Posts Tagged HMO
It is change your Medicare season so the advertisements are blaring for Scan, Secure Horizons and the other Medicare HMOS. Many Medicare patients do not understand how things change when they sign with a Medicare HMO. Regular Medicare patients have choices and do not need to wait for approval before receiving care.
I saw a Medicare HMO patient this month with a wound on his foot. The wound looked ready for skin grafting. As his HMO does not have a plastic surgeon under contract at the hospital where this patient was admitted, I was told he would have to wait for evaluation by their podiatry doctor. An operation I could have offered him in days waits weeks or longer. That is the HMO compromise. You wait for them to decide what you need.
Ultimately the podiatrist saw him and decided the wound would heal without surgery. It might, but it will take longer…maybe months longer. Then again passing on surgery will cost the IPA (HMOs usually contract with other health care companies called IPAs) less money and that is often the name of the game in health care.
When you change your health insurance you really don’t see the big picture unless you come to really need it.
John Di Saia MD
Originally posted 2010-12-22 07:30:57.
My dad’s wife called to ask if I could see a friend of my brother’s. This 30 year old woman had been “put through the ringer” by her HMO dermatologist. He looked at her nose diagnosed a “pre cancer” and treated her with freezing. Then he put her on a cream. The “wart” is still there and she can’t get in to see the doctor (actually a physician’s assistant) for 2 months.
Welcome to capitation medicine.
This evil creation of your local managed care plan pays a doctor a fixed fee to take care of a group of patients. It is sold to the doctor as “money for nothing”…no not the Dire Straits song. The doctor then is paid nothing additional to take care of you. He has an incentive to ignore you (as he keeps the money) and none to care for your issues. The amount paid per patient is pretty low….like a couple of dollars. The doctor only makes money if he doesn’t provide much care. This is the evil part as far as I am concerned.
I have been very hesitant to deal with capitation medicine. This woman’s health insurance coverage will pay nothing toward my involvement as I am a non-Provider. That’s what you get with mangled care.
John Di Saia MD
Originally posted 2005-11-07 09:17:00.
We have discussed health insurance games before. They commonly entrap doctors and patients in red tape and denials of care and payment. The public only occasionally becomes involved in the situation when they are affected directly. This time 20,000 Orange County Blue Shield HMO patients are involved, so there is interest:
Nearly 20,000 Orange County HMO patients are caught in the middle of contract dispute between Blue Shield of California and Monarch Healthcare, an Irvine-based medical group with more than 2,000 doctors. Starting May 1, Blue Shield will no longer have a contract for its HMO patients to see Monarch’s network of doctors across the county. Yet the insurer alleges that patients are being falsely told they are losing their doctors this month, and in a few cases, have been denied care.
Health care contracting is a complex maze. HMO patients generally buy their insurance from one of the large health care insurers such as Blue Shield. Few if any doctors can bill an HMO directly though. The usual arrangement is for the large health care insurer to sell (yeah, sell) the responsibility of the care of the patients in groups to an IPA (Independent Practice Association.) The kicker is that the large HMO insurer gets to keep up to 30% of the premium payments in this sale. That amounts to less money available for the care of the patients! Physicians must join an IPA to get paid on HMO business. The IPAs pay poorly for specialty services, so many sub-specialists (like Dr D ) do not deal with them.
The bottom line here is that for HMO patients to get regular care they need to maintain a relationship with a doctor who is a member of an IPA that is contracted to their HMO. They essentially enroll in that IPA to set up the linkage. When the chain is broken, the patient finds him or herself without a doctor. In this case that happened due to a contracting dispute between Blue Shield and Monarch IPA.
John Di Saia MD
Medicare HMOS confuse patients for a living. They basically seize your Medicare benefits and sell the responsibility for your care to an IPA, which then controls your access to care.
I saw a Medicare HMO patient who had his care contracted to ADOC, the Affiliated Doctors of Orange County. I was asked to see him in the wound care hospital where he was staying with large wounds in his leg. The doctors taking care of him wanted skin grafting to facilitate healing of these wounds.
In order to expedite a patient’s care, the better IPAs will agree to fund care by non-contracted doctors at an mutually agreed upon rate. ADOC is not such an IPA instead choosing to transfer the patient to a nursing home without surgery to delay the cost of surgery. They actually sent him by ambulance to the office of a provider doctor within days of my first inpatient visit with him.
ADOC prefers to deal with the patient’s wounds at their convenience as an outpatient when a contracted doctor can get to him. This delays his time to skin grafting for weeks to months. In my opinion, this defines poor quality care. If they were your wounds would you rather have them dressed with gauze for the additional time or have the repaired before you left the hospital?
This is why your Dr D is not an ADOC member.
Sneaky HMO Tricks:
ADOC used two Sneaky HMO Tricks here:
(1) Transfer the patient out of the hospital before surgery happens even if it delays or denies the patient care.
(2) Without so much as a phone call to the consultant on the case, send the patient by ambulance for an office visit with a provider doctor.
John Di Saia MD
Recently a patient came to the office with the need for a complicated breast reconstruction after finding that she had a Brca gene. She had already had breast surgery and radiation therapy and now was looking at complete breast removal and reconstruction. She was pretty clear that she had no money to pay for anything, but was waving around her Blue Cross PPO card like it was a VISA.
What was she even doing with a PPO card?
When patients sign up for PPO insurance, they are basically saying: “I am willing to pay more, but I want choice.” PPOs generally allow patients more selection with coverage for doctors (both in and out of network,) but patients pay a higher share of cost for that care. When you are on the cusp of expensive breast cancer surgery, a PPO card means you are going to pay thousands if not tens of thousands of dollars by the time you go through the multiple operations to remove and re-build your breasts.
HMO plans on the other hand have limited doctors (less or no coverage for out of network) and hurtles to care, but once you get in for that care, it costs you less.
EPOs tend to be somewhere in between. Now with this being said, each plan by each carrier can be quite different. Plans often have multiple deductibles for in and out of network doctors, facilities and hospitals. You really need to look into your plan before you sign up for it. But if you are looking to pay little or nothing over and above what your insurance pays, you should be looking into HMO coverage most often.
John Di Saia MD
Bravo Health Inc. did something in 2009 that most venture-backed companies can only dream about: It had revenue of more than $1 billion.
Bravo, specifically, is a Medicare Health Maintenance Organization. People on Medicare utilize HMOs such as Bravo in order to protect themselves against the so-called “gaps” that Medicare does not pay like co-payments and deductibles.
Medicare HMOs basically get paid by Medicare to administer Medicare member’s benefits. They also get the “right” to deny coverage for care. And they are making bank doing it.
On the doctor’s end, they require contractual reductions in fees paid…in many cases they pay much less than Medicare rates for services. They also require approval for services before they are provided and limit the doctors to which you can go to have them. In other words they are making this money off the backs of patients and doctors.
I do a fair amount of regular Medicare work for a plastic surgeon…skin cancer, wounds and breast cancer are the bulk. I do little or no Medicare HMO work. Taking a fee cut for companies that make millions is a bit too much to bear. There is only an inconsistently slim margin on Medicare business as it is.
Obama’s healthcare reform package didn’t to my knowledge limit payments to these companies or regulate how they underpay and deny your care. How about regulating them like a utility particularly if they subsist on public funds?
John Di Saia MD
Originally posted 2010-02-08 09:00:13.
Politics goes at a pace that seems ever accelerating. I lost track of the fact that the former governor of Alaska Sarah Palin had originally coined the term. That term has become a political football as of late as the liberals and the conservatives play that big game to secure popular opinion and more importantly control of our country.
Recently I called Larry Elder’s show in Los Angeles as the subject was being discussed. Surprisingly I got on. To many of us in medicine, the concept of “death panels” is a stretch but not that much of a stretch. Obama Care puts some 30 million Americans who were not insured into the freebie health care the government provides…meaning YOU provide with your tax dollars to someone else. The philosophy behind this rubs many of us the wrong way. How such a move can make medicine less expensive seems like fuzzy math. This President with the popular media in his corner doesn’t often get called on such illogical statements however. Lucky him.
Americans already provide free health care to many who do not visibly pay into the system by way of the disability, MediCal and other such systems. The health care system is already too expensive partially due to over regulation and government control. Adding 30 million new freebie members will make it even more expensive. This is not good for the President who was less than 100% truthful when he stated his system would be less expensive than the one in place currently. The numbers are coming back and it will cost us more. Big surprise.
My point to Mr Elder was that the current health care system already has incentives for lack of care. They are “utilization bonuses” paid by HMOs to primary care doctors for not referring to specialists. As a plastic surgeon, my friends in primary care joke that they get paid to not send patients to surgeons for unnecessary hernia repairs and the like. That is great unless you have that hernia of course. It is not too much of a stretch for a new health care system that plans on adding 30 million non-payers to the mix to try to cut one of the highest costs in the system at present; that of end of life care. Encouraging doctors to “discuss” not choosing to engage in expensive end of life care such as dialysis, artificial ventilation, and chemotherapy was an expected move by many of us in heath care. How far the concept will go is another thing.
On my “call in,” Larry pointed out that HMOs are not the government. That distinction has been blurred however by the link Medicare has allowed to HMOs. Medicare patients are allowed, even financially encouraged, to assign their benefits to HMOs like Scan and Secure Horizons (called Scam and Insecure Horizons by myself and other cynics.) When they do so they get lower premiums at the cost of the loss of choice and ultimately rationed care.
The loss of choice and rationed care are very likely the common denominators in Obama’s fuzzy math. This is how he plans on making health care cheaper. You get less care. Get it?
John Di Saia MD
I have this nice lady for whom I operated and have been seeing for wound care (she had several wounds) since late last year. She changed her Medicare coverage effective January 1st and didn’t let my office know until two months later.
The problem is that she went from a Medicare plus secondary plan to a Medicare HMO and I am not a provider for the HMO. She is going to end up with a bill for everything from January 1 to March. We called the HMO and they pretty much said that this is her problem.
When you change your health insurance coverage realize that not all plans cover care by all doctors. I would advise that you notify all your doctors before you make the change. If you do not bother to do so, you increase the risk of ending up with a bill that is not paid by your new insurer.
John Di Saia MD