The Problems With Hmos Essay Research Paper — страница 4

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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