HMO's Don't Pay

Who says we don't have Richard Nixon to kick around anymore? This President let HMO's creep in on his watch. Kaiser Permanente reinvented the health care insurance model and did so with Nixon's blessing.

When you first look at HMO's the concept doesn't sound too bad. Catch and cure problems before they become big and expensive medical catastrophes. If you join and use in plan Doctors, testing facilities and Hospitals, you pay a minimal amount, if anything out of pocket beyond your periodic insurance fee. You get check-ups to make sure you don't have any major problems that can be caught and treated early. Medications are cheaper because the HMO plan administrators can bargain with Pharmaceutical Companies to get medications at a much cheaper rate than any individual.

So far, so good except the HMOs found out they could make a lot more money by not paying for Doctors, Testing Facilities and Hospitals than by just paying less. They therefore, invented the phrases "reasonable and customary", "elective procedures", and the plan's "pharmaceutical list".

To the HMO reasonable and customary fees means the fees charged decades ago by the least expensive Physicians or Hospitals. My wife recently underwent surgery which resulted in a Hospital bill of $60,000. The HMO paid less than $5,000. So far so good since we didn't have to pay the difference out of pocket. However, we had to use the Doctors assigned by the Hospital instead of the Doctors we wanted to use. My wife was in the Hospital for 14 days and only saw the Doctor in charge of her case on only 3 occasions. The result was that she put on 30+ pounds of water weight, while eating virtually nothing. If we had a Doctor who showed up they might have noticed this problem developing and given her diuretics to shed the water. Instead they released her and a day later she was readmitted through the ER for Congestive Heart Failure. She could not breath because the water filled her chest cavity causing heart failure and the inability to use her lungs which were compressed by the vast amount of liquids surrounding and compressing them.

The Hospital floor seemed to be divided into two sections. One for indigents and HMO patients who got minimal Doctor and Nursing care and the other side by people with Major Medical, PPO and self pay patients who received intensive Doctor and Nursing care.

My wife after a total of 18 days in the Hospital was told she would need standard Physical Therapy for patients with congestive heart failure. The HMO plan rejected this as an elective procedure even though the Doctors said it was necessary. I was forced to give her IV medications at home even though I never did this before. If I made one mistake it could have been fatal.

Personally, I was taken off of prescribed medications that worked well and forced to use over the counter medications which of could I had to pay for 100% out of pocket and which did not work as well as the prescription they didn't want to pay for. I got a letter from them with this switch and a coupon for $5 off the price of the first box of the over the counter medication. They have tried to switch other medications I take and I had to appeal their decision and get letters from my primary care Doctor to say that I would not do well with the medication switch.

I also noticed that HMO patients had to wait up to two months for a Specialists appointment. I asked the appointment desk if I was paying cash could I see the Doctor sooner. They said yes.

HMOs seem to reward Primary Care Doctors who give fewer referrals , cheaper medications, and who just plain refuse treatment. My Doctor admitted this to me. Then he switched me to the office Physician's Assistant rather than spend his precious time with me.

There are some major problems with our current medical system. HMO's are leading the way to poor quality health care in this Country. By the way, for this insurance my wife and I have to pay a fee of over $500 each month and my Employer has to kick in even more than that.