HMO Crap
Okay, so today in class we were learning about HMOs and the law. (HMO stands for Health Maintenance Organization- examples are Aetna, Blue Cross/Blue Shield, etc).
Now in general, doctors (and med students) hate HMOs. They seem to be constantly trying to tell doctors what is best for the patient and what that doctor or hospital can and cannot do to aid in the care of their patients.
Today, I have even less respect for HMOs after hearing what they plan on doing next. They are calling their new plan "Pay for Performance." That SOUNDS good, right? Like if you're a good doctor, you get paid. Well, it's not quite how it sounds.
This is what "Pay for Performance" means: (I'll give an example using a patient with diabetes)
Case A: Patient with diabetes comes in (usually every 3 months or so) for his usual check up. He is very good about taking his medicines, his blood sugars and staying away from "bad" foods. He brings with him his list of home blood sugar monitorings and gets his blood drawn for a long-term blood sugar test (hemoglobin A1c). That test comes back within normal limits, so he is a well-controlled diabetic. The HMO reimburses the doctor for this office visit and for the blood work taken.
Case B: Patient with diabetes comes in (after missing one or more of his appointments) for a check up. He says he's only taking one of his medications because three pills is too many to take in one day. He has not been monitoring his blood sugars at home (maybe once a week- when he remembers) and he's been having a lot of trouble steering clear of twinkies at the grocery store. Even though we know what the result will be- we do the hemoglobin A1c test. It of course, comes back way higher than normal. The HMO is trying to make it so that the doctor doesn't get reimbursed for this visit because the doctor has "Failed to Perform" ("Pay for performance" concept). In this scenario, the doctor has absolutely NO control over what her patient does when he leaves her office, but the doctor will be penalized for his failure to comply.
This is going to mean one thing for poor diabetics out there- doctors are going to start refusing to see them if they are anything less than well-controlled because let's face it- doctors need to make a living too! (And with the way most insurance companies and HMOs reimburse now adays- every patient is important for doctors' livelihoods!)
What will those lovely HMOs think of next???
Now in general, doctors (and med students) hate HMOs. They seem to be constantly trying to tell doctors what is best for the patient and what that doctor or hospital can and cannot do to aid in the care of their patients.
Today, I have even less respect for HMOs after hearing what they plan on doing next. They are calling their new plan "Pay for Performance." That SOUNDS good, right? Like if you're a good doctor, you get paid. Well, it's not quite how it sounds.
This is what "Pay for Performance" means: (I'll give an example using a patient with diabetes)
Case A: Patient with diabetes comes in (usually every 3 months or so) for his usual check up. He is very good about taking his medicines, his blood sugars and staying away from "bad" foods. He brings with him his list of home blood sugar monitorings and gets his blood drawn for a long-term blood sugar test (hemoglobin A1c). That test comes back within normal limits, so he is a well-controlled diabetic. The HMO reimburses the doctor for this office visit and for the blood work taken.
Case B: Patient with diabetes comes in (after missing one or more of his appointments) for a check up. He says he's only taking one of his medications because three pills is too many to take in one day. He has not been monitoring his blood sugars at home (maybe once a week- when he remembers) and he's been having a lot of trouble steering clear of twinkies at the grocery store. Even though we know what the result will be- we do the hemoglobin A1c test. It of course, comes back way higher than normal. The HMO is trying to make it so that the doctor doesn't get reimbursed for this visit because the doctor has "Failed to Perform" ("Pay for performance" concept). In this scenario, the doctor has absolutely NO control over what her patient does when he leaves her office, but the doctor will be penalized for his failure to comply.
This is going to mean one thing for poor diabetics out there- doctors are going to start refusing to see them if they are anything less than well-controlled because let's face it- doctors need to make a living too! (And with the way most insurance companies and HMOs reimburse now adays- every patient is important for doctors' livelihoods!)
What will those lovely HMOs think of next???
posted by Alison | 4:06 PM
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