

The past year has seen some leaps and bounds in the way me and my team can rapidly handle publicly reportable data and get it onto Web sites. The two underpinnings of this are CLAIRE, the Claire Lightweight Agile IPRO Reporting Environment; and Pellucid, the health care transparency database system. CLAIRE is a software framework built on CakePHP that allows the dev team to grab up Pellucid data and quickly deploy Web applications. Pellucid is a MySQL data warehouse we built to house every single publicly reportable value we know of or can calculate in house. More on both of these technologies later.

So last week I initiated a test. I gave the dev team a week to come up with a complete rewrite of our Hospital Satisfaction Web site, and lo and behold they did it! You can go visit and review patient surveys of nearly every hospital in the US! Why are you still here? Click the link already.

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Good Driver Discount

Seems to me the health insurance companies go on and on about how it should be more like auto insurance, everyone needs to be in the pool. I’m in favour, generally, although I wish it were a single-payer pool, but that aside… if we are all going to be in the pool, how about some good driver discounts? If I quit smoking, I don’t get my premium lowered last time I checked. For auto insurance I can take a defensive driving course and knock 10% off the bill. How about reducing my premium for attending wellness sessions?

The difference between auto insurance and health insurance is that it’s not a definite that you’re going to have a car accident. You are most definitely going to get old and die. If you take good measures along the way to reduce your level of sickness, shouldn’t you get a discount? Insurance companies wishing to adopt my proposal can do so free of charge, but I wouldn’t mind a carton of cigarettes and a bottle of scotch as a nice thank you. INCENT ME!

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Save MySQL

Sign The Petition.

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Why Not The Second Best?

‘Tis the season to work all night every night for a couple of weeks. The newly updated went live this weekend, with a spiffy new look and four gajillion new rows of data.

Well, truth be told it’s about six million rows. But it’s still a lot. WhyNotTheBest is a Web property funded by the Commonwealth Fund that is geared toward health care providers and policy makers, the basic intent being to identify the top performers for a range of measures and allow anyone to compare (benchmark) themselves against these top performers.

The new design is thanks to Digital Wave who laboured over a very functional search engine that allows any user to add as many hospitals to a comparison list as they want.

The new site contains a bunch of new data, notably the readmission and mortality rates published by CMS for several conditions, and we included average Medicare reimbursements for the same conditions.

In addition we added a whole slew of new filters, so it is now possible to create groups of hospital by Dartmouth HRR (Hospital Referral Region), by ownership, by health system and a whole lot more.

As always the data drives the user to improvement tools and intervention material that will help improve quality of care for the measures being published.

Please go check it out and comment here if you have some feedback!

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