Acupuncture Today – November, 2002, Vol. 03, Issue 11

Myths about HMOs -- What You Need to Know before Making the Jump, Part Four

By Kevin McNamee

Editor's note: This four-part series of articles is intended to dispel some of the misconceptions about HMOs. Parts one, two and three appeared in the August, September and October issues of Acupuncture Today, respectively.

HMOs: Myth vs. Reality

Myth #10: Your professional association's leader is on the panel and serves as a consultant to the HMO. Your leader says you should join the HMO; it's good for your practice, and it's good for the profession.

Reality: One HMO marketing tactic is to "recruit" the leaders in Oriental medicine and hire them as consultants for promotional purposes. The professional association leader's purpose is to persuade members to become HMO panel doctors, expand the HMO's market share, and advise the HMO how to do this. This creates a conflict of interest. When a bill to limit an HMO's influence is introduced in the legislature, how will the leader vote: for the association, or for the HMO and his/her consulting fee?

If your professional association's president is a consultant to an HMO, insist that the leader either discontinue working as a consultant or step down as the leader of the association. This is a clear conflict of interest.

Myth #11: The HMO will increase the doctor's fee reimbursement when the insurance company contracts are renewed.

Reality: Knowing how the market works, this is very unlikely to occur. In fact, the opposite (reimbursement reduction) has happened in some cases. Insurance companies and HMOs try to keep their costs low and their profits high. Patients want services at the lowest possible cost. Conversely, the doctor's interest is to provide services at the highest price, so market pressure is to give low reimbursement to the doctors for their services. The HMOs will reduce reimbursements until the doctors begin to drop off the panel because they can't stay in business.

Myth #12: Join the HMO when you are first starting out to gain patients, but then drop off as your practice grows to the point that you don't need HMO patients anymore.

Reality: HMOs are able to contract with other insurance companies because the panel doctors are willing to take less for their services in the hopes of seeing more patients - in essence, work more and get paid less. Given the lesser rate, the HMOs are able to sign up the employer groups to covert their employee coverage from the better-paying insurance plans to HMOs only. Employers save money, and the employees still have Oriental medical care, but the providers lose out. Your practice suddenly has 50-50% or more HMO patients when it once had 1-2%, and you find yourself unable to drop off the HMO panel because your practice will go under.

Myth #13: Stay with the HMO, take a loss on each patient, and you will make up the loss if the patient is injured at work or in a car accident. Workers' compensation and personal injury cases pay better than the HMOs.

Reality: There is a movement afoot to have the HMOs get into workers' compensation and personal injury. What this means is that the reasonable reimbursement enjoyed by doctors for personal injury and workers' comp cases will disappear unless you are with the HMO. In this case, the reimbursement is at the low HMO rate regardless of the nature of the injury or jurisdiction. By remaining on the panel, the HMO thrives as it captures more contracts, including those for workers' comp and personal injury.

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