HMO

Practical advice - if nothing else.

Misti26- The reason that the joke is so hilarious, is because it is sadly, true. I have friends who are on H.M.O.s, and every time they need to get anything done, it is a real hassle. I think that H.M.Os, instead of making medical care better, has just added on another layer of inefficient bureaucracy. The people who suffer are the patients- The stockholders are doing fine!

Phoenix:

Unfortunately you are correct. I work with this insurance business every day and know only too well the havoc they cause.

I understand there's new legislation in progress to disallow them to continue underpaying the doctors and hospitals.

I know the general public think the doctors are raking it in, but believe me, they're not.

Misti - there are times i wish we had HMO's here. Not often, but when trying to sort out things when i know i'm dealing with a russian-mob-based staged accident with $10,000 in chiropractic costs incurred in 6 weeks, i wish i could say - take it to your HMO and i'll match what they pay.

eBeth, you would be surprised at how many people do that. Not so much with the HMO's because they have dotted all the 'i's and crossed all the 't's so that providers cannot do that. But we have some hospitals who will accept what the PPO pays to the network facility and agree not to charge the patient anything more than if they went to a network provider.

ehBeth- Be careful what you ask for. You might just get it!

Misti- On top of everything, the malpractice insurance premiums have gone up the roof. Doctors have to scramble to keep up their incomes. They need to have so much more help now, just to deal with health insurance companies.

In the eight years that I have lived in Florida, I have used the same internist. He is bright, astute, and a superb diagnostician. He has also become like a "rat in a cage" over the last few years. He has to work longer and harder, and is not getting properly compensated.

I have spoken with many of my friends, and they have noticed the same trend.

It must still be better in the U.S. than in Canada, as a lot of our top docs pick up and move to the states, and then report a 10-fold increase in their incomes. Interestingly, the medical researchers seem to travel the other way. They can get better funding at the universities here, while still maintaining small practices.

Phoenix: The malpractice insurance issues were the reason we didn't receive an increase this year, and the doctors took a 20% cut in salary as the malpractice insurance went up 400%.

Also, we have four surgeons in our practice and each one of them sees about 90 patients a day to make up for the very minimal reimbursement rates the HMO's pay.

So, we have too many patients, receiving very little care for their dollar, and insurance premiums that are out to ying-yang, and not only can't you see a doctor of your choice you are forced to see your PCP (Primary Care Physician) prior to seeing a specialist, etc. etc.

More work, less pay!

eBeth, it's six of one, half dozen of the other. My parents were under socialized medicine in Ireland, and unless they were dying they had to wait two years for specific treatment such as joint replacement. My poor mother was tortured by the pain waiting for a hip replacement, for two years.

So, the scale doesn't always balance, we just need to decide which is the lesser of the two evils.

EhBeth & Misti-I had to switch my mom from a regular Medigap policy, to a Medicare HMO, because the cost of the Medigap was too high for her to handle. When I was doing my "homework" I asked for some info. that is contained in this letter. It is five years old, but nothing really has changed.
If you read it carefully, you will perceive some of the implications of this system, and believe me, it is horrendous!Dear Medicare Complete Member:

Thank you for inquiring about our physician incentive -arrangements. We have several different types of contractual arrangements with our physicians, depending on the physician, physician group, or location within Florida. Your physician is paid according to one or more of the following types of arrangements: -

Arrangement A: We pay some physicians negotiated fee for service, which is a predetermined amount for each service they provide. This amount may be different than the amount the physician usually charges. Physicians under this arrangement do not receive any additional payments as part of an incentive plan. -

Arrangement B: We pay some physicians a salary - this applies only to the CAC Medical Center physicians. There are no additional incentive payments made to these physicians based on their referrals to other providers.

Arrangement C: We pay some physicians a capitation for primary care and/or specialty services. Capitation is a fixed amount of money each month to provide specific services to the members they see. This fixed amount is the maximum amount a provider would receive. No additional payments are made as part of an incentive arrangement.

Arrangement D: We pay some physicians a.capitation, and withhold a certain percentage of this fixed amount of money. If their expenses are less than budgeted, the health plan gives the withheld money back to the physicians. They may also be eligible for an extra amount of money (a ."bonus") if the costs of referral services are less than a budgeted amount.
Arrangement E: Some capitation arrangements provide the physician or physician group a global budget, with which the providers are responsible for providing or arranging for A types of care, including primary care and all referral services (both inpatient and outpatient). if the physicians' expenses are less than budgeted, the health plan rewards the physicians with an additional payment. The physicians assume substantial financial risk if costs-are greater than the' budgeted amount.
Note: In order to reduce the financial risk in arrangements such as D & E above, the Plan or the physicians purchase "stop-loss insurance," which is special insurance to protect the physician or
physician group ftom very large financial losses.

United HealthCare of Florida is required by the Health Care Financing Administration to survey .our current and previously enrolled members to ask if they believe they received the care they needed and if they were satisfied with the quality of care they received. The results of our survey W'@l be available after Januar@ 1, 1998, and can be obtained by contacting the health plan Member Services phone number on your ID :card or in your Member Handbook.

Thank you for your interest in United HealthCare of Florida.

HCFA T 4255 A 04/97

Misti - I think our system in Canada is generally quite good. There are longer than desirable waits (rarely gruesome) for some very specific exams and treatments in some provinces, but in Ontario, at least, they are now bringing in legislation which will pay for people to go to the U.S. for some treatment and to pay for the treatment as well.

It is becoming more litigious here now - lawyers with practices in New York State and Ontario, for example, bringing the U.S. approach to us. I expect this is going to have very negative effects on our entire medical system.

No perfect system, but I'm glad I'm in Canada. I'm willing to pay taxes that help support a decent health-care system for everyone.

Phoenix, i truly would not like to have to be involved in a system like the one you posted.

As i noted earlier, i would however, like to have power like that when i'm working on a true fraud file.

Phoenix: That is horrendous! I wonder how long this will go on? How long can the HMO's hold out before the lawsuits break them or us?

The system is so convoluted, it is geared for failure.

eBeth: Neither system is far from perfect, but right now it's all we've got.

Hopefully, there will be some positive changes in the near future.