Comment on HMOs

[platinumdoc]

The problem with medicine, nowadays, is the financial bottom line and the quantity of patients seen. HMOs, in my opinion, have sacrificed QUALITY for QUANTITY. Keep in mind the latest phrase in the healthcare field is 'CUSTOMER DELIGHT'. You are no longer a 'Doctor' or 'Physician' but a Primary care manager (PCM) or Provider. People are no longer 'patients' but 'clients' or 'customers'. As physicians, we need to take charge and control of the situation. We need to hold these HMOs more accountable for the detriment that they have created for patient care. We need to move towards the end of HMOs. Give the decision-making back to the 'patient-physician' alliances rather than to the big insurance companies.

Have these changes caused you reasses your career goals and dreams?

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[MacGyver]

I see what your saying and definitely agree with your ideology.

However, from a practical standpoint HMOs and their affiliates are NOT going to go away, EVER.

Unless the American population can suddenly afford to pay out of pocket for their healthcare (which they will never be able to do) then HMOs will always be around.

The cost cutting measures they use are sometimes nefarious, but there HAS to be some kind of managed care. Otherwise, the only kind of patients you will be able to treat are those that live in the rich, affluent communities and can afford to pay $30 per aspirin and $1500 for an MRI.

 

[Flea]

MacGuyver,

Have you ever worked for an HMO??... it's not cost containment, it's all a illusion- they preach "cost-containment" in one hand and so thier best to get out of paying with the other (even when it drives up the cost)

If HMO's were such a great idea. Why have cost sky-rocketed?? The simple answer (maybe alittle too simple ) is that the HMOs have continued to focus on short-sighted cost containment and pay dodging.

A prime example of presbyopia.........

My clinic was FORCED to switch the majority of the hyperlipidemia patients to BAYCOL--even when they were well controlled on thier current med!! (if you didn't, your day was further drug out by filling out extra "excuse" forms). Because of "short-sighted" studies that said it was "as good" as lipitor, zocor, etc--we now are making hundreds of calls and extra pt visits ($150 dollars a pop- for f/u labs/lipid manegment)-- the fact that people died on the med means nothing except in the cost of the hospitalization and the final code.
Even of it was not taken off the market, it still required frequent LFTs--all money that the presbypotic bean counters didn't add together !!! I switched as few people as possible -- why because in my MEDICAL opinion it did not have a long enough track record...

Pay Doging

Failing to pay for/approve/"loosing" procedures requests until the forms have been REPEATEDLY submitted-- this requires more support staff and Physicians time/pay to continually fill this crap out---
People with a high school education are turning down procedures because "a cook book" says so... For example, I request a DEXA screening for one of my post-menopausal females turned down for one of my patients because I used the word "screening" in the diagnosis slot- So I spent an extra half hour trying to fix it-- just to PREVENT a costly hip fracture (ie death) in the future....why don't they want to pay for it..they are hoping she'll be kicked out of the system before she breaks something......

That NOT cost-containment....

There's a reason " 50% of California's Physicians plan on either retiring, quiting medicine or leaving the state in the next 3 YEARS" AMA News August 2001

There are doctors offices that have gone to taking only cash or discount people that pay cash--- most are doing well with HAPPIER staff-- why, no more arguing with the bean counters- they were able to cut the patient visit cost IN HALF--why, they were able to cut their staff size in half (no more repeated filings).

HMO's are an interesting ideas-- but the current version will bankrupt things as fast, if not faster.........

 

[MacGyver]

What do you mean costs have skyrocketed? Costs to whom? Doctors or patients?

The fees charged by HMOs to patients are FAR CHEAPER than paying out of pocket for healthcare.

Now I dont agree with everything HMOs do, but you got a better idea to where patients dont have to pay $4,000 for a one night hospital stay?

It sounds like the HMO affiliated with your clinic is a bad apple. All HMOs are not like that one.

Are HMOs a perfect solution? No. Do they allow patients to get access to ALL areas of healthcare, regardless of the cost? No. But they do recognize that there HAS TO BE A COMPROMISE between costs and state of the art healtcare.

All I'm saying is that something has to bend. The average American can't afford to pay out of pocket for healthcare. Therefore, there has to be a compromise on the very expensive technologies that the patient utilizes.

We all know that HMOs are MUCH CHEAPER for patients than trying to pay for everything out of pocket, so I dont understand your point about increasing costs. From the patients perspective, joining an HMO brings DOWN costs.

Take me for example. Awhile back I had a broken arm and had to go to the hospital. My HMO charged me a $100 deductible. All other costs were covered by the HMO.

Do you know how expensive it would have been for me to pay out of pocket? I would have been looking to pay at least 3500-4500 dollars.

So lets see here... $100 vs. $3500? No contest.

 

[platinumdoc]

Macgyver,

I agree with regard to the 'patient/client/customer' point of view, I was venting out with regard to the 'practioner/provider/healer/physician/doctor' point of view....How about the single mother who can barely cover her expenses to take off of work but has to make another appointment to cover another issue because 15 minutes is just not enough?

The HMO has taken away much of the incentive to do more. It makes MDs/DOs frustrated. It makes patients/customers/clients frustrated.

For example, how can a person be evaluated in 15 minutes, given counselling regarding their condition, cover preventive medicine topics, and give time for questions? Try seeing a woman with lower abdominal pain and fever in 15 minutes and cover the above. How about the sobbing depressed female with no relatives in the area,except for the 4 preschool-aged children, and has been passed around the health care circle...completely frustrated...?

The focus is quantity not quality. The system forces us to practice at such a high pace but patients expect delivery of much more than that...in the same amount of time.

 

[mcwmark]

Unfortunately, critics and supporters of HMOs will always battle. Critics of HMOs give the classic arguments as detailed above.

But many people overlook the benefits of having such an organization. Cost to the consumer, is addressed by a post above. "Access" to health care is increased (debatable) as the inital cost of an appointment is cheap and accessable (15 minutes for an appointment is better than nothing!). HMOs, being a large organization, have more power in bargaining for lower prescription drug costs. There is an incentive for HMOs (or at least should be) to keep their patients healthy, so you will see health awareness programs, aggressive screening programs, vaccinations, etc. Finally, there is a watchdog to prevent gouging of the system: ordering every single test and doing unnecessary procedures to pad your own pocket.

While you say this makes patients and physicians frustrated, look at it from before HMOs existed. Who got medical care? The rich. Many unscrupulous physicians made a ton of money doing procedure after procedure, many unnecessary. The advent of HMOs have shifted the balance (sometimes too far) toward cost-efficient health care.

HMOs are not evil, but they are far from good. I would argue that the general prinicples of the HMO is the best way to administer health care. Cost containment is a necessary evil in today's expensive health care arena: while it's hard to justify withholding a $200,000 experimental treatment on a patient that has a 5% chance of survival based on the principle of beneficience, it's hard to justify (justice) that when you can use that money to vaccinate 100,000 kids against childhood diseases. If you had only $200,000 where would you spend the money?

The person that eventually figures out how to make it work well...should win the Nobel prize.

 

[mcwmark]

Get rid of HMOs? Here's one thing that can happen:

From today's SF Chronicle: (I cut out some of the more mundane stuff)

Health care nightmare
Retirees hit hard as HMOs pull out of state's rural areas

Take the case of Bobby and Irene Dickens. The couple ran into problems finding affordable health care last March when they moved from Vallejo to Redding. The Dickenses finally found health insurance options that cost $264 a month plus another $175 for their prescription drugs. Under their old HMO plan, they paid $30.

The higher costs have dashed their dreams of traveling in their retirement. "You can't do that when you've got to pay for your medicines," said Irene Dickens, 63.

What makes HMOs a tough proposition in those markets is essentially a numbers game. HMOs rely on a system in which doctors' groups and hospitals are paid a set amount per patient each month regardless of whether that patient is seen. The theory is that with a large enough pool of patients, those patients who are healthy and hardly ever go to the doctor will subsidize the bills of those who are ill.

In rural areas, the whole system is thrown off kilter because there simply are not enough residents to make it work. Also, rural people tend to have more health problems: They are often older, sometimes poorer, and tend to be more independent and seek help after rather than before a health problem becomes serious.

"There really aren't enough people in those areas to make it possible to negotiate discounted prices," said Roger Greaves, chairman of Health Net of California. "It's a shame it's not possible to provide those kinds of services throughout the rural areas, . . . but it's not financially viable for health plans to go into rural areas."


Older residents -- including the many Bay Area people who chose to retire in rural Northern California -- often discover that their health care doesn't cover them once they move, or they have to drive hours to the nearest region that will accept their coverage, Paoli said.

"I didn't even think of there not being an HMO here. When I got up here I found there was no HMO at all," said Lorrene Henningsen, 69, who moved from outside Sacramento to Redding about a month ago.

"I moved up here not knowing what I was going to do with my health care," she said. "I knew I needed more than what I got under Medicare, and I knew I had to pay more for it."


PATIENTS SCRAMBLE
The upshot is that many people in rural areas have to switch insurers, pay higher premium and out-of-pocket costs, or possibly travel outside the area for care.

Rachel Dickerson, a 30-year-old mother of two boys in Eureka, thought her family was already paying a lot at $164 per month for a Health Net HMO. She switched to the plan earlier this year when it was first offered to her husband, a Humboldt County correctional officer, through CalPERS.

Now the family has to switch to another option, a preferred provider organization, or PPO, beginning next year, when no HMOs will be available in the area. A PPO, also a form of managed care, charges higher premiums and other costs in exchange for greater choice in physicians and treatment options.


RURAL DOCTORS JUST SAY NO
Doctors and hospitals also contribute to the anti-HMO atmosphere in rural areas. Because there tend to be fewer doctors and hospitals, there is less competition for rates. Insurers say the doctors and hospitals can refuse to accept the traditionally low reimbursement rates offered by the HMOs.

Dr. Antonio "Ben" Balatbat, an internist at the UC Davis Medical Group in Colusa, which is about 70 miles north of Sacramento, acknowledges that the lack of HMOs was one of the draws to working in a rural area because he has more control over patient care.

Balatbat said he would like to accept more HMOs because it would make his services available to more people, but he has been unable to negotiate a contract through the university.

Not everyone agrees that the cost of providing health care in rural areas is higher and that HMOs cannot work.

Steve McDermott, chief executive of Hill Physicians Medical Group Inc., a large doctors group with headquarters in San Ramon, doesn't believe that medical care is higher in those regions, because various expenses, such as labor and rents, are generally lower.

He said his group can no longer provide care to some 20,000 patients -- 12, 000 Blue Shield members and 8,000 Blue Cross members in Shasta and Tehama counties -- because of a CalPERS rule that requires HMOs that provide service in a county to make that service available to all CalPERS members.

CalPERS spokeswoman Patricia Macht confirmed the rule, but said it exists to prevent HMOs from picking some members over others.

McDermott said he believes that an HMO can work in rural areas, but he questions whether or not everyone has the right to HMO coverage in every area.

"If you're living in a rural area, you're making a conscious decision about lifestyle and access to certain services," he said. "You're going to have limited access to certain kinds of services."

 

[MacGyver]

I dont agree with everything HMOs do, and its true sometimes they are out of line.

And they do place caps on what the doctor can do for the patient.

But lets face it, SOMETHING had to change. Patients cant afford to pay for $1500 MRIs and other expensive procedures.

There MUST be some costsaving measures in healthcare. No matter how you cut it, its going to pinch us all, but it must be done.

Otherwise many millions more will lose access to healthcare. At least with an HMO, patients can get basic access to medicine. Without HMOs, they would be excluded from medicine completely.