Date: Thu, 17 Nov 1994 12:34:26 -0800 From: Deborah Stiles Subject: Re: HMOs To: Multiple recipients of list SOREHAND Warning-lengthy. Only read if you are interested in the HMO subject. I hear all of your stories and am sorry for your difficulties with some of the health care providers at HMOs. I have some relatives in NJ who are not too crazy about HMOs either. There are differences between HMOs just as there are differences between private hositals, clinics, private specialists, etc. (Like the fillings, vibrator story--not even an HMO! :-)) I think it is good that HMOs and all other private medical services be under the toughest scrutiny and investigations for any alleged unethical activities. If there are some HMOs that operate with "trade secrets" and withhold necessary treatment, then they need to be exposed and closed or whatever. These types of HMOs ruin it for all the others that are trying to provide quality care while maintain reasonable costs. Actually there have been far more investigations about the unethical nature of private services profiting from over-prescribing unnecessary procedures or, for example, ordering X-rays on everyone to pay for there new office x-ray machine; or ordering CTS surgery or hysterectomies on everyone in order to pay for the operating rooms; or prescribing an expensive drug because the pharmaceutical company will take the doc to France, etc.. I could on and on. The sad part is, the patient thinks they are receiving "quality care" because the doc ordered everything possible. The point is law suits and investigations are everywhere, whether HMO or non-HMO. I read a study in the WSJ that actually showed some HMOs (I forget which) had better breast cancer detection and prevention compared to non-HMOs thereby decreasing radical procedures, saving money and saving lives. It will be interesting to see what future research will show. Special interest groups really want to show poor results with HMOs because they are a threat to their incomes which have nicely continued to exorbantly climb. Having worked in private family practices, I soon discovered that many private docs, practice business first and take care of people second. HMO family practices generally allow the physicians and staff to do what they are trained to do, and leave the business to the HMO administration. I think it is important that we do not judge an entire private hospital or a HMO based upon one or two incompetent providers, unless there are case after case of unethical practices. It is also important that we all become educated about our bodies in order to better determine what is an emergency vs non-emergent condition. We are spoiled in this country. We expect treatment immediately even for acne. If we don't get the immediate and lengthy care for acne (just an example), then we say there has been a drop in the quality of care. I have worked triage in "urgent care" settings (ERs) and am amazed at the impatience and expectations of being immediately "cured" for a cold or a chronic back ache. As we have seen so much on this List, chronic conditions and grey areas are difficult for health care providers to "cure". There is no magic pill. Self-management needs to become a way of our lives. It is important that you find a provider who you trust. If you can't see your records, I would go see someone else. Switch doctors several times within an HMO until you find someone you like. There are ways to do this; some HMOs are easier than others. One thing I learned in the HMO, you can't be a wimp, but you can't be too aggressive either or everyone will think you are a "difficult patient". You have to learn the system so you know how to work it to your benefit. If your HMO does not provide you with the service or care that you need for your problem, request that your primary doctor help you get an outside referral, and write letters to the top of the organization and assertively request an outside referral. Or get Workman's Comp to pay for it if you can. Keep complaining politely and you should get somewhere. You may also have to find the outside provider yourself and prove that their services are what you need and that the HMO does not have it. It's a pain in the butt, but it can be done in many HMOs. It is a difficult process to get health care services paid for, or get Workman's Comp., or Disability benefits because it is ESPENSIVE and the burearcracy determines necessity (whether that be insurance companies, HMOs, or the government). Health Care Reform is desperately needed in this country. Sorry to say, we will probably not see any significant change for a very long while due to special interest groups, the new political agendas, and public fears like not being able to choose our providers. I guess I feel we are lucky to even have a few choices; and besides, our so-called present system of provider choice isn't really the believed "freedom to choose" because choice is dictated by what plan our employers provide. There are so many misconceptions about the "wonders" of our current system. Change is needed. Sorry for the length of this. I could talk about managed care and health care reform forever, but this really is not the forum to do this. Feel free to respond privately to me. Debbie Stiles, MN, RN dstiles@u.washington.edu