HMO, Health Maintenance Organizations

The Insurance industry is failing the consumer. The concept of fraud is being used by the insurance industry to deceive the public. "Our current national health care system is simple: don't get sick."

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Because of the rising costs of health insurance rates, the American public and governmental agencies turned to HMO's in the hope of controlling the increases in healthcare. They accomplished this task by limiting access to health care. By having primary physicians determine the validity of a medical need to see a specialist. The patient could not have immediate access to these specialized healthcare professionals HMOs had listings of physicians that patients could use and if the insured was to go outside of this listing-a higher co-pay would result. This practice also applied to hospitals.

Hospitals in order to be included with an HMO insurance company had to negotiate with the HMO on the amount of remittance it was to receive for services. Many times this cost would be reduced substantially for the going rate of charges for other insurance companies.

This price competitiveness between hospitals for patients was used against hospitals (by the HMO)…pitting one against the other-for the privilege of this
HMO contract. This in turn resulted in each insurance carrier wanting and demanding a better contact than the other

Because of this competitive nature of business, hospitals would slash prices for their services to the point that they were losing money. They believed that if they had the volume of patients that this practice would offset the low prices.

Other insurance carriers and governmental agencies began to use this same leverage tactics against the hospitals. Pitting one against the other in order to reduce costs. This practice help reduce the cost in the short term; however, this practice also reduces profit margins and margins to cover lost monies from bad debts.

This loss of profitability for many hospitals has resulted in closures of many of the smaller rural hospitals. Some professionals believe that by the year 2010, that only the larger metropolitan areas will have hospitals. Smaller towns will see the closure of their local hospitals and the opening up of medical clinics to replace those lost hospitals. Depending on the demand for these services, many of these clinics will only be open on specific days and hours. (If an acute health emergency case may end up traveling several miles for vital hospital care.)

The impact of HMO's on the healthcare industry is having a devastating impact. The question to ask, "How far can costs be cut before the system is destroyed?" There is waste in all businesses. The cost of limiting this waste can exceed the actual cost of the loss itself.

Document Name & Link to Document	Description	File Size /Type
'Cheating can be disastrous' HMO owes $334 mil. for avoiding insuring pregnant women	The case, brought by a civil whistleblower and then joined by federal authorities and the state attorney general's office, charged that Amerigroup cherry-picked "healthies" and purposely avoided women in their third trimester of pregnancy because they cost more to insure.
Controversies in Management: Access should be denied	"Patients have a right to expect that you will not discloseany personal information which you learn during the course ofyour professional duties, unless they give you permission. Withoutassurances about confidentiality, patients may be reluctantto give doctors the information they need in order to providegood care."--General Medical Council, Duties of a Doctor
Humana, Inc. v. Forsyth and Federal Claims Against Insurance Companies	The application of federal law, especially RICO, to the insurance industry should provide policyholders with additional remedies to combat persistent and repetitive practices of insurance companies that damage large numbers of policyholders. The Court’s decision may also result in the application of numerous other federal civil and criminal laws, including federal consumer protection law and civil rights law, to the insurance industry and HMOs as well.	Pdf 82 kb
Physicians in the Management of Patients With Hepatitis C	Many patients with hepatitis C are not aware that they are at risk for Hepatitis C Virus infection. In addition, the vast majority of patientswith hepatitis C have no or nonspecific symptoms until cirrhosisis established.
Re unaffordable meds.	Many Americans can’t afford needed prescription drugs because they lack insurance, suffer low incomes, and can’t afford high American prices	PDF / 27KB

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