Health maintenance organizations (HMOs) are growing rapidly. And so is the evidence that the managed care they provide is not all it should be.
According to the September issue of Consumers' Research, "the main difficulty with HMOs is the financial arrangement made with doctors." That arrangement may include "a fixed amount of money per covered patient," as well as "bonuses for delivering care on a frugal basis." Such incentives "reward physicians for deferring or withholding care that is seen as being too expensive -- in essence pitting the financial interest of the doctor against the medical interest of the patient."
Consumers' Research reports that, with HMOs, "the less your doctor does for you, the more money he gets to keep." That means that HMOs have built-in incentives "against referring you to a specialist, authorizing a high-tech procedure, or approving a costly operation. In some HMOs, there may be a review board empowered to deny you such treatment even when your doctor says you need it."
Consumers' Research offers a sampling of "the mounting number of press accounts and official studies" indicating that, once you join an HMO, "you may receive inadequate care, or be denied some procedure that could improve your health or even save your life." A Washington Post story from August of last year reports that some doctors believe the managed care system "changes the way physicians think about patients for the worse and may encourage them to shun patients with high risks or expensive health problems." This past August, the Washington Post reported on the situation at a San Francisco medical center, where "organ transplant specialists have turned down patients who might have been given transplants in the past even though they had poor prospects for recovery." Without transplants, of course, such patients are doomed.
Last November American Medical News reported the comments of an emergency physician in Sacramento regarding "dangerous interference by managed care plans" lobbying the state legislature to restrict the scope of their coverage. He cited the case of a patient with a possible spine fracture whose plan denied authorization for care, and a patient with "an externalizing arterial hemorrhage" who was ushered out of an emergency room and sent off to a plan physician's office. "There has been a great deal of gatekeeper misbehavior and failure to understand emergency medical procedures," said the doctor. "That puts patients in a position of choosing between their lives and their pocketbooks, even though they are insured and these services should be covered."
According to the July 9th New York Times, "hospitals across the country report that HMOs are increasingly denying claims for care provided in hospital emergency rooms." Early this year, the Department of Health and Human Services revealed that up to 25 percent of former HMO participants surveyed "said they failed to receive primary care, referrals to specialists, and HMO coverage of emergency care they believed they needed." The Department found that "chronically ill and disabled patients" have expressed "an alarmingly high level of dissatisfaction with the care provided by HMOs."
