The Truth Behind Managed Healh Care

Managed Care: Sacrificing Your Health Care for Insurance Industry Profits

Questions You Must Ask Before Joining an HMO

Managed Care:
Sacrificing Your Health Care for Insurance Industry Profits

Managed care seems to be the wave of the future. Big insurance companies and health maintenance organizations (HMOs) are becoming major forces in America, clamping down on which health care providers we can and cannot see -- and when we can see them. The media routinely carries stories about assembly-line medicine and for-profit health care companies that make money when they deny us access to health care.

Just look at what happened to Joyce Ching, a wife and mother in Agoura, California.

Enrolled in an HMO, Joyce repeatedly visited her primary care doctor for three months complaining of severe abdominal pain and bleeding, but was routinely denied referral to a specialist because of the costs involved. When she finally got the referral, it was too late -- she soon died of colon cancer. She was 34.

These managed-care conglomerates, eyeing impoverished minority communities as untapped sources of Medicaid dollars, are now targeting minority-owned and managed health care plans for eradication. This assault on our communities and health care providers by profit-driven corporations that previously showed little interest in the medical fate of minorities is unconscionable. At a time when African-Americans are facing higher-than-average rates of mortality from cancer, heart disease and diabetes, the focus should be on improving our access to quality care, not bottom-line profit.

All Americans can surely agree that there's no place in our society for a health care system that delays essential treatment and gives doctors a financial incentive to underserve patients.

• Managed Care Creates a Conflict of Interest. Insurance companies, being businesses, naturally keep their eye on the "bottom line." Their interest is not in ensuring that you receive top quality medical attention, but rather in minimizing medical expenses and maximizing profits. It is a conflict of interest for the same insurance company that is focused on profits to be deciding what is appropriate medical care for you and your family. There is economic pressure for the company to choose physicians that provide less medical care and fewer diagnostic tests and referrals as opposed to more quality treatment.

• Managed Care Forces Doctors to Provide Less Treatment. A physician who signs on with a managed care organization often is paid a flat monthly fee ("capitation") per policyholder who selects that doctor, regardless of whether that policyholder needs treatment or not. Increasingly, doctors receiving larger capitation fees are being forced to pay for any referrals, diagnostic tests or emergency care up to a negotiated maximum per patient. This policy creates an economic incentive for doctors to not provide the most thorough treatment and to not refer their patients to specialists, but instead to treat you as quickly as possible so as to not lose money.

• Managed care further encourages physicians to curtail services to patients by offering financial incentives or "bonuses" to doctors who keep their medical costs down, or by withholding a portion of the doctors' pay and distributing it at the end of the year if spending was less than projected. The result? Doctors slashing the amount of time they spend with patients and patients not receiving the treatments and referrals necessary to their health.

• Managed Care Destroys Informed Consent. Informed patient consent requires a physician to fully communicate to you all the medical options available and the risks involved, leaving you to be the ultimate decision-maker as to the type of treatment that's best for you. Under managed care, however, your insurance company and its reviewing panel select your treatment, thereby preventing you from choosing the care that you and your physicians deem necessary for your health. To reduce costs, the insurance industry will be inclined to decide that certain expensive procedures, such as new high-technology tests, are unnecessary. This squashes your right to choose the health care that is best for you.

Joyce Ching's doctor received $27.94 per month to provide her health care services. A referral to the gastroenterologist she desperately needed to see would have had to have come out of the doctor's pocket -- an amount that easily would have exceeded his monthly stipend for seeing Joyce. Such financial inducements can be disastrous and in Joyce's case, proved deadly.

Questions You Must Ask Before Joining an HMO

Do the HMO's primary care doctors get more money if they deny referrals to specialist, testing centers or hospitals?

Can the HMO terminate its contract with the doctor if the HMO feels the doctor is overutilizing services or taking too much care in treating patients?

What are the most frequently requested procedures presently being denied by the HMO on the basis of "experimental/investigative" or "not medically necessary" exclusions?

Do primary care doctors receive bonuses at the end of the year from the HMO if they keep costs below a certain level or limit referrals to specialists or hospitals?

Used with permission from The Association of Trial Lawyers of America. All rights reserved.

DISCLAIMER

This information has been prepared only for general purposes and is not legal advice. Presentation of this information is not intended to create an attorney-client relationship. Do not act upon this information without seeking professional counsel.