Hmo Regulation Essay Research Paper Mark MillerENG

Hmo Regulation Essay, Research Paper

Mark Miller

ENG 101

December 2, 2000

HMO Regulation

Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. They involve elements such as beneficial health care programs like Medicare for seniors and Medicaid for the poor. HMO’s are sometimes referred to as managed care programs, which involves participation through clinics, physicians and insurance companies. Other essential parts of HMO’s include prescription drug plans, such as distribution and cost, and they are also important for information needed by emergency room residents in cases of emergencies.

Although HMO’s are not always seen as positive and helpful institutions, they are definitely important when it comes to medical care. Most of the criticism comes from consumers using these HMO’s and the politicians implementing their procedures. Some of the major problems involved are denial of treatment by physicians. This has to do with the people they see and what people will receive as far as treatment. According to the Associated Press, “Consumers who have been denied a treatment that the HMO says is not covered, or who inadvertently fail to follow HMO guidelines in seeking treatment and are therefore denied reimbursement, will continue to have little recourse.” [12] Basically not much is being solved or controlled.

HMO’s and managed care programs have been subjected to countless regulations and attempted reforms. HMO’s are a combination of doctors and insurance companies that are formed into one organization. They provide treatment to their members at a fixed cost and decide on treatment based on the severity of the patient’s ailments. HMO’s main concerns are to control costs and provide the best treatment possible to their consumers using their programs. The reasoning behind this is to keep patients healthy so no further treatment is needed. A lot of the time these organizations seek out people with less destructive ailments, in other words healthy people. They provide the best possible treatment to their patients to get more people enrolled and to maintain current premiums paid by consumers using their HMO’s. Most HMO’s are groups of doctors hired by insurance companies and are controlled or regulated by the hospitals who facilitate them. They also limit what kind of care they receive. Most pressure comes from the government and its ability to influence hospitals to deny treatment. These regulations are expensive and result in revision of private employee health care claims. This type of behavior results in increased spending by the public and more people become uninsured, approximately 50 to 60 million people go without insurance for at least one month each year.

Particular HMO’s face many additional problems due to attempted government control through regulations. One such institution is the United Health Group in New York. The United Health Group said, “that it returns decision-making power over patient care to physicians on issues like admitting health plan members to hospitals or providing other treatments.” [4] This kind of decision is made to eliminate frustrating features of most doctors’ work: like getting insurance companies to approve medical decisions that the doctors think they should make. This is a problem because most hospitals are influenced by government officials and make their decisions based on what government wants to do. California based HMO’s are constantly reevaluating their service, so they formed the California Managed Health Care Improvement Task Force. This organization worked on ways of making private, employer-based health care systems work more effectively. The head of (CMHCITF) said, “His experience resulted in a clearer understanding of why HMO’s are so widely disliked.” [10] Many people do not understand HMO’s and that is why there are constant questions of why they should be regulated. People need to consult their health care providers and get a better understanding of what is provided and what is not, so later there is no confusion of what type of care they should have received.

Another problem lies in selective-contracting. This is a process where hospitals deny treatment to patients because their HMO is not on the hospital’s provider list. The patients usually pay capitation fees and fee-for-services (FFS). These costs are at a fixed rate and patients are provided specific care at the best possible quality. “Selective contracting is common in managed care throughout the United States. It was created so that managed care could negotiate discount prices for physician, ancillary, and hospital services.” [1] These contracts provide people with quality service at fixed costs. It maintains stability and faith between patients and their HMO’s.

Control and implementation of forced regulations is another important issue. Many health care plans include gag clauses in their contracts with physicians. Gag clauses impose contractual limitations that interfere with physician-patient relationships. They include types of contract clauses that limit a physician’s ability to advise patients of all medical appropriate treatment options. They include extent to which these different types of clauses exist in current HMO contracts with physicians. They are likely to implicate contract language on physicians’ practice. In 1996, the Amer