The ABC’s of health insurance
HMO, PCP, PPO, POS — feel like you’re wading through alphabet soup? Read on for translations of common terms.
• Health maintenance organizations (HMO) require you to choose a primary care physician (PCP), who coordinates all of your care, including visits to specialists.
• Preferred provider organizations (PPO) let you make your own choices from a network of preferred providers (in some plans, you can pay a higher fee for out-of-network care) and may not require you to have a primary care physician.
• Point-of-service plans (POS) let you choose between receiving care from participating providers (you’ll be reimbursed more for this), or non-participating providers(you’ll be reimbursed less for this).
Some plans offer lower premiums (monthly payments) in exchange for a higher yearly deductible (the amount you must pay personally before insurance provides any coverage). Some plans require co-pays, a set fee you pay for health care visits or medications. Others ask you to pay co-insurance, which means you’re responsible for a portion (20 percent, for example) of eligible expenses charged by a provider or the amount the insurer agrees to pay for specific services.
Many plans require preauthorization or precertification for certain services, such as surgery or visits to a specialist. Some pick up the tab on preventive care services, such as flu shots, cholesterol tests, or colonoscopy. Most have formularies that list pre-approved, commonly prescribed drugs.
The root of the problem
Medical histories play an essential role in determining future lifestyles
Knowing a family medical history can sometimes reduce the risk of inherited diseases through timely screenings and lifestyle changes.
Many of her relatives were dead and their medical histories — to the extent they were written down — died along with them.
That didn’t deter Robertson. The information that she could collect was a good start — and changed her life.
Both of her parents died from strokes, but it was her father’s history that particularly stood out. He had two strokes, and the second one was fatal. He was 44 years old when he died.
Those genes were passed down. Already, Robertson’s older sister has had a stroke, as has one of her nephews. So far, Robertson has been spared, but she is not taking any chances.
“I want to prevent these illnesses in myself,” she said.
Knowing that strokes and diabetes run in her family, Robertson has changed her lifestyle to control those risks.
She has substituted water for sugared beverages, reduced her portion sizes and eats more vegetables. And she exercises.
“I walk a lot now,” she said.
The value of family medical histories is enormous, largely because many illnesses are passed down from generation to generation. Many diseases, such as cancer, diabetes, high blood pressure and even mental illness, have a genetic link.
So important is the family history that the Surgeon General in 2004 launched a Family History Initiative to encourage families to learn more about their inherited health risks. The Surgeon General designated Thanksgiving — a holiday when families gather — as National Family History Day. The Department of Health and Human Services has created a web-based tool at https://familyhistory.hhs.gov that allows users to enter, print out and save the information.
The family history tree is an essential tool for patient empowerment.
In the 2004 HealthyStyle survey, the Centers for Disease Control and Prevention found that 96 percent of the respondents believe that family history is important for their own health; yet a paltry 30 percent reported that they actively collected necessary information. One difference was noted, however. Those with a personal history of type 2 diabetes were more likely to have collected information from relatives.
The family medical history tree allows a doctor to assess risks for a certain disease, determine the type and time of screening tests and judge the risk of passing the conditions on to the next generation.
For instance, women who have a history of breast cancer — especially when diagnosed at a young age — may require initiation of mammograms before the age of 40 as well as a concomitant MRI.
“The biggest concerns are cancer and heart disease, especially in the young,” said Dr. Mark Drews, an internist at Whittier Street Health Center. “If you’re 40 and your brother died of cancer at 40, you should know which cancer. If it was prostate cancer, you need to start screening now. If it was lung cancer and he was a heavy smoker, there is less concern.”
An ideal family history includes at least three generations. Primary relatives — parents, children and siblings — are most important. But grandparents, aunts, uncles and cousins should not be overlooked.
What should trigger attention is a disease that occurs at an earlier age than expected, a disease in more than one close relative, a disease that is atypical for that gender — for instance breast cancer in a male — and certain combinations of diseases, such as breast and ovarian cancer.
It takes a bit of detective work to complete the history. Ask questions, review death certificates and available medical records. Determine age of diagnosis and age and cause of death. List ethnic backgrounds as well.
The history is a work in progress and should be corrected and edited as new information comes to light. Most important is to pay attention to what’s been revealed.
Lifestyle changes — healthy diet, exercise, and smoking cessation — will not change your genes, but can reduce the risk of the diseases. The fact that your family has a certain history is not a guarantee that you will likewise be afflicted.
Originally from the West Indies, Robertson readily admits she is not through with her history. “I’m going home this year,” she said. “I can get more information from my family then.”