From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,sci.med.cardiology,alt.activism,talk.politics.medicine
Subject: Re: Backlash against HMOs: a declaration of war (was Doctor-bashing)
Date: 9 Apr 1999 12:59:46 GMT

In <7ekqdv$it5$2@birch.prod.itd.earthlink.net>
kurtullman@sprintmail.com (Kurt Ullman) writes:

>        Actually HMOs have been around since the 60s and in the 70s
>there was legislation requiring all employers over a certain size to
>offer HMOs in addition to "regular" insurance. The first HMO was Kaiser
>Permanente in CA and it was NFP.
>
>>But, insurance and Medicare "contract" to pay for certain proceedures and
>>therapies.  You know this in advance.  Only the HMO's have used the
>>concept of after the fact denial of payment for care delivered to their
>>"clients".
>
>        MCare does this with fair regularity. I have had my indemnity
>company do the same. Acutally, I have had far more problems with my
>indemnity company paying for things then my HMO. The HMOs do the denial
>care schtick only in the ER (rarely) and if you don't get precertified.



    And so do insurance companies.  Grisham's novel and the movie about
the insurrance company that won't pay for the kid with leukemia (what
was the name?) are not about a bad HMO.  There are plenty of bad
insurance companies to go around, even if Blue Cross isn't one.

    Look, it's not very complicated.  You can get screwed by insurance
companies or organizations that deliver health care any time somebody
goes back on their word.  There's nothing special about size.  A PPO
(preferred provider organization) is merely a system of resources
efficiently put together, and ready as a turnkey resource, wherein your
insurance plan contracts for such a good rate, that it pays only if you
see particular contract doctors, and often only in a particular
heirarchical referral way.  Many insurance plans (eg Mailhandler's)
require use of particular test laboratories or pharmacies to get your
labs or prescriptions paid for.

  So: you've got two companies: the insurance carrier and the PPO.  In
cosy cases where each has only one other for a customer, and each has
each, then, voila, that's an HMO.  It's nothing that isn't already in
PPOs and HMOs, except it's an exclusive contract.  If you're assured of
buisiness and can shard adminsitrative resources, everything gets more
efficiency.  And that savings can potentially get passed to customers.
But only if they have the freedom to drop out.  Make it all mandatory
(as in, say, Canada) and the feedback drops out.