An HMO (or “health maintenance organization”) requires you to select a primary care physician (PCP) who acts as "gatekeeper." Think of your PCP as your personal health-quarterback, strategically coordinating all of your care and providing for your basic healthcare needs. If you ever need to see a specialist or require a diagnostic service (such as a blood test), you will need a referral from your PCP. Your referral will always be to a provider within your HMO network. If you choose to see a doctor outside of the network or without a referral, you will generally have to pay all costs out-of-pocket unless it is a true medical emergency or you have no other options. With an HMO, your physician network is local.

A PPO (or “preferred provider organization”) is a health plan with a “preferred” network of providers in your area. You do not need to select a primary care physician and you do not need referrals to see a specialist. If you see a “preferred” (or “in-network”) provider, you will only be responsible for paying a portion of the bill (according to your plan's coverage structure). If you choose to see a doctor who is outside the preferred network, you will generally have to pay a larger portion of the bill than you would for an “in-network” provider, but most plans will still cover a portion of the bill. With a PPO, you will have access to out-of-state providers that are considered in-network.

An EPO (or “exclusive provider network”) is a bit like a hybrid of an HMO and a PPO. EPOs generally offer a little more flexibility than an HMO and are generally a bit less pricey than a PPO. Like a PPO, you do not need a referral to get care from a specialist. But like an HMO, you are responsible for paying out-of-pocket if you seek care from a doctor outside your plan's network. An EPO is a good option if you want to see specialists without a PCP referral within your network.

A POS (or "point of service”) plan is also a hybrid of an HMO and PPO plan. Like an HMO, you will need a referral from your PCP in order to see a specialist. But, like a PPO plan, you will pay less if you use doctors, hospitals, and other healthcare providers in the plan’s network, and you will have access to out-of-network providers at an increased cost.

FACTS & STUDIES

The 35 most expensive conditions accounted for 70% of all hospital costs in the US...Medicare covered 46% of that cost, with Medicaid pitching in 17%. Private insurance paid for 28% of the cost, while 5% went to patients who were uninsured.

1. Cardiac and circulatory congenital anomalies  Congenital heart disease and heart murmurs are among this group of heart and lung problems.

Average cost per stay: $63,460 Percent of all US hospital stays: 0.1%

2. Heart valve disorders Heart valve disorders is a catch-all term for any illness stemming from the improper use of any of the four heart valves that controls blood flow.

Average cost per stay: $42,647 Percent of all US hospital stays: 0.4%

3. Aortic, peripheral, and visceral artery aneurysms  Aneurysms have different names depending on where the weakened artery is located.

Average cost per stay: $34,656 Percent of all US hospital stays: 0.2%

4. Coronary atherosclerosis  Coronary atherosclerosis is a heart disease caused by plaque buildup in arteries, preventing proper blood flow.

Average cost per stay: $20,936 Percent of all US hospital stays: 1.1%

5. Acute myocardial infarction (heart attack)  Acute myocardial infarction is the medical name for a heart attack.

Average cost per stay: $20,246 Percent of all US hospital stays: 1.7%

6. Complication of device, implant or graft  Devices, implants, and grafts are placed in the body during surgery to correct a clinical condition.

Average cost per stay: $20,175 Percent of all US hospital stays: 1.8%

7. Intracranial injury  A traumatic brain injury is a serious blow to the head causing brain dysfunction.

Average cost per stay: $19,539 Percent of all US hospital stays: 0.6%

8. Spondylosis, intervertebral disc disorders, other back problems  Spondylosis refers to any degeneration of the spine. Intervertebral disc disorders is the breakdown of the discs in between the bones of the spine.

Average cost per stay: $18,978 Percent of all US hospital stays: 1.5%

9. Septicemia  Septicemia— or sepsis — is blood poisoning caused by a bacterial infection.

Average cost per stay: $18,031 Percent of all US hospital stays: 4.3%

10. Respiratory failure, insufficiency, arrest (adult)  Respiratory failure and insufficiency happens when the lungs cannot produce enough oxygen or expel enough carbon dioxide. Respiratory arrest is the cessation of breathing.

Average cost per stay: $17,868 Percent of all US hospital stays: 1.2%

11. Cancer of bronchus, lung  Lung cancer— or bronchial carcinoma — mainly caused by smoking.

Average cost per stay: $17,530 Percent of all US hospital stays: 0.4%

12. Secondary malignancies  New cancers that arrive as a result of treatment of a first cancer are described as secondary malignancies.

Average cost per stay: $17,163 Percent of all US hospital stays: 0.5%

13. Fracture of lower limb  Broken hips, knees, tibias, ankles, and other lower body bones are included here.

Average cost per stay: $16,796 Percent of all US hospital stays: 0.6%

14. Peripheral and visceral atherosclerosis  Atherosclerosis restricts blood flow to the heart by clogging of the inner walls of the arteries.

Average cost per stay: $16,771 Percent of all US hospital stays: 0.4%

15. Fracture of neck of femur (hip)  Breaks in the neck of the femur are common among athletes and elderly individuals with osteoporosis.

Average cost per stay: $16,133 Percent of all US hospital stays: 0.9%

16. Maintenance chemotherapy, radiotherapy  Chemo and radiation therapy are both types of cancer treatment .

Average cost per stay: $15,988 Percent of all US hospital stays: 0.4%

17. Osteoarthritis  Osteoarthritis — or degenerative joint disease — is the wearing down of tissue between joints.

Average cost per stay: $15,897 Percent of all US hospital stays: 3.0%

18. Acute cerebrovascular disease  Cerebrovascular disease impacts the blood flow in the brain and often results in strokes.

Average cost per stay: $15,378 Percent of all US hospital stays: 1.7%

19. Abdominal hernia  A hernia is the protrusion of an organ through tissue and often occurs by the pelvic floor or abdominal wall.

Average cost per stay: $14,447 Percent of all US hospital stays: 0.5%

20. Other fractures  This category includes broken bones that are not in their own category such as skull breaks.

Average cost per stay: $14,149 Percent of all US hospital stays: 0.6%

21. Rehabilitation care, fitting of prostheses, and adjustment of devices  Rehabilitation includes "services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled."

Average cost per stay: $13,877 Percent of all US hospital stays: 1.1%

22. Complications of surgical procedures or medical care  Any side effect of surgery or a basic medical procedure is included here.

Average cost per stay: $13,565 Percent of all US hospital stays: 1.3%

23. Other nutritional, endocrine, and metabolic disorders  Osteoporosis, cystic fibrosis, and obesity are major diseases related to glands and metabolism.

Average cost per stay: $12,173 Percent of all US hospital stays: 0.6%

24. Hypertension with complications and secondary hypertension  Unlike pulmonary hypertension (heart disease), secondary hypertension is high blood pressure caused by another medical condition.

Average cost per stay: $12,164 Percent of all US hospital stays: 0.7%

25. Biliary tract disease  Biliary diseases are a group of conditions that affect the biliary system — including gallstones and pancreatitis.

Average cost per stay: $11,764 Percent of all US hospital stays: 1.1%

26. Pulmonary heart disease  A high blood pressure that affects lung arteries and the right side of your heart results in pulmonary hypertension .

Average cost per stay: $11,564 Percent of all US hospital stays: 0.5%

27. Other gastrointestinal disorders  Food allergies, lactose intolerance, and celiac disease are some of the many disorders that harm functionality of the stomach and intestines.

Average cost per stay: $11,564 Percent of all US hospital stays: 0.6%

28 . Other nervous system disorders  Trauma, infections, and tumors are some of the many conditions that affect the brain, spine, nerves, eyes, ears, or other parts of the nervous system.

Average cost per stay: $11,538 Percent of all US hospital stays: 0.7%

29. Congestive heart failure  Congestive heat failure is the inability to pump an adequate amount of blood through the body and can be caused by many diseases.

Average cost per stay: $11,500 Percent of all US hospital stays: 2.5%

30. Intestinal obstruction without hernia  Intestinal obstruction is a food or liquid blockage that may be caused by Crohn's Disease, colon cancer, or other diseases.

Average cost per stay: $10,944 Percent of all US hospital stays: 1.0%

31. Cardiac dysrhythmias  Cardiac dysrhythmia is the medical term for an irregular heartbeat.

Average cost per stay: $10,191 Percent of all US hospital stays: 1.9%

32. Diverticulosis and diverticulitis  Diverticulosis is the presence of bulging pouches in the digestive track and diverticulitis occurs when the pouches become inflamed or infected.

Average cost per stay: $10,169 Percent of all US hospital stays: 0.8%

33. Diabetes mellitus with complications  Conditions that occur from poor treatment of diabetes are wide-ranging, from vascular diseases, blindness, and chronic kidney disease.

Average cost per stay: $9,850 Percent of all US hospital stays: 1.5%

34. Pneumonia  Pneumonia is a lung condition — an infectious inflammation of the air sacs.

Average cost per stay: $9,793 Percent of all US hospital stays: 2.5%

35. Pancreatic disorders  Acute pancreatitis, chronic pancreatitis, hereditary pancreatitis, and pancreatic cancer are several of the more common disorders that lead to digestive problems in the pancreas. Average cost per stay: $9,727 Percent of all US hospital stays: 0.9%

Source:  https://www.businessinsider.com/most-expensive-health-conditions-hospital-costs-2018-2#30-intestinal-obstruction-without-hernia-6

UP YOUR GAME … ADDITIONAL GREAT READS

https://healthpayerintelligence.com/news/top-10-most-expensive-chronic-diseases-for-healthcare-payers

https://money.cnn.com/2018/03/19/news/economy/emergency-room-er-bills/index.html