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The Problems With Hmos

.. h care for ten hours each day (Cohn 6). Shortly thereafter, when the assigned nurse was off-duty, there were sudden complications, and the fetus died (Cohn 6). If this was not tragic enough, Ms. Corcoran was then informed that she could not file a suit for damages because of the 1974 Employment Retirement Income Security Act, a federal health benefit regulation which prohibits the filing of pain and suffering lawsuits (Cohn 6). Do HMO members have adequate rights? Unfortunately, in 1998 the House of Representatives rejected a bill that would allow patients or their estates to sue HMOs and other insurers for denial of treatment.

But there is much controversy over this issue and several pending bills. Presently consumers lack adequate rights in three areas: consumer information; access and quality; and appeal/grievance rights. Except for emergencies, all care must be authorized by a primary care physician, limiting access to specialists. In fact, when attempting to get a referral says Dr. Stephen Cohen (Founder of Physicians Who Care, MSNBC internet 1999) When the person on the other end of the phone line doesnt even know how to pronounce the name of the disease, its ridiculous. If a referral is granted, according to the HMOs guidelines, the choice of doctors is usually limited and those contracted by the HMO may not have the expertise to treat the medical problem.

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Grievances must be handled by an appeal to the HMO, the same entity which denied care in the first place. Moreover, the grievance process can take months or longer, in some cases resulting in serious harm to the enrollee. There are no statutes in place to allow for malpractice cases against HMOs, enrollees are usually forced into a binding arbitration case. Under federal law, workers enrolled in employer-sponsored health plans can sue their HMO to recover the cost of treatment that was wrongly denied, but they cannot go to court to seek compensation for pain and suffering and to seek punitive damages. (Dallke) Patients are not the only losers in the web of the HMO scheme. Physicians are also becoming victimized by HMOs as are their patients. But in this case, it is financial rather than physical.

Like HMOs, physicians are paid a fixed amount for each patient, and this figure does not vary. In other words, if the patient doesn’t show up for treatment, the amount is not adjusted. What this means is that if there are any savings, the physician benefits. However, when there are not, which is most often the case, the physician, not the HMO, assumes the liability. Simply stated, The patient is costing the physician money the minute she walks in the door (Evans).

Managed care replaces Hippocratic ethic with veterinary ethic. The owner paying the bill, the HMO, makes the decision. If they decide Fifi isnt worth the cost, the needed care is not given. Managed care is perverse. It destroys patient choice. It leaves the ethics of our profession in ruins.

(Jane Orient, MD). Dr. Linda Peeno testified before the U.S. House of Representative Committee on Commerce on May 30, 1996. She began her testimony.

In the spring of 1987, as a physician, I caused the death of a man. Although this was known to many people, I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was rewarded for this. It brought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the good company doctor.

I saved a half million dollars. The man died because I denied him a necessary operation to save his heart. I felt little pain or remorse at the time. The mans faceless distance soothed my conscience. Like a skilled soldier, I was trained for this moment. When any moral qualms arose, I was to remember: I am not denying care, I am only denying payment. At the time, this helped avoid any sense of responsibility for my decision.

As a medical director, Dr Peenos priority was to protect the interests of the business, not the patients. There is no code of ethics for the company doctor. The physician code of ethics addresses clinical physicians, not physician executives. On previous occasions Dr. Peeno was reprimanded for not denying enough care.

She was even told by the HMO to use data which was known to be inaccurate to justify a denial. At one point she was assigned the task of presenting to a group of 500 medical directors and nurse reviewers how her plan had used the denial process to get specialists costs down. If physicians do not play the game they can be labeled unsuited for managed care. So, while HMOs are advertising that you and your doctor, not an administrator, make your medical decisions, your doctor is actually acting as a medical director, for the good of their employer. (Peeno 1) Apparently, some of the largest HMOs are also the slowest-paying ones.

For example, Oxford Health Plans, an HMO covering New York’s metropolitan area owed millions to both participating physicians and hospitals (Terry 44). They blamed the delay on computer glitches and payments which had been advanced to medical practices. However, these excuses were considered lame by the physicians who were owed money in light of the HMO’s profits increasing 65 percent at the end of the second quarter of 1996 (Terry 44). According to Dr. Michael Rutigliano, whose private practice was owed $50,000 by Oxford Health Plans, It’s obviously very frustrating — and it can certainly cause cash-flow problems (Terry 44). What is really the cause of the delay in HMOs paying physicians? Many believe it is so that the HMOs can draw as much interest on the money as possible in their own account before having to turn it over to the designated physicians (Terry 44). HMOs, of course, vehemently deny this charge and blame the private practices for inaccurate record keeping and unfamiliarity with the HMO policy process, which they maintain is responsible for the payment delay (Terry 44).

However, even HMO representatives have admitted that it is probably next to impossible for private practices to keep up with HMOs evolving policies, which seem to change daily (Terry 44). Again, these losses for physicians mean higher costs for patients as the vicious cycle continues. Are there any winners in the HMO process? Well, maybe this is something you should decide. In 1996 there were 20 for-profit, publicly traded companies which owned HMOs, registered with the Securities and Exchange Commission. The SEC reported that Mr.

Wiggins, CEO of Oxford Health Plans (the largest and slowest-paying HMO) was paid $29.1 million in 1996, and held an additional $82.8 million in unexercised stock options. The 25 highest paid HMO executives among these companies had an average compensation of over $6.2 million, and average unexercised stock options of $13.5 million. (Families USA Study) Ron Pollack, executive director of Families USA, summed it up very well, when HMO executives make many millions of dollars in compensation, that may be okay. But when those same HMO executives complain about pennies being spent for basic consumer rights, that is pure hypocrisy. Managed care companies are considerably more cost conscious when they oppose the establishment of consumer rights than when they approve compensation for their top executives. (Slass) How can potential HMO enrollees protect themselves from being a worst-case scenario? Educating oneself on the proposed HMO is the best strategy. In other words, leave nothing to chance. Know exactly what you’re getting into.

If an employee has no input as to which HMO he may join, he or she can still question the HMO representative. Some of the most important questions include: How long has the HMO been in operation? Usually, a gauge of two to three years may be used (Luciano PG). If the HMO has operated for less than three years, what experience does it bring to its new operation (Luciano PG)? What is the working relationship between the HMO and the doctors and hospitals with whom it has established contracts? Ask the HMO representative to supply a list of telephone numbers to assess if the working relationship has been a good one, or has been problematic (Luciano PG). Although HMOs are forbidden to divulge names of their members, if you know of anyone currently enrolled in the proposed HMO plan, ask the person to evaluate the HMO’s coverage and general satisfaction (Luciano PG). The unfortunate reality is, the problem with HMOs is probably going to get worse before it gets better.

However, like it or not, HMOs are a permanent fixture in the health-care landscape. Unless the government can institute some actual reform that does not involve its quick fix cost-cutting measures (such as the ineffective fixed cost per patient practice), which is highly unlikely, HMOs in the future are going to be synonymous with ‘wrongful death,’ rather than patient care. Health Care.


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