HMO AND MANAGED CARE MEDICINE
Protect Yourself Against Inadequate Care
by Your Managed Care or HMO
or private doctor
As HMOs have become a very frequent medical plan of choice, it is
increasingly important for patients to take responsibility for what goes
on when they go to see a doctor, especially for something serious. Within
the HMO environment the standard of medical care in the United States is
very rapidly declining. In order to understand why this is a fact, one
should understand exactly how an HMO works.
HMO stands for "health maintenance organization". HMOs demand of their
doctors that patients are treated so that the costs to the insurance
companies (HMOs) are as small as possible. This attitude causes the
doctor to give the patient as little medical service as possible. Under
traditional health insurance plans, the doctor treats the patient and tries
to ensure his or her recovery. As long as the doctor does not engage in
unnecessary treatment, the insurance plan pays most or all of the
patient's bills, after the patient pays the deductible. The doctor under
traditional health insurance plans has the freedom to fully diagnose and
treat the patient, even if some testing or treatment later proves to be
unnecessary. While this system definitely results in higher health
insurance costs, it possibly helps to prevent missing the proper diagnosis
and the
best treatment.
HMO's change all this. HMO's pay a given doctor, called the Primary Care
Physician (DOCTOR) a set fee per patient per month. This fee is usually
small, possibly as low as $1.50 per patient per month. The DOCTOR has
to have lots of patients on his patient rolls to meet his overhead. The
DOCTOR receives $1.50 per patient per month (if $1.50 is the set fee)
no matter how often he treats the patient, and no matter what procedures
the DOCTOR uses on the patient. So, the DOCTOR receives $1.50 for the
healthy patient he does not see, and also receives $1.50 for the
cancer-stricken patient who needs nearly constant care.
The DOCTOR, then, profits when he doesn't see or treat the patient, or
when the DOCTOR, sees him or her as seldom as possible. This is in
contrast to the traditional health insurance plan, where doctor profits
when they treat patients fully and completely. Under HMOs, doctors only
show profit for themselves when they never or very rarely see patients..
Doctors lose money on patients they have to see often, because the doctor
then has to spend a lot of time and office resources treating and re-
treating the same patient. No matter how often the doctor treats the
patient, the HMO fee to the doctor does not increase.
HMOs vary among themselves on providing specialist care. Some HMOs are
very strict, and will not pay extra for a patient who needs a referral to a
specialist. Some HMOs will even charge the DOCTOR if the patient's
specialist care exceeds a set minimum. Of course, the HMO decides to
whom a DOCTOR can refer a patient for a given specialty, and the
specialists are also under the same set-fee program as the DOCTOR's.
This explanation is easy to follow. The DOCTOR has to make a decision;
how much money he is to keep against how extensive or complete the care
is to be given to the patient. HMO doctors answer these economic tensions
by cutting back on care, and only doing what is absolutely necessary for
patients whose symptoms cannot be questioned, (an acute heart attack,
broken bones, etc.) often denying necessary care to other patients whose
symptoms are less severe.
So-called "second opinions", while common in
"private practice" medicine are almost non existent in the HMO practice.
The DOCTORS, in many HMOs are forbidden by the HMO to tell the patient
about treatment choices that they may have regarding their problem,
although many States have passed laws forbidding this conduct. The
patient is presented with only one way to treat the problem, even though
another method may be more favorable for the patient and cure him or her
in a much shorter period of time, but that treatment is more costly than
the treatment which is chosen by the DOCTOR, because it saves the
DOCTOR money, or because the cheaper form of treatment is dictated by
the HMO policy. As an example, many HMOs forbid the DOCTORS to
administer the medication that has proven to be the most effective for the
patient, instead the DOCTORS must use the cheaper and less effective
drugs that is decided upon by the HMO.
The DOCTORS themselves are rarely ill-willed towards their
patients, and rarely ill-intended. It is simply a case that these doctors
need to survive economically, and the HMO system forces hard choices
upon those doctors who would wish to make their monthly overhead.
