Kaiser Insurance- San Diego: good, bad or ugly?

I have to credit Kaiser for finding my tumor. I was under 50 with dense breasts, and after having my first mammo at age 45 (outside Kaiser) which resulted in an ultrasound follow-up, I realized mammos were always going to be complicated for me and I never wanted to have another. But Kaiser is all about preventative medicine. First, they sent me letters saying I could get a free gift if I came and had a mammo. Then, they called and asked "When can we schedule you for a mammo next week. Appointments are available every day from 8am to 8pm." (They did the same thing when I got behind on pap smears too.) How can you refuse that? My tumor was discovered on the mammo and I had the biopsy and was seeing a surgeon 10 days after I went in for the mammo. 

I have been happy with my care, however, I have also been proactive. When I said I wanted TC not AC+T because evidence coming out of UCLA was showing A wasn't effective for ER+ bc, I got it. It took a couple of visits of pleading for a cyp2d6 test to see how well I was metabolizing tamoxifen, but my onco did give in. Kaiser does do things by "evidence based medicine" which means you may not get what you want, but you also won't get stuff that hasn't been shown to work. (I do sometimes wonder what I would do if I were stage IV. I think I would pay out of pocket for a 2nd opinion at UCLA and then take the suggestions back to my Kaiser onco. If it was in any way possible I think she would try to get me the treatment I wanted.)

One thing we've learned about dealing with Kaiser -- they like to keep you in your geographical area BUT you can get referred to other areas. Like, San Diego has a great pain center so we got my daughter with chronic headaches referred there and they gave her the treatment that finally got her functional again. I have mild lymphedema and my Kaiser doesn't have a fully trained therapist for it. They tried to pawn off an OT who didn't know how to do complete decongestive therapy on me, but when I said that I needed someone fully trained, I got someone in another area. I know that my area only does implant reconstruction, but there are SoCal Kaiser plastic surgeons who do other types and some women have been referred to them. Again, you have to be proactive, but isn't that the way all medicine is getting?

Also, many docs want to be in a system like Kaiser's so that they can have a life, treat patients, and not have to deal with insurance issues. They have a lot of quality physicians as a result, especially women. I'm ok with male docs (my PCP is one) but I also thought it was cool that my whole bc team -- surgeon, medical oncologist, radiation oncologist -- were female. 

Hi Soccermom,

I posted a reply yesterday.  Not sure what happened to it.  But here is a basic overview of the situation re: your insurance decision

*From what I understand in your post, you don't qualify for Cobra re: ex's PPO because you already had your own insurance - Kaiser.

*You wouldn't be able to get the new PCIP California insurance plan - - because you must have been without insurance for 6 months before applying and have a current medical condition.  You can't do that. You would not want to risk being without insurance for 6 months. The new California plan is partially subsidized so it is a little cheaper than some of the other plans though.

*Re: buying your own PPO - an individual plan.  Well, this has been a problem for years.  It is very hard to be accepted for an individual PPO plan.  They do underwriting first - that means that they look into both past and present conditions.  If you are presently taking any medication - that could be called a current condition. You could be denied coverage.  For this reason, it has been very difficult for folks to buy a private policy in the US unless they are very healthy.

*Even if you could pass the underwriting, you might not be able to afford an individual PPO plan.  I have seen them cost anywhere from $600 to $1,200 per month - for someone between 50 or 60 years old.  Increasingly, they are more in the $800+ range per month.

*Yes, it is true.  You are lucky to have an employer sponsored plan where the employer pays most of the premiums.  Have you asked the employer if they offer more than one plan during the yearly open enrollment?  Most larger companies offer a number of plans - HMO and PPO.  However, the new copays and out of pocket maximums can really be expensive.

*Some patients don't like HMOs because they can't get a referral outside of the plan to see a specialist who might have more expertise.  For that reason, they want to stay with a PPO.  Increasingly, I see that most patients can't stay in the PPO - even if they have the choice at work - because of the cost of these plans - not the premiums but the out of pocket maximums. 

* One important thing to remember is that you can always appeal to the HMO.  This means that you ask them to send you to the outside specialist.  Your HMO then pays the bill.  I have done a number of these appeals and have won a number of cases.  However, we usually had to prove that the HMO did not have a specialist - for a particular type of rare cancer- within the HMO.  In cases of rare cancers, that is not too difficult to prove.  There may be only one or two specialists in a region who are experts.  And, those two specialists don't work for the HMO.  Those cases usually have positive results.  The HMO agrees to send you out of plan.  And, the HMO pays. 

*The problem comes in when the HMO has many qualified specialists in your type of cancer.  Then, it is very difficult to win the appeal. 

*At any rate, it is always worth a try.  Most patients don't understand how to appeal and how to win their case. 

Good luck. 

Thriver