HMO rules your doctor won't discuss

As the Nov. 7 election nears and the major presidential candidates
heat up their rhetoric, health care promises to be a major last-minute
issue, as it has been all campaign season, that GOP nominee George W.
Bush and his rival, Democrat Al Gore, will use to woo undecided voters.

But as is usually the case, there is much more to the health care
"debate" than either side seems willing or prepared to discuss with
voters. Even less likely to discuss the reality of today's health care
systems under the management of health maintenance organizations are the
doctors who contract with HMOs to provide care.

According to a recent report in

Smartmoney.com, there are "10 things your HMO doctor won't tell you," though not all HMOs require doctors to sign off on each of these mandates:

• Many HMOs penalize physicians if they order too many tests or prescribe too many medications. The HMO will withhold payment to doctors as a "punishment" of sorts because tests and drugs cost the insurer money.
• Doctors who don't order what an HMO considers too many tests or prescribe what the insurer considers too many medications will often receive bonuses from the HMO. Patients have sued HMOs and doctors for "failing to perform their fiduciary duty" to patients by providing all the necessary care and treatment warranted by a physician's specialty and capability, but the Supreme Court has ruled that federal law does not go that far in outlining the HMO's responsibilities.
• "Under a system called capitation, many HMOs pay primary-care doctors a set amount per month for each patient assigned to them. Even that amount can drop if a doctor orders too many expensive referrals or hospital stays," said the Smartmoney.com report. "So, sick patients become a financial burden."
• Some physicians head off HMO punitive financial measures by getting rid of, or refusing to see, truly sick or chronically ill patients. They excuse their refusals by claiming they don't treat particular (meaning expensive) illnesses; as a result, their average patient is more healthy, less likely to need the doctor and less likely to need tests and drugs. For patients already enrolled in an HMO and assigned to a doctor who later develop a serious illness (like cancer or Diabetes), the physician "use tactics to grind unwanted patients into the turf, then surf them out to other doctors."
• HMOs sign contracts with doctors for just a year or two; if the physician costs the insurer too much, the HMO can drop the doctor when the contract expires. That isn't a problem for physicians with multiple HMO contracts, but for a doctor who has just one, being dropped could end or severely cripple his or her practice.
• HMOs have "sophisticated computer tracking programs" that track the care a doctor is providing each patient he or she sees, and then lets the doctor know when he or she is doling out "too much care" to certain patients. "Those who rack up more than the average -- or more than some predetermined target -- may get a call from the HMO. Or maybe they'll get pinched by the methods described above," said the report.
• Physician reviewers who work for HMOs have admitted trying to find ways -- any ways -- to reject a doctor's request for compensation and coverage for tests and other procedures the attending physician said was important to the patient's care. The HMO employs these reviewers to reject -- not approve -- requests for compensation and claims, which must be approved in advance of treatments done or medicines prescribed by the physician.
• If patients belong to HMOs with a noted reputation for "penny-pinching," some physicians are less apt to spend time with patients enrolled in them.
• Some of the more expensive medications are not covered by HMO plans. Even though a particular medicine might be the best one suited for a patient's problem, if the HMO doesn't pay for it, physicians will prescribe lesser medications or drugs not necessarily best suited to take care of the problem diagnosed by the doctor.
• Some HMOs have on staff doctors called "hospitalists," who take over care from a patient's regular physician once that patient has been admitted to a hospital. Naturally, analysts said, since the hospitalist works directly for the HMO, there is a strong incentive to limit care, restrict testing and usher the patient out of the hospital as quickly as possible.

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"Not all HMOs use all these measures to pressure docs into limiting care," said the report. "But you can bet the contract your doctor signed with your HMO contains a few."

How the problems endemic to care, cost and coverage offered and paid for by HMOs and their physician members are solved differs in the Bush and Gore campaigns.

For his part, the vice president prefers "steps, both practical and bold, that move us step-by-step towards universal health coverage for everyone in America -- the children, the elderly and their families."

In particular, Gore wants to expand the Child Health Insurance Program and "hold states accountable for signing up eligible children for health insurance." He would also like to extend that program to parents.

And, the vice president would "make health insurance more affordable for small businesses by offering a 25 percent tax credit for the premium costs of each employee," and "strengthen health care delivery systems for the uninsured."

"... Gore is a strong supporter of the Patients' Bill of Rights that would ensure patients critical health protections and take medical decisions from insurance companies and HMOs and give them back to patients and doctors," said a statement released by the vice president's campaign.

Meanwhile, Bush prefers to use a network of existing community health centers and other programs to expand coverage to "medically underserved and under-insured or uninsured Americans."

Bush would work to "increase the budget for Community and Migrant Health Centers by $3.6 billion over five years in order to double the number of people they can serve," as well as "encourage health centers to partner with local hospitals and providers, managed care organizations, or other community health centers to ensure a more stable health care delivery system and financial environment."

The Texas governor would also "create a 'best practices' clearinghouse so that health centers have access to information and data on efficient operations at centers across the country," said his campaign.

In Texas and 22 other states there are laws against an HMO providing financial incentives that provide an inducement to limit necessary care. However, the Supreme Court, this past summer, issued a ruling that seems contrary to such state laws.

"In an HMO system, a physician's financial interest lies in providing less care, not more," Supreme Court Justice David Souter said. "No HMO organization could survive without some incentive connecting physician reward with treatment rationing."