Tips for Deciding Whether to Change Healthcare Plans

Tips for Deciding Whether to Change Healthcare Plans

In November, many of us decide whether to keep our current healthcare plan or make a change. I’m relatively happy with the HMO I have. My husband, who has been with a different HMO for the past three years, has been researching other options. 

Together, we’ve learned what is available in our geographic area, and have determined the factors of a healthcare plan that are most important to each of us. I’ve realized that the deciding factors for someone with fibromyalgia may be quite different from a person who doesn’t have it. 

For example, an important issue for me is the ease and speed with which referrals are made. Those of us who are frequent consumers of healthcare know that primary care physicians have been treating fewer and fewer conditions and making more and more referrals. When those conditions are frequently accompanied by acute pain, a wait of several weeks can be a nightmare. 

With my current HMO, my wait has been as short as a couple of hours and typically less than a week. With my husband’s HMO, the wait is commonly 6-7 weeks. This is where the difference comes in. Because his health issues are different from mine, and because he has a high pain tolerance, he often is content to wait. 

Regardless of what health plan you choose, knowing your rights is important. In California, where I reside, the Department of Managed Healthcare, which oversees the state’s HMOs, says that an HMO must provide “timely access to care.” For a specialist’s referral, a “timely” wait is considered to be three weeks. (FYI: Whenever I’ve had occasion to quote this requirement to a staff member at a doctor’s office, it has resulted in the scheduling of an earlier appointment.)

Equally important as the speed of a referral is the quality of the physician. In addition to education, experience, and professionalism, I’m also interested in availability, communication style, and compassion. Because of fibromyalgia’s many symptoms, I’ve met more specialists than the average patient.

In the nine years I’ve been associated with my current HMO, I’ve only been disappointed with one specialist. And even that wasn’t a big issue. No explanation was required for me to simply switch specialists within the same department during my next visit.

Of vital importance to me is communication. I am fortunate to have a relationship with a primary care physician who is an excellent communicator. If I email him with a concern, he responds the next morning.

This is in sharp contrast to the communication at my husband’s HMO. If he emails his primary care physician, he can expect a reply within a week, and it likely won’t be from his doctor, but rather one of the clerks who rarely interprets an issue correctly. This results in a phone call and additional waiting for a reply. In all, it could easily take 10 days to have a question answered.

Of course, there’s much one doesn’t know about any health organization until becoming a member. A recommendation from someone you trust is a valuable resource. However, if you happen to be assigned to a different primary care physician or have different health issues, your experience may be different than theirs. 

If you’re also struggling with this decision, try listing the items that are most important to you. Then see how many are available with the care you now have. If many are missing, you might try asking friends, relatives, or neighbors for suggestions. Most people are happy to share the names of doctors they really like, and they are even more anxious for you to know about the ones they would never recommend.


Note: Fibromyalgia News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Fibromyalgia News Today, or its parent company, BioNews, and are intended to spark discussion about issues pertaining to fibromyalgia.

Leave a Comment