What Your Doctor Can't Tell You About HMO's

Noted economist, Robert J. Samuelson has written in The New York Times Book Review: "Offering an urgent expose of the medical juggernaut that is sweeping the country and endangering our health, Health Against Wealth takes an unflinching look at the profit-hungry entrepreneurs who have poured into this new "health industry" and provides alarming examples of political manipulation by powerful HMO lobbyists. "

The reason this information is being sent to you anonymously is because this physician who cares could be dropped by the HMO for disclosing this information to you, yet he, like many other physicians throughout the country, feel that you must make an informed decision about your medical benefits when your company asks you to do so.

What are the costs?

We understand that many times, the decisions you make regarding your family's health are based on how much it will cost you out of your pocket, and we cannot argue that managed care is the least expensive option.

However, never before have insurance companies spent so much money to advertise health insurance, than they have with managed care. You cannot drive into a major city without seeing massive billboards boasting about the great care you'll receive with this plan or that, ads on TV, and in print, and on radio. . .these companies are making so much money they can't spend it fast enough. But when it comes to your health, where do you want to see your health insurance premium dollar spent, on TV, or to give you the best care?

HMO's fabricate their own statistics to make themselves look great.

" 'Which HMO is best? Which one is right for me?' The numerous health-plan report cards that appear in consumer magazines or employee benefit brochures purport to answer those questions.

Most of these assessments are dominated by two types of statistics: How reliably HMO's provide cholesterol checks, and other preventive care, and how each plan rated in a quick survey of member satisfaction. That data may be better than nothing, but it suffers from glaring defects and omissions. And, in some cases, ostensibly independent report cards are nothing more than marketing gimmicks underwritten by the plans themselves. As one HMO surveyor confesses, "our primary business is to sell to the Aetnas' and Cignas' of the world. We don't want anything in print that would get them irritated. "

Our concern is your health.

You may be wondering why a dentist (who has never participated with managed care) would undertake to perform this service for your health and your physicians. Many of my friends are physicians, and for years I have been hearing them moan about the shortcomings of managed care. I don't know of anyone who would be real excited about making less, working harder, with their hands tied and their mouths taped shut! Someone had to get the word out, and unfortunately it's probably too late.

It is our collective hope, that once you read this, that you will think twice when you sign your family up for health insurance renewal, and you will speak with your employer about the decisions they are making that will effect your well-being. Most importantly, you will learn how to deal with the managed care companies when they do not provide you with the level of care you would expect in America.

Periodicals, newspapers, TV news, your friends and relatives all have their horror stories to tell about managed care

The book talks about :

"An elderly woman hoping to live out her last few months in dignity may find her health plan pushing for a transfer to a low-grade nursing home that is grossly unsuited to her needs.

A middle-aged man needing heart surgery may find his HMO steering him to a hospital that has worse than average mortality statistics in the interest of saving money.

A young woman fighting breast cancer may find that her managed care plan is badgering her doctors not to go ahead with a costly long-shot treatment that has already been recommended as her best hope.

A country doctor trying to stop an epidemic of a parasitic disease may find that the antibiotic he wants to prescribe has been declared off limits by a local managed care plan for reasons of cost. While he appeals that decision, townspeople must cope with the epidemic by reverting to the public health norms of the 1940's: boiling clothes, washing hands incessantly, and closing schools.

Patients in a crisis must go through nurse at remote site, to get approval the emergency room. 's job is do everything she can encourage wait and see their primary physician.
The elderly in Medicare HMO's receive an even shorter end of the stick (because the premium dollars are even lower, in a bidding war that will sicken you).

The origins of managed care.

"The only effective way to change the way medicine was practiced some employers and insurers came to believe was to intervene before doctors ever saw a patient. The name for such intervention was managed care. "

We all know that the thrust of managed care was to manage the costs of care. What has evolved is a system in which the insurance companies now manage costs by denying needed treatment, or traditional treatment is curtailed somehow to make the bottom line of the insurance company look better each year.

There has been a transfer of wealth, from the pockets of those who worked so hard, for so long, to learn how to be a physician, to the pockets of those industrious enough to form an HMO and to dictate treatment by crunching numbers.

"The wealthiest HMO tycoon of all has been Leonard Abramson, the founder of US Healthcare, who appears each year on the Forbes 400 list of richest people in America (estimated wealth: nearly one billion dollars). The early stages of Abramson's career exemplified the self-made virtues of a Horatio Alger novel: driving a cab to pay his way through college, quitting a safe hospital/company job in 1976 to start a tiny HMO with $16,000 of his own savings, and answering the switchboard himself on Saturdays when health plan members called.

As his company prospered, Abramson developed a taste for luxury that overshadowed his early commitment to thrift. He built a three hole golf course next to his suburban Philadelphia home. He put two daughters and a son-in-law on the corporate payroll at various times, paying them salaries as high as $300,000 a year. In his biggest spree, Abramson bought a 78' yacht for more than one million dollars.

Are such achievements part of the way that healthy American capitalism works? Or was there something troubling about the piling up of wealth within the HMO industry?

What HMO executives cannot bring themselves to admit is that their business priorities are fundamentally at odds with the workings of almost any other industry.

"Successful HMO's do the exact opposite of most normal companies: they order less of everything. HMO's are not like steel companies that try to sell record tonnage, or restaurants that try to fill every table so that everyone shares in the prosperity at the end of the year. A good year at an HMO is one in which the doctors order fewer tests, patients are discharged faster from the hospital, and not every request for a specialist consultation is approved. That frugality is a tough message for HMO's business partners (the physicians) to swallow. It would be more palatable if those being asked to make sacrifices can see that even the rule-makers are being parsimonious. "

When people in the midst of a medical crisis discover that the supposedly thrifty HMO is spewing out enough wealth to allow the top executives to buy jets, yachts, and other extravagances, it raises bitter doubts about how wisely, or selfishly, HMO's decide what is wasteful and what is not. "

Patients in a crisis must go through a nurse at a remote site, to get approval to go to the emergency room. The nurse's job is to do everything she can to encourage patients to wait and see their primary physician.

The elderly in Medicare HMO's receive an even shorter end of the stick (because the premium dollars are even lower, in a bidding war that will sicken you).