HMO's. Time to get out...

[Moses]

If you are in a HMO and have the option to get out, now is a good time. The supremes have removed the last obstacle to corporate profiteering at the expense of your health. Scary stories? I've got hundreds. Have I seen people suffer to protect the HMO bottom line? Yes. Have I seen people die to protect the bottom line? Yes. Healthcare is about to get more dangerous.

http://story.news.yahoo.com/news?tmpl=story&cid=514&e=3&u=/ap/20040621/ap_on_go_su_co/scotus_hmos

[BlueSkyJaunte]

Holy crap. WTF is wrong with this country???!

[RallyJon]

Pay Wal-Mart prices, get Wal-Mart quality.

[nostatic]

I've got a PPO.

You sure you guys don't want some form of socialized medicine?

[widebody911]

Originally posted by nostatic
I've got a PPO.

You sure you guys don't want some form of socialized medicine?

Oh no! That would be like Canada! Can't have that! Next thing you know, hockey will replace baseball as the national pastime...

Actually, come to think of it, that wouldn't be half bad.

[juanbenae]

PPO= prefered provider? no primary care doctor? am i correct in this?

[vash]

i had a PPO, when first dating my gfriend, i cut the crap out of my hand shucking oysters. so i had to go to an emergency room. i think the financial thrashing ended up hurting more.

my HMO is pretty sucky, but for other reasons.

[304065]

The supremes have removed the last obstacle to corporate profiteering at the expense of your health

Moses, you aren't usually given to hyperbole. What gives?

The point of the Davila and Calad cases is that plaintiffs who sue their HMOs, claiming that the HMO's cost-containment efforts resulted in clinical harm to the patient, have to sue in Federal court, not State.

The patient originally sued their HMO for medical malpractice, a "Tort" claim. The lower court distinguished that from a "denial of benefits" claim and ruled for the plaintiffs. The Supreme Court said that it doesn't matter how you style the action: the HMO's liability is to be determined under the federal ERISA statute (which covers retirement benefits and has been extended to HMO coverage). And the proper place to bring an ERISA action is in FEDERAL court, not STATE court.

Now, state courts generally, not always, return bigger verdicts for plaintiffs, and they are easier to access, again generally.

Successful malpractice claims hurt the HMO, in the form of higher insurance premiums, direct settlement costs, and legal fees (the lawyers ALWAYS win). So moving the claim to federal court probably reduces the HMOs costs from med-mal claims.

And yet you say that's a bad thing?

Does the HMO's benefit design or formulary necessarily mean that patients are going to get substandard clinical treatment?

Isn't this a matter of contract, e.g., if you want better care, aren't you free to purchase traditional indemnity insurance? If you want an off-formulary drug (in the cases cited, Vioxx) can't you buy it yourself?

Ahh, but the answer is, you can't afford traditional indemnity insurance, you can't afford to buy branded drugs for cash, they are too expensive!

But the HMO was developed as a legal healthcare purchasing cartel, to negotiate with physicians and hospitals and defend med-mal suits in scale, to reduce the monthly premium to a level that ordinary people can afford!

So we're back to the whole clinical care debate: do Americans have a RIGHT to clinical care at any cost, whether they've contracted for it or not?

Would your answer change if the plaintiff were seeking heroic end-of-life surgery to prolong her life and didn't get it because the HMO's medical management committee said it wasn't likely to result in a meaningful increase in life span? What if they sued based on that, claiming it was a violation of standard of care?

Here are the cases FYI.

http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court=US&navby=case&vol=000&invol=02-1845

[Dantilla]

Health care by the same people that brought you the DMV? No thanks.

The Government already controls health care for the Veteran's administration and Indian affairs. When those two areas are run efficiently, Maybe I'll be ready to listen. Untill then, no way. Let them fix what they already control, first.

[Moses]

Originally posted by john_cramer

And yet you say that's a bad thing?

Absolutely!

The HMO determines far more than which doctor you see and which medications you can use. They also decide which type of surgery your cancer patient can have. They generally allow the least expensive treatment alternative with little regard to patient choice or outcome.

When disaster strikes as a result of HMO directed treatment protocols, they claim no responsibility. A typical HMO response is, " Your physician should always provide you with the very best treatment. If that is not the HMO approved treatment, we will not pay the doctor and the patient will be stuck with the entire hopsital bill, but this should not alter the doctors decision making."

When an HMO insists on specific treatment protocols, they are in effect "practicing medicine." Many states have seen that logic and the spectre of malpractice has limited their intrusion into the physician/patient treatment plans. With the threat of litigation removed, expedient, inexpensive and frequently dangerous treatment protocols will be mandatory.

When bad outcomes result, lawyers will go for the deep pockets. Your doctors.

[BlueSkyJaunte]

Maybe we'll get to see a live re-enactment of "John Q.", after all.

[Moses]

Years ago I had a patient who needed laparoscopic surgery. She also had a platelet disorder that could cause excessive bleeding. Because her surgery was an "outpatient" procedure, her HMO insisted that I do her case in a less expensive surgicenter. I wrote a letter of appeal, citing the patients risk factors and the increased safety of the hospitals operating room. Appeal denied.

The patient could not afford to pay for the hospital costs herself, and I refused to operate on her in a surgicenter. Her primary care physician referred her to a different surgeon who was willing to comply with the HMOs requirement. She had a bleeding complication. She was transferred to the hospital by ambulance where she died.

[singpilot]

I have a PPO. Can't say that is any better. I get top notch care, but the deductibles ALWAYS out weigh the benefits. Imagine that. $1000 dollar hospital bill; for a $250 procedure. Deductible is $1000 per incident. They make sure bill is $1000 so that I can pay for the guy that cannot pay anything.

Hmmm. $3900 premium, PLUS $1000 patient out of pocket.

What was the other option? Go self insured. Not likely.

Bend over, this isn't going to hurt at all.

[pbs911]

That was a bad decision. Like it or not, med mal cases are the checks and balances of below standard medical care. Without a plaintiff's ease of access to State courts the HMO has won a battle to put profits ahead of quality medical care.

There is going to be lots of activity in state courts the next month as defendant move to have their case dismissed in State courts.

This decision takes the US one step closer to the saying, "if you think the cost of medical care is outrageous now, just wait until its socialized."

The issue I want to see brought before the court is a case where a doctor is tried for manslaughter on grounds of gross negligence.

[BlueSkyJaunte]

My HMO plan supposedly allows POS (no joke) -- Point Of Service. In addition to having a Primary Care Physician and going through the rigamarole of getting referrals in-network etc., I can supposedly go to ANY doctor and pay 20% of the costs.

Supposedly. We'll see how that shapes up....

[Dantilla]

Moses, thanks for sharing that. And thanks for making wise decisions.

[Moses]

Originally posted by BlueSkyJaunte
My HMO plan supposedly allows POS (no joke) -- Point Of Service. In addition to having a Primary Care Physician and going through the rigamarole of getting referrals in-network etc., I can supposedly go to ANY doctor and pay 20% of the costs.

Supposedly. We'll see how that shapes up....

A POS plan is a great option. It protects your right to seek the best care available during a crisis. Your 20% should also have a maximum out of pocket expense. Good choice.

[nostatic]

my PPO plan says I can have any physician I want, and go to any hospital I want. The rub is that PPO docs are 90% covered, "in-network" docs are 80% covered, and "out-of-network" are 50% covered. We have a max out of pocket also. I don't mind paying small chunks for the ability to choose whatever doc I want (the in-network" list if pretty damn big). Plus if it is anything serious, our PPO is aligned with a teaching hospital/med school.

[JavaBrewer]

Great timing on this thread. Our company was recently assymilated and today was open enrollment for us strangers. I converted my HMO to a PPO this morning - and came back to see this thread.

The bottom line was our primary care and pediactric physicians dropped us this year as they were no longer accepting HMO patients. We're sick of seeking out doctors that will compromise their pay.

[350HP930]

I'm suprised no one has chimed in yet to blame all these problems on lawyers and lawsuits.

I think this thread is quite insightful for such dolts since in this case you have a doctor telling you that malpractice claims keep doctors and medical organizations in check.