So, are you considering buying or have an HMO health insurance plan. You are reading a good brochure, and the coverage is similar to what you were looking for. They tell you about great things and show you beautiful color photos of happy people who use their plan. So what could be wrong? Why not buy their plan? There are many things that they tell you that these are half truths, and the most important things that they will not tell you at all. If you already have a HMO, compare the 10 points below with how your plan was handled with you. This should help to understand all this. If you are considering a purchase, be careful.
1. "The less your doctor sees you, the more he earns." - One of the great things about joining a health organization is convenience. You visit a doctor, the HMO pays for it. Most of the time you do not fill out any form. But how does your doctor HMO really get paid? You may be surprised.
According to the Washington Remuneration Review Commission, 60% of all managed care plans, including HMOs and preferred provider organizations, now pay their primary health care providers with some kind of “per capita” system. This, and not just the payment of any bill submitted to them by your doctor, most HMOs pay their doctors a fixed amount each month - a fee for including you among their patients. For example, in the Chicago Primary Health Care Network (GIA), physicians receive $ 8.43 each month for each man aged 25 to 44 years and $ 10.09 for each patient aged 20 to 24 years.
You can argue that these pillow programs are an incentive for maintaining health: even if you don’t need your doctor, he or she is paid. But what you need to pay attention to is the additional financial incentives that come with some capitulated payment systems. Some HMOs, such as Oxford Health Plans, Cigna and Aetna, have “containment” systems in which the percentage of doctors' monthly payments is withheld and then reimbursed if they keep their referral rates low enough. Others, such as US healthcare, get bonuses for low referral rates. Others, such as Health Net, have so-called risk pools, according to which primary physicians receive a lump sum at the level of their per capita level to pay for any patent test or referral specialist. All that's left is their bonus. “Capitating is the strongest reason for not recommending a patient to a specialist,” says Carolyn Clancy, director of the Center for Primary Health Care Research at the Agency for Health Policy and Research in Rockville, Maryland.
According to Dr. Lee, a family doctor in West Plan Beach, Florida, the pressure to avoid a specialist can be significant. When he was with CareFlorida, a regional HMO, he every month kept 20 percent of his salary, coughing money only if he left referrals low or did not order too many tests or X-rays. Ultimately, Fisher decided to completely abandon HMOs. “We spent more and more time on a small pool of patients, and we weren’t paid a lot for it,” he says. A spokesperson says that when CareFlorida merged with the Health Foundation in 1994, he revised his pillow system. “He probably wouldn't have had the same problem if he had signed a contract with CareFlorida today,” the spokesman said.
2. "Your primary care doctor is your specialist." “Everybody wants a doctor to be versatile, but sometimes, trying to curb expenses, HMOs really overdo it. How? Pressing your primary care physician to take on the additional responsibilities of being a specialist. “The specialist immediately attacks the problem with expensive procedures,” says David Scroggins, medical consultant and industry consultant with Clayton L. Scroggins Associates. "Consequently, HMOs have contracted a primary care physician for a wider range of responsibilities."
Dr. David Himmelstein, primary care physician in Boston, saw these contracts again and again. “This is typically vague, you are responsible for all type of language,” he says. Some of them are even set to reduce the monthly payment of doctors if he refers to you at a job that was “reasonably available” in his own office, Skoggins says.
As a result, you will have primary care physicians who perform procedures for which they are not sufficiently prepared, or, more often, simply cut corners. They will do flexible sigmoidoscopy in vitro to check for colon cancer, instead of referring you to a gastroenterologist. Or maybe they will aggressively prescribe antibiotics for an infection of the ear or sinus, instead of sending you to a specialist in ear, nose and throat. What can you do? Speak out If you do not pester the primary care physician for specialized referrals, you can never get them.
3. "Your health is a numbers game for us." “Everyone knows that HMOs have guidelines on the types of treatment they will allow and the duration of care you are entitled to. Here's how they lower their costs. But have you ever wondered where most of them get these recommendations? Actuaries.
That's right: the number of markers in actuarial firms, such as Milliman & Robertson, collects data on historical care and conducts research on the results of various procedures and length of stay. They then provide information for the HMO for use in industry standards. So no matter how you feel. If you have a caesarean section, according to Milliman, you must leave the hospital within 48 hours. Did you have a hit? Usually you go home within three days, even if you cannot leave.
It sounds a bit cold, well, that's because it is. “We have no scientific basis for actuarial recommendations,” says Carolyn Clancy. "Any recommendations are based on someone's" expert opinion ", and this can happen from different points of view."
And make no mistake: these guidelines are strictly adhered to. Lee Wesner, electronics production manager with Komsat, had a pinched nerve and needed repeat surgery. The condition was so bad that he lost the use of his leg and actually dragged it. Delaying the operation can cause “serious damage,” said his orthopedic specialist, Dr. Neil Kahanovitz, who asked for Wesner’s health plan, Jefferson Pilot, to approve the operation. Kahanovitsa was told that this condition lasted only four weeks, and Wesner had to wait six weeks.
“The denial was based on the interpretation of recommendations that are not considered by the doctor,” says Kahanovich. Another doctor “Did not understand that the guide was designed to be used that way, that is, a guide for proper, timely, and proper care.” Kahanovits later performed the operation, and Wesner recovered. However, the surgeon says; "My patient suffered no problems for another two weeks." A Jefferson-Pilot spokesperson replies that the company considers each case individually and believes that its guidelines are appropriate.
4. "Our exceptions can kill you." - Want to try an experimental medical procedure? If you're in the HMO, good luck. Many are not only unhappy with experimental or non-FDA procedures, they strictly prohibit them. Take a bone marrow transplant. “In general, they are performed for patients with leukemia,” says Dr. Martin Malaver, Washington, DC, orthopedic oncology surgeon. "But over the past 10 years, they have also proven to be effective for treating breast cancer, although this is not an FDA approved treatment." Because of this, many HMOs with which he works will not pay for it. Malaver believes that logic is wrong. “Standards of care developed over time and these HMOs impede such development.” He says. By all means, you should spend a few minutes checking the fine print of your registration contract. Here is where your HMO rules about these procedures are laid out. Most likely, your contract will also explain that the policy covers only “medically necessary” treatment methods.
Unfortunately, this phase is widely open to interpretation, notes Dr. Laura Sudarsky, a plastic surgeon practicing in New City, N. Ya. She recently saw an asthmatic patient whose medical doctor at the Oxford Medical Center recommended breast reduction surgery. For asthmatics, breast reduction is often the case — it eases some of the weight on the chest, but before Sudarsky could work, the HMO refused the procedure. “Oxford said that it did not meet their criteria for reconstructive surgery,” says Sudarsky. Tom Travers, vice president of health care for xcare at Oxford, refuses to comment on this incident. Nevertheless, he adds: “There is no small black box in which we put health care and go out with a 20-30 percent saving. This should come from giving away unnecessary services from the healthcare dollar. ”
5. You do not hurt until you say that you are sick. " - Most HMOs require prior approval for almost any help you receive. Virtually any care you get, be it a simple referral to see a specialist or an emergency. Why? "It is clear that the approval process is an obstacle to the reduction of procedures and referrals, - says David Himmelstein." This is not a problem. This is a hassle for doctors.
Eric Jung, a Bellcore computer programmer, knows this from his own experience. Last summer, he was returning to New Jersey from Rhode Island when the disaster struck. After stopping to eat, he was overcome by sudden and extreme diarrhea. “I realized that I was not going to go home,” he says. "Then I realized that I was not going to get to the bathroom." After the initial onslaught, he says, he came out from under the road and, deliriously, his girlfriend drove him to the emergency room in Summir, N.J.
Jung thought he was following all the rules for filing claims with his HMO, PruCare: he called his main doctor within 24 hours after his visit to the ER and left a detailed message. But a month later he received a bill of $ 541 from the hospital and one for $ 259 from the doctor, saying that PruCare denied it. Explanation of the HMO: A visit to the emergency service was not previously allowed.
As a result, Jung received compensation for hospital fees. But it took five months for phone calls and letters, and as of mid-January there was still a dispute over whether PruCare had fulfilled its promise to pay the doctor’s bill completely. Replies to Kevin Heine, Prucare representative: “When he filed an appeal, PruCare said they would notify him of the decision. In early December, he was informed that part of the facility would be taken care of and that PruCare was still considering the doctor part of the bill. Would we like this process to be faster? The answer is yes.
6. "Your ignorance is our bliss." - Managed service providers are happy to tell you about certain things, such as their child care coverage or their compensation in the amount of $ 125 for new glasses. But for the most part they refer to really important information, such as state secrets.
How many patients dropped out of their plan last year? Do doctors pay on the pillow system? How good are the doctors? We ask these questions of six different HMOs, and only two - United Healthcare and Oxford - can provide any answers. “You would like to know that your percentage of survival for a heart attack, based on all variables, is better with one plan than another,” says Robert Kruehoff, president of the consumer checkbook. "This is exactly what you are comparing; you cannot do among the plans."
About one single place for general information about HMOs right now is the National Quality Assurance Committee. This Washington monitoring service in Washington collects various data on the effectiveness of HMOs and provides them to employers. The group, which is just starting to sell its information to consumers, also works with the fairly useful World Wide Web model (http://www.nega.org), where you can see when your HMO was last checked and whether it has a seal of approval NCQA. But it pretty much ends. Want to see factual information about your HMO? Sorry, this is not available to the public. Another negative: only about half of all HMOs volunteered to conduct an NCQA audit. "This is a developing area, and it is very young," says NCQA spokesperson Barry Scholl. "I mean, this is an embryonic."
7. "We are free from facts." - You call the toll-free number of your HMO and get a fun representative who answers your question quickly and with authority. But when you do what it offers, the HMO denies your claim.
Sounds familiar? It happens all the time. A recent HMOs study by a public lawyer in New York has shown that companies; Representatives of the phones often gave badly misleading advice. For example, five of the 12 HMOs surveyed stated that all of their doctors were certified onboard, which is an exaggeration of up to 25 percent. When a customer service representative at one HMO was asked if she understood what the certified board meant, she replied: "This means that they graduated from medical school." (In fact, this means that the doctor has completed a postgraduate course and passed the exam in his specialty).
The study pointed to a number of other problems. Representatives gave inconsistent information about the number of allowable visits by specialists, for example. And they gave the wrong advice about how soon you should notify the HMO after an emergency.
Robert Krukhov, first, was not very surprised by the results of the study. His group conducted its own surveys and found, among other things, that the medical turnaround is often much higher than the numbers claimed by HMOs. “You should never accept your applications at face value,” he says. "Without an audit, the HMO data does not make sense."
8. "We use minor parts." - The “top shelf” does not quite describe the hip or knee joint replacements that you can get from the HMO. In fact, the “common” may be more like it. “HMOs will often use low-cost versions of medical devices,” notes surgeon Malawer, who consults with several medical companies. “In fact, entire product lines have been developed for the HMO market.”
Although there is a constant stream of new devices included in the marked, do not expect to receive the latest recnology. “The best medical devices often appear on the market than are used, but HMOs are engaged in a silent rationing policy,” says Steve Spale, a representative of the Association of Healthcare Industry Manufacturers. "They do not tell the patient about alternatives, because they have to spend extra money."
How can you tell if you are getting a real thing or a brand name? Ask how it is done. According to Dr. Charles Miller, a professor of orthopedic surgery at the Center for Medical Sciences at the University of Virginia, most implants are forged or cast. "Forging is much, much stronger." For larger jobs like hip replacement, “these less expensive molded implants are not suitable,” he adds.
9. “Give you a dear therapist? Are you crazy? ”- Mental health treatment is one of the most difficult problems for any insurer, be it a service charge or a HMO. How much therapy in the end is really enough?
Unfortunately, some HMO critics say that managed companies have an easy answer to this question: very few. Their answer is often to prescribe medication instead of therapy because it is much cheaper, says Russ Newman, executive director of the American Psychological Association. Medicines are not the wrong treatment, ”he adds.“ Just [in some cases] therapy is completely excluded. "
Dr. Edward Gordon, president of the New York State Psychiatric Association, refers to a recent case involving a severely dysfunctional family registered with the HMO Medical Health Services. My father had problems with drugs and alcohol, and he threatened his wife. Their child suffered from learning deficiencies and chronic depression. Gordon would recommend family counseling at least once a week. But the HMO, whose psychiatric care was administered by a separate company, the health of CMG allowed only four visits for mother and child for a three-month period. Между тем, двое были помещены на антидепрессанты. «CMG имеет репутацию единомышленника сосредоточиться на сокращении услуг», - говорит Гордон. Отвечает Алан Шустерман, председатель и главный исполнительный директор CMG: «Мы жестко настроены, но не о стоимости; [not are we] антипсихиатрии. Мы очень агрессивно относимся к тому, чтобы пытаться получить максимально эффективную и эффективную помощь пациента ».
10. «Несчастный? Иди вперед, просто попробуй подать нам в суд». - Поскольку врачи уже давно являются магнитом для практики, вы можете подумать, что HMOs, которые часто диктуют лечение, теперь будут брать на себя долю судебных ударов. Но не так, потому что большинство HMOs были скрыты с защищенным статусом, сравнимым с тем, что у пятнистой совы.
Для многих HMOs, предлагаемых через крупных или средних работодателей, закон штата заменяется Законом о защите доходов от пенсий сотрудников от 1974 года (Erisa). Поскольку Эриза изначально предназначалась для регулирования пенсионных планов сотрудников, не существует особого характера для регулирования плана здравоохранения, и в результате законодательство делает иски против плана медицинского страхования в гору и невыгодную битву.
Во-первых, любой иск против вашей HMO, управляемой Erisa, является предметом федерального закона. «Будучи федеральным законом, это более-неоднозначный правовой ландшафт, и есть меньше[Адвокатыистцадоступны»-говоритМаркХейплермгражданскийсудебныйследовательизКалифорниикоторыйуспешноподалвсуднанесколькокалифорнийскихHMOsХужетоговсоответствиисErisaуваснетшансовнаприсуждениештрафныхсанкций«ВсечтоHMOдолжносделатьэтозаплатитьзаспорныепретензиипроцентыневыплачиваются»-говоритКэролО'БрайенстаршийюристАмериканскоймедицинскойассоциации«Существуеттольковозможностьоплатыадвокатовирасходов(лечения)ноникакихубытков»[plaintiff'sattorneysavailable"saysMarkHeiplermaCaliforniacivillitigatorwhohassuccessfullysuedseveralCaliforniaHMOsWorseunderErisayouhavenochanceatanypunitive-damageaward"AlltheHMOhastodoispayforthedisputedclaimwithnointerestpaid"saysCarolO'BrienaseniorattorneywiththeAmericaMedicalAssociation"There'sonlythepossibilityofattorneysfeesandcost(oftreatment)butnodamages"[Адвокатыистцадоступны»-говоритМаркХейплермгражданскийсудебныйследовательизКалифорниикоторыйуспешноподалвсуднанесколькокалифорнийскихHMOsХужетоговсоответствиисErisaуваснетшансовнаприсуждениештрафныхсанкций«ВсечтоHMOдолжносделатьэтозаплатитьзаспорныепретензиипроцентыневыплачиваются»-говоритКэролО'БрайенстаршийюристАмериканскоймедицинскойассоциации«Существуеттольковозможностьоплатыадвокатовирасходов(лечения)ноникакихубытков»[plaintiff'sattorneysavailable"saysMarkHeiplermaCaliforniacivillitigatorwhohassuccessfullysuedseveralCaliforniaHMOsWorseunderErisayouhavenochanceatanypunitive-damageaward"AlltheHMOhastodoispayforthedisputedclaimwithnointerestpaid"saysCarolO'BrienaseniorattorneywiththeAmericaMedicalAssociation"There'sonlythepossibilityofattorneysfeesandcost(oftreatment)butnodamages"
Три исключения: если вы являетесь участником плана правительства или плана, спонсируемого организацией, освобожденной от налогов, или если вы покупаете свою медицинскую страховку самостоятельно (не через работодателя), вы планируете не покрывать Эризу. В этих условиях у вас есть потенциал, чтобы получить как недобросовестные, так и штрафные убытки, - говорит Хиплер. В противном случае вам не повезло.
Медицинское страхование может быть очень сложным. Поручите себя, прочитав исключения и ограничения политики, прежде чем покупать их план. Большинство страховых компаний неохотно дадут вам образец политики, прежде чем покупать, если вы спросите их. Всегда помните ... они в бизнесе зарабатывают деньги, так или иначе.
Эта статья показалась бы смешной, за исключением того факта, что это правда.
Я написал несколько других статей по соответствующим темам для вашей информации и осторожности. Магазин мудро.
