INSIDE THE HEALTH-CARE SYSTEM – HOW TO GET THE MOST FROM YOUR HMO (GENERAL INFORMATION)
It’s common for doctors to receive a flat monthly fee for every patient under their care. Under this arrangement, known as capitation, the cost of lab tests, procedures and other care comes out of the doctor’s pocket. If the doctor orders an $80 X ray, $80 is deducted from his paycheck.
Frequently, HMOs give bonuses and assess monetary penalties according to how much the doctor spends. For example, many HMOs reward doctors who limit the number of patients they hospitalize or who minimize referrals to expensive specialists. Using a technique known as “economic credential-ing,” managed-care plans terminate doctors who spend too much on patients.
To further limit costs, HMOs set up barriers to care. Under most managed-care plans, you can’t see a specialist without being referred by your primary care doctor. Visits to the emergency room require pre-authorization. And it can take weeks—even months—to get an appointment.
Given these new realities, here’s how to protect your interests. If you’re thinking of joining an HMO or are already enrolled, learn as much as you can about the plan. Read the membership materials carefully. If possible, talk to current and former members about their experiences with the HMO in question.
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