interview question - HMO ?

[shch0730]

so I was strugging with the following sample interview question. What would you guys say about it? How you you answer this question?

"How would your plans differ if you knew that all physicians would be working in HMO’s in the future?"

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[VikingLegacy]

baleeted

 

[laxplayanumba16]

Instead of being a nearly completely independent physician who can be a jack of all trades in addition to being my own man and planning my own days, I would show up from 8 to 5, give checkups to strangers and write referral letters, whereas in private practice I could be doing knee replacements, delivering babies and giving out psych meds all in the same day.[/B]

I'm not too sure about all these claims, particularly the bolded, but like you I don't claim to be an expert on the matter. From what I've just now read after a google search, it seems that HMOs do provide a steady stream of patients, which is great because you don't have to worry as much about running short of business, but being an HMO PCP severely limits the scope of your practice. If you don't follow the preset guidelines of the HMO, you either fight tooth and nail to be able to provide what you want for your patients, absorb the costs yourself, or risk getting booted from the network. There is actually a financial incentive to NOT stray from the HMOs guidelines.

Most of what I said was gleaned from this site, which helped to simplify the subject for dummies like me. http://www.smartmoney.com/spending/deals/10-things-your-hmo-doctor-wont-tell-you-3924/

 

[LizzyM]

HMO stands for Health Maintenace Organization. It is a type of capitated system whereby the physican is either paid a flat fee to care for a group of patients who have chosen him as their primary care provider or the physician is an employee of the HMO and is salaried to care for patients within the closed system (meaning that patients are not covered for care provided outside of the HMO, except in specific emergency situations).

Obviously, being a salaried physician is different than being a small business owner as one is in a solo or small group practice. While patients in HMOs need a referral to get care from a specialist, it only means that you get to do more first line treatment before giving a referral whereas in a fee for service practice, patients can bypass you and to directly to a specialist.

In a solo practice you are your own boss and you need to hire people to work with you to handle things such as billing and record keeping (there are fewer and fewer solo practitioners these days except perhaps in psychiatry & derm). In an HMO, you are an employee and you are subject to a boss. Patient care decisions are still your call (although you may be encouraged and even nudged toward providing evidence based care and foregoing diagnositic tests and treatments that don't meet that criteria) but work hours and some other issues wil be decisions made by others.

I guess this question would boil down to, "would you still want to be a doc if you couldn't be your own boss?"

 

[VikingLegacy]

baleeted

 

[Vanguard23]

Viking is actually right about the bolded stuff. From what I read, that's the way that it used to be. But with HMO's becoming more prevalent, PCP have mostly been relegated to gatekeepers to specialists.

 

[Big Dog]

for a good example of an HMO with salaried physicians, look up Kaiser, which is big on the west coast. Note, one big plus to Kaiser is the near lack of insurance forms; thus, administrative costs can be lower. Kaiser is also a leader in practice guidelines, which can be a good thing since they are generally based on outcomes. Of course, the downside is that the newest and latest (and EXPENSIVE) drug will not be adopted too quickly.

 

[Vanguard23]

From what I can tell, the biggest downside to HMO's is the fact that patients' treatment options are extremely limited as well as the fact that physicians are "encouraged" to take on a higher patient volume since it's on a capitation basis. Therefore, a physician gets more money for more patients, as opposed to spending more TIME with each othem.

 

[DrBowtie]

Regardless of your feelings, the answer is, nothing would change in my desire to become a physician.

Just like the answer to "What would you do if you don't get in this cycle?" is always reapply.

 

[LizzyM]

I shadowed a family practitioner who did all of that in one day. The guy's a beast, he's been practicing forever and he's board certified in everything. He's like a one-man hospital.

Anyone who has a knee replacement done by someone who does fewer than 50 per year is an idiot. A family practice doc who delivers babies and does major orthopedic surgery? I wouldn't want to know what his annual malpractice insurance bill looks like!

That is highly unusual.

 

[VikingLegacy]

baleeted

 

[byurazorhog]

A very informative topic here; thanks to the OP for bringing this up. I'm hoping someone could clarify a few points for me though. It's been mentioned a few times earlier in the thread that HMO is a capitated system whereby a physician is essentially paid a flat fee to care for a group of patients. Now I'm not a fan of fixed salaries but isn't it true that being paid a flat fee does not provide an incentive to see more patients and hence physicians may actually be more thorough with each patient? Someone said above that HMO docs would be encouraged to see more patients and sacrifice the quality of each appointment for a higher volume and as a result higher income. BUT this is true of our fee-for-service delivery system as it is right now regardless. So I guess my confusion is: Is the flat fee per patient seen, irrespective of the nature of the care provided, OR is it a flat salary regardless of the number of patients one sees?

 

[bigbad]

Anyone who has a knee replacement done by someone who does fewer than 50 per year is an idiot. A family practice doc who delivers babies and does major orthopedic surgery? I wouldn't want to know what his annual malpractice insurance bill looks like!

That is highly unusual.

It is unusual. He's a local legend because of how broad his repertoire of skills is and how great his attitude is. We joke that he's the lord of all doctors and the mold from which all family practitioners were cast.

I have no idea if or how it works out for him financially, but he certainly loves his job and did a great job making me want to go into family practice.

Now, I don't want to sound like an idiot but can someone explain this to me. Since doctors are limited in their scope of practice, who limits it and how are these things regulated? Also, I know that PCPs have a very wide scope but how far does/can it go?

Also, very informative thread.

 

[VikingLegacy]

baleeted

 

[LizzyM]

A very informative topic here; thanks to the OP for bringing this up. I'm hoping someone could clarify a few points for me though. It's been mentioned a few times earlier in the thread that HMO is a capitated system whereby a physician is essentially paid a flat fee to care for a group of patients. Now I'm not a fan of fixed salaries but isn't it true that being paid a flat fee does not provide an incentive to see more patients and hence physicians may actually be more thorough with each patient? Someone said above that HMO docs would be encouraged to see more patients and sacrifice the quality of each appointment for a higher volume and as a result higher income. BUT this is true of our fee-for-service delivery system as it is right now regardless. So I guess my confusion is: Is the flat fee per patient seen, irrespective of the nature of the care provided, OR is it a flat salary regardless of the number of patients one sees?

In a capitated system, you are paid "per head". If you have 100 HMO patients in your practice you are paid x. If you have 200 HMO patients in your practice you are paid 2x. The idea is that averaged over the whole bunch, what you are paid covers the cost of providing their care. The other idea is that you are motivated to keep your patients healthy (being proactive about keeping their chronic conditions under control, encouraging flu shots, etc) because it will take more effort to take care of them when they are sick than to maintain their health.

In a closed panel HMO, you are salaried to take care of the patients in your treatment panel. Again, you will have a more managable work load if you successfully provide preventive care to prevent disease or prevent worsening of existing disease.

In either case, as a primary care provider, you will be encouraged to handle first line care yourself before referring patients to a specialist (e.g. only patients who do not respond to first line therapy for high cholesterol, depression, etc are referred to a specialist).

 

[LizzyM]

Now, I don't want to sound like an idiot but can someone explain this to me. Since doctors are limited in their scope of practice, who limits it and how are these things regulated? Also, I know that PCPs have a very wide scope but how far does/can it go?

Also, very informative thread.

Doctors are licensed as physicians and surgeons. They can legally do just about anything within that scope of practice. However, good judgment keeps physicians from practicing beyond what they are qualified to do by their training.... a malpractice lawyer would have a field day with a physician who goes far beyond his training and subsequently has a tragic outcome.

 

[Vanguard23]

So basically HMO's look great on paper but less so in practice? I mean, isn't the fact that you're only paid a certain amount per patient going to be a *deterant* against performing potentially necessary procedures(let's say ordering certain lab works) because it'll eat up what you're reimbursed?

 

[LuciusVorenus]

Doctors are licensed as physicians and surgeons. They can legally do just about anything within that scope of practice. However, good judgment keeps physicians from practicing beyond what they are qualified to do by their training.... a malpractice lawyer would have a field day with a physician who goes far beyond his training and subsequently has a tragic outcome.

I had no idea! So (I know it wouldn't really be possible) technically if I do a FM residency I can get board certified as an orthopedic surgeon?

 

[LuciusVorenus]

So basically HMO's look great on paper but less so in practice? I mean, isn't the fact that you're only paid a certain amount per patient going to be a *deterant* against performing potentially necessary procedures(let's say ordering certain lab works) because it'll eat up what you're reimbursed?

That's the concern most people have. Another one that used to be common a few years back (don't know if it still is) is HMOs won't pay for access to a specialist without a referral from your FM and if your FM wasn't on hand it could cause some major problems. There was an article a while back on some kid who lost vision in one eye because his HMO wouldn't clear him to see an ophthalmologist until it was too late. Plenty of those stories if you look for them.

 

[accidentprone]

Now, I don't want to sound like an idiot but can someone explain this to me. Since doctors are limited in their scope of practice, who limits it and how are these things regulated? Also, I know that PCPs have a very wide scope but how far does/can it go?

Also, very informative thread.

Another limit is malpractice insurance. The company that writes your malpractice policy will base the premium on the activities you do. So if you decide to be a jack-of-all-trades, you'll need to buy coverage for a wide range of procedures which will get very expensive. At some point, you may not be productive enough in each procedure to justify the cost of coverage for that procedure, and as a result, you'll stop doing the procedure.

Also, if the procedure requires hospital facilities, the hospital credentialing committee may require you to have appropriate training and to perform the procedure a certain number of times annually before they'll let you use their facilities. It would be a liability for the hospital to let any doctor use its facilities without some way to help ensure the doctor's level of competence.

 

[LizzyM]

I had no idea! So (I know it wouldn't really be possible) technically if I do a FM residency I can get board certified as an orthopedic surgeon?

Board certification means that you have taken and passed the Board Exam. You are not eligible to sit for the exam until you have completed the necessary residency or fellowship training for that specialty or subspecialty. (generally when a new board certification is created there is a grandfathering period during which current practioners in the field can take the exam without having done a fellowship).

Legally, a licensed physician can practice orthopedics without being board certified in orthopedics. But, as has been mentioned earlier, hospitals are unlikely to give you permission to practice orthopedics in their hospital unless you have board certification and buying malpractice insurance is difficult or very expensive in some fields if you aren't board certified or board eligible (meaning that you are eligible to take the test but haven't yet passed it).