The Problems With Hmos Sarah Cay Bradley English 320 May 20, 1999 The Problems With HMOs It was no surprise when I interviewed my English class about HMOs, that out of 13 students, seven currently having HMO coverage, 77% felt HMO healthcare inferior to traditional insurance. This group closely represents the U.S. population, as HMOs have become practically synonymous with health care and the idea that Americans are no longer receiving the quality care they received from unmanaged plans. Managed care plans have succeeded in dramatically cutting the rate at which medical spending in the United States has been growing. Does it matter that 100 years after Lincoln freed the slaves that we have found another way to trade lives for money? HMOs have introduced an innovative way to provide health services: incentives for doctors not to treat patients. The less a physician practices, the more the company makes.
HMOs make money by not providing a product. (Physicians Who Care, Internet 1999). What exactly is an HMO? HMO is an acronym for health maintenance organization. An HMO is an organization that provides comprehensive health care to voluntarily enrolled individuals and families in a particular geographic area by member physicians with limited referral to outside specialists and that is financed by fixed periodic payments determined in advance. (Merriam-Websters Dictionary-1996) Sometimes considered a new concept, HMOs have been around since the 1930s. The difference today is that consumers are being nudged into them by their employers, in an attempt to hold down costs, and out of traditional insurance plans, in which the insurer reimbursed the patient directly and covered most of the cost of medical treatments. To encourage consumers, the HMOs promote their preventative services.
Since the HMO has the patients money up front, it is important for them to keep the patient healthy. (Sinclair Community College-1999) An HMO can also be described as what seemed like a good idea at the time, but quickly became a concept out of control, thanks to medical bureaucracy, and just plain greed. At the beginning of the 1990s, there were nearly 600 HMOs across America and they were regarded as a practical alternative to escalating medical costs. By 1998, it was clear that HMOs were out of control, leaving a trail of angry and neglected patients in their path. Physicians have also begun speaking out against HMOs in increasing numbers. According to Dr.
Daniel J. Esposito, the main problem with HMOs is that, there are no economic incentives to take care of people. The incentive is not to do anything (More Trouble With Managed Care PG). What happened? How could something, which started out so promising, have gone so terribly wrong? In a survey conducted by Harvard University in conjunction with the Kaiser Family foundation, it was revealed that 51 percent of Americans polled believe that HMOs are responsible for the deteriorating quality of their health care. Fifty-five percent expressed concern that HMOs were more preoccupied with cost-cutting measures than with providing the best possible medical care for the patients they serve (The HMOs Image Problem; Public Distrust Can be Cured By Ensuring Patient Rights 8).
This certainly does not sound like the all-purpose solution to quality and affordable medical care the government was looking for when it began addressing the issue of a national citizens’ health plan back in the 1960s. What has sparked this widespread public mistrust of HMOs? Part of the problem has been the exceptional growth of HMOs during the 1990s. By 1996, HMOs boasted a membership of 110 million enrollees, a figure four times higher than 1986 (Evans). The federal government’s attempts at reform have only added fuel to the growing fire. With their ineffectual price controls and budget slashing, the bottom line is that people are receiving less health care instead of more — hospital stays and specialist referrals are kept at a minimum to defray costs (Evans). This leads to the question, if people are so unhappy with the cost and quality of HMOs, why are they continuing to sign up in record numbers? It should be understood that, first and foremost, an HMO is not a public service organization.
HMOs are in business to make money, and the more people they can enroll, the greater the profit. When the general public or their employers go shopping for a health care alternative, they are often unaware that they may become victims of a slick marketing campaign on the part of the HMO. One such glossy, potential patient-friendly brochure, as quoted in Consumers’ Research Magazine, read, No Medicare deductibles, affordable copayments, and unlimited hospital stays when medically necessary. Emergency care anywhere in the world. Virtually no claim forms to file…
Routine physical exams (preventive health services). Prescription drug discounts, dental coverage, vision coverage (Evans). As we all know, if it sounds too good to be true, it IS NOT TRUE. Language in HMO plans is purposely ambiguous and is intentionally subject to broad interpretation. The flyers frequently mention unlimited hospital stays, but never clearly define what these stays are for (Evans PG).
Then, of course, there is also the equally vague qualifier, for treatments that are medically necessary (Evans PG). What does this mean? What may constitute a medical necessity for the patient may not for the HMO. Because the HMO is the provider and paying the medical bill, it is responsible for making a determination as to medical necessity, not the patient or his physician. The patient is primarily concerned with his or her medical condition, whereas the HMOs main focus is the costs which will be incurred in treating this ailment. However, what the HMOs advertisements do not tell us is that inefficiency has always categorized HMOs.
In 1995, it was reported, that over 25% of HMO members said they waited more than 12 days for a scheduled appointment with their primary care doctor.. In more than one-third of the HMOs, up 50% of the members said consistently busy telephone lines and the mirage of phone numbers and transfers caused them to sometimes give up scheduling an appointment… In 52% of HMOs, up to 50% of disenrollees said their doctors failed to refer them to a specialist when needed… In 40% of the HMOs, from 11% to 50% of disenrollees reported the medical care they received from their HMO caused their health to worsen (Evans and Kline 10). What happens when your physician and your HMO administrators do not agree? Lets look at the following case study.
Sandy C. had struggled with her weight all of her life. Finally, when her 5’2 frame ballooned to 260 pounds, she was considered at high risk for hypertension, heart attack and diabetes (Kowal). Her internist recommended a stomach reduction surgery to curb her urge to overeat. According to Dr.
John Cosgrove, who is chief of laparoscopy at Long Island Jewish Medical Center, The benefits of the surgery for those classified as morbidly obese are clear. When you do this surgery, patients live longer (Kowal). However, one year after this proposed surgical procedure, this obese young woman is still waiting. Why? Quite simply, Sandy’s HMO refused to pay the $10,000 price tag, and the surgery could not be afforded otherwise (Kowal). Sandy’s HMO determined that this procedure did not constitute a medical necessity and would create more problems than it would ultimately solve, and therefore, have repeatedly denied the surgeon’s compelling efforts to cover the surgical cost (Kowal PG). Sandy is naturally upset and unable to understand her HMOs reluctance to authorize the surgical procedure, lamenting, I work for a living, but I can’t have surgery that my doctor says is necessary for my health. I think it is so unfair (Kowal).
Another case recently reported by MSNBC News, the story of the Kuhl family of Kansas City causes us all serious concern over US health care. Mary Kuhls husband, Buddy, suffered a heart attack in 1989. The Kuhls HMO refused rehab services; they said he didnt need it. Mary explained that her husband was going to have a catheter run to find out exactly where the blockage was, and what damage it had caused. We went to have the procedure done, and we waited all day, and finally they came in and said that the HMO was denying the procedure. After several delays and denials, Buddy Kuhl collapsed in his yard and died in the arms of his wife.
This same type of situation could happen to any of us, and does happen everyday. HMOs cost cutting has a devastating impact on both the born and the unborn. In Louisiana, when Florence Corcoran entered her eighth month of what had been considered a high-risk pregnancy, it had been recommended by her physician that she enter the hospital (Cohn 6). Despite the fact that Ms. Corcoran’s obstetrician’s recommendation was also approved by another physician, her HMO would not approve the hospitalization. Instead, it opted for home healt …