Surgery Center of Oklahoma Blog

September 21, 2011

HMO Bait and Switch

Filed under: Uncategorized — surgerycenterok @ 2:12 pm

Ok.  This is really important so let’s go over this again.  Health maintenance organizations are organizations designed to make money by denying you health care. I decided to write this blog after seeing an editorial in our local paper pushing people to consider HMO’s as a way to decrease  ”out-of-pocket” costs.  Deeper in the newspaper was a large HMO ad aimed at teachers,  picturing our former governor’s wife.  These organizations have come and gone through the years but not before causing great pain and suffering. Check out this article on the origins of HMO’s. Your primary care doctor in this scheme is compensated by the extent to which money is not spent on you.  Bonuses are typically paid at the end of the year based on the primary care doctor’s gatekeeping skills.  That is, if your diabetes is complicated and difficult to manage, the primary care doctor makes more money by making damn sure you never get to see an endocrinologist.  There may not even be an endocrinologist on the plan. If your hemorrhoids are difficult to manage and all of the ointments and steroids aren’t working, you will be told that “ just need to give it more time..”..or something like that.  It is very unlikely that you would be able to see a colorectal surgeon for your condition, let alone have anything done about it.  Here’s my favorite, though.  Your child needs their tonsils removed because of their apnea and frequent throat infections.  You are told that “tonsillectomies are a thing of the past.” “This operation is just not necessary.”  ”We can manage this with antibiotics.”  You watch your child suffer and notice that the families whose children had their tonsils removed aren’t sick all the time like your little tyke.  You get angrier and angrier, and are now on to the HMO denial game.  You mention to your pediatrician that you have decided to file suit against him for denying your child appropriate care and PRESTO!! have an appointment with an ear, nose and throat surgeon… 5 months.  ”That’s the soonest we could get you in.”  Why?  Because there is only one ear, nose and throat surgeon on the HMO plan.  And he is horrible.  A reputation so bad that even you as a non-physician know that you will never let him touch your child.  And the only reason he is signed up for this crappy plan is that the folks running this HMO guaranteed him that he would be the only one….he would get all of the business.  He would get all of the business, not because he is any good, but because he was on the plan and whose practice is so bad that he would sign up for anything.  The HMO pays him horribly, but his waiting room is full.  This idiot would be out of business were it not for schemes like this.  The free market would have crushed him many years ago.

HMO’s are a little like Canadian health care, but worse.  If you poll Canadians, the vast majority will tell you that their health plan is great.  Why?  Because the vast majority of Canadians have never tried to access their health plan.  It is a great plan until you get sick.  HMO’s are the same sort of thing….with this caviat:  in Canada the physicians aren’t incentivized to deny you care like they are in HMO’s. In Canada, everything is limited by the government.  In HMO’s, your suffering translates in to larger dividend payments for the shareholders holding HMO stock.  Your child’s chronic infections and denial of their tonsillectomy results in a bigger Christmas bonus for your pediatrician.

Get it?

If you are a teacher working for the state of Oklahoma, you will probably be increasingly pressured to sign up for crap like this.  You will likely be told that it is for your own good and will save you money.  Herding you into an HMO is very much like taking away the health benefit portion of your compensation entirely.  You are probably better off uninsured.

G. Keith Smith, M.D.

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  1. Keith, If you want more grist for the mill about how bad Canadian health care is and the implications for reform in the U.S., check out my book, “Health Reform – The End of the American Revolution?”.

    Comment by Lee Kurisko — September 21, 2011 @ 3:12 pm

  2. Will do. Didn’t ever think that the Canadians’ biggest export would be their crappy health care system!

    Comment by surgerycenterok — September 21, 2011 @ 4:09 pm

  3. After reading your blog, I thought I needed to comment. First of all I hate HMO’s, they do try way to hard to dictate what Primary Care Physicians do in regards to referrals, but what I didn’t like was the implication that we won’t send a “complicated” diabetic to an endocrinologist. As I am sure that there have never been questionable surgeries, caths, scopes, etc. by “sub-specialist” just to improve their bottom line. I don’t give a squat about my “gate-keeping” skills; I care about the outcome of my patient. Now if your intent was just to bash HMO’s and you used PCP’s as a way to make your point, then I am OK with this. However if your intent was to make PCP’s look inferior to the “sub-specialist”, I have a huge problem with that. As a Family Medicine specialist, I may not have the depth of knowledge that some “sub-specialist” have on a particular subject, but I do possess the breadth of knowledge, that has to encompass many areas of medicine and surgery. I would challenge any “sub-specialist” to try to keep up with the ever widening array of information that the Family Medicine physician has to, OB/GYN, Pediatrics, Psychiatry, Geriatrics, General surgery (amazingly they ask us lots of questions about their recent surgery that the “surgeon” didn’t answer for them), Orthopeadics, Gastroenterology, Endocrinology, Cardiology, etc.

    I don’t like the Canadian health system nor HMO’s and I can’t stand O”bummer”care, but in the future, please don’t infer that PCP’s are inferior physicians or that we would not put the welfare of our patients first by taking care of their needs including referring to a specialist over a potential bonus check.

    Cary Carpenter, M.D.

    Comment by Cary Carpenter — September 22, 2011 @ 1:37 pm

  4. Thanks for your response. Glad you saw the blog. My intent was the former, an HMO bashing blog. You sound like the kind of doctor I would want to see and the last kind of doctor an HMO would want on “their panel.” Cudos. I also bashed an unethical surgeon in this blog toward the end….there are plenty of them out there. Their presence in the medical marketplace is, I believe, due to the absence of the normal market discipline that weeds out frauds in every other sector of society. My brother is a family practitioner and I am and remain permanently impressed by the breadth of material he and you have to keep up with.

    G. Keith Smith, M.D.

    Comment by surgerycenterok — September 22, 2011 @ 1:54 pm

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