-VISIT OUR OTHER FORUMS- OB-GYN-L Ultrasound Ultrasound History Fibroid Forum Physicians-in-Training Tech Talk OBSTET-L (portuguese) OBGIN-L (spanish) Nursing

Re: Bob, HMO's and God From: Joanne Bulley (jbulley@cheshire.net) Mon May 10 19:40:37 1999 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: john r miklos : "Re: Tension Free Vaginal Tape for Bladder/urethral suspension" Previous message: Ealgail@aol.com: "Re: R: HMO's and God" Well, Bob, in the purest sense, yes the HMO would deny all care, however they can't quite get away with it. The industry jargon for what is spent on patient care is indeed "loss" - not patient benefit. The "for profit" HMO's goal is to keep the "loss" at under 75% of the premiums taken in, while the "not-for-profit" HMO's aim to keep the "loss" at a maximum of 85% If they are TRULY interested in providing the care for the best $ value, explain the following HMO decisions I have worked with for my patients: 45 year old woman getting married this summer, has previously used IUD's for contraception - including a Dalkon shield (with NO problems, not involved with that class action), a Lippes Loop and a Copper-7 - her HMO will cover a laparoscopic sterilization for her at a cost of $2500-3500 (depending on total hospital costs on top of surgeon's fee) but they will not cover a Paraguard IUD (copper T) insertion and subsequent removal of $450 total (depending on what the removal charg is at that point in time. So - for perhaps 5 years of contraception, depending on her date of menopause, they will pay $3500, but not $450... 43 yo woman with major gi symptoms, seen by PCP who involves the gen surgeon same day, CT scan the next day shows a 14 X 18 cm complex cystic and solid mass with multiple septations most consistent with ovarian cancer, sees me, placed on the OR schedule. HMO reviewing MD spends 15 minutes on the phone hasseling me (and preventing me from seeing patients already scheduled in my office in a timely fashion) asking me why I am rushing her to the OR for possible hysterectomy... He finally says "OK you can take her to the OR, but if you do a hyst rather than just an oophorectomy the company will review the case and decide then if they will cover" [the fees]. Well, the next day in the OR we find a stage one ovarian cancer AND the colon cancer causing the symptoms that brought her to the PCP. The insurance reviewer (same person) is called back to inform him of TWO - not one - primary cancers and says he has no recollection of the discussion the preceding day (less than 20 hours before) 25 yo woman with newborn with major complications from a rare isoimmunzation syndrome, who used an IUD (as a nullip) without complications but had had complications with OCP's and will not use any hormonal contraception - whose HMO (different one from that above) will not cover her IUD - but would cover a pregnancy PLUS the complications of isoimmunization when she conceives as a result of condom failure.... I can stock Depot-Lupron in the office and have a 5-10 minute visit for injection, but because the HMO contracts with Pharmacy manager X the patient and I have to fill out forms, mail or fax these to the Pharmacy manager half way across the country, the Pharmacy plan then mails the drug for ONE patient to me, then I can call the patient to come in for the injection... Or if I have already scheduled the patient for when I think the drug will be there I have to spend my personnel's time making sure it is there for her visit... Why don't they strongly encourage the men to have vasectomies - for under $500 most of the time - since tubal ligations will run $2500 or more? Also - the vasectomy has a failure rate of 1.5 per 1000 while the tubal ligation has a failure rate of 4.5 per 1000 (or higher...) Gee ... 3 times more effective at 1 fifth the cost..... I realize they can't force this particular issue for reasons of sexual discrimination, but they could put out quite the ad campaign for vasectomy for the cost of a fraction of the tubals. I do not believe for one minute that all the personnel costs of those MDs and RNs working 9 AM to 5 PM plus all that paper work plus all our time can really be cost effective - just roadblocks in my opinion - since except for the lack of IUD coverage, I nearly always can convince them of why my patient needs what I am fighting for... The CEO of an HMO here out East recently received over $1 million above his pay and standard benefits in cash benefits for one years bonus... I bet he never got called at 2 AM to save a life, make critical decisions ... on top of working all day the day before and the day after and taking care of a family... The CONCEPT of the HMO is fine and upstanding, and they may have worked that way in days gone by, but that is not how they are working any more. They just keep putting in more and more layers of overhead between the patient and the provider of that care... If there is a problem, a new department is created to deal with it, study it, etc - that department never goes away. It is like a rabbit warren. It is now a big business begetting itself over and over and over. -- Joanne Bulley, MD Keene, NH PS: No Wolly-Bully jokes, please. I was in a new school in 7th grade with a kid whose last name was Wooley (first name not Robert) when "Wooly-Bully" was recorded. Needless to say there were many jokes based on our names. > Date: Mon, 10 May 1999 11:06:59 -0500 (CDT) > From: Robert J Woolley <wooll005@tc.umn.edu> > > > In many HMOs physicians "risk share" with > > the HMO, which means the incentive is to provide as little care as > > possible in order to make the profit margin as high as possible. > > This is quite obviously false. By your logic, the smartest thing the HMO > could do would be to provide *no* care, no benefits whatsoever, so that > they could keep the entire premium as pure profit. Why don't they do that? > Because nobody would sign up. Similarly, though less drastically, they > will lose business in the long run if they don't provide the services that > people want. Their incentive is to provide the care that is needed for > optimal health, not more, not less. > Next message: john r miklos : "Re: Tension Free Vaginal Tape for Bladder/urethral suspension" Previous message: Ealgail@aol.com: "Re: R: HMO's and God"

Return to

Mail a New Message to the Forum: ob-gyn-l@obgyn.net Forum Administrator: geffrey.klein@obgyn.net Report Technical Problems: webmaster@obgyn.net Last Updated: Mon Nov 2 05:31:30 2009

The American Medical Association is no longer designating CME hours for AMA Category II CME credit. However, physicians themselves may self designate learning activities as Category II CME credit hours if they feel it is of sufficient educational merit and meets the formal definitions of continuing medical education. OBGYN.net believes these interaction in this forum meets these criteria. For further information see the AMA web site.