One of my partners, an ear nose and throat surgeon resigned years ago from a particularly abusive HMO.  He said, “never again,” as did all of the reputable ear nose and throat surgeons in the area, physicians whose practices were already solid and busy without having to deal with this outfit.  Even though many of the HMO’s are long dead and gone from Oklahoma, this particular HMO has lingered on, only to crawl back to this partner of mine, telling him to make them an offer.  They had, very simply, lost every single ear nose and throat surgeon from their “panel,”even the not-so-good ones.

He made them an offer he knew they would refuse, a ridiculous amount, one that would make this pathetic organization his best source of payment.  They accepted.  

His presence on their “panel” allowed the HMO to advertise….well…to advertise his presence on their “panel.”  Having quality ear nose and throat coverage made their product easier to sell to reluctant employer groups, most of which know the HMO hunger games by now.  Things seemed to be going well for about three months when he noticed a sudden change.  The HMO had made it impossible to schedule a patient for surgery.  Phone call after phone call.  Extended phone consultations with remote nurse manager-gatekeepers to review the indications and justify the need for surgery.  Lost, needing-to-be-refiled paperwork.  Waiting on hold for 30 minutes while attempting to obtain pre-authorization for CT scans for patients needing sinus surgery.  And more.

It dawned on my partner that what the “beneficiaries” of this HMO had as a benefit, was not unlike what the beneficiaries of the Canadian system have and what people in this country under “Obamacare” will have:  a right to hope for care, or a right to a place in line.  A health care card in your wallet may mean nothing.  As Dr. Jane Orient has now famously said, “coverage doesn’t mean care.”  

The poor child with gigantic tonsils and adenoids with sleep apnea and chronic ear infections who could be spared all of this misery with a 20 minute operation is left holding the bag.  The parents, frustrated with this waiting game of insurance approval, are now very troubled to find out that my partner has resigned once again from this HMO.  What will they do now?

If they follow the example of many patients that have been down this road, they will wind up at our facility, paying a fair price for their child’s surgery, a price that is within their budget and having their child’s surgery done immediately, and done by the surgeon they have rightly come to trust and respect.  They will wonder afterwards why they have “insurance” at all.  They will wonder if some “insurances” are really a black mark, that actually prevent them from receiving care.  Finally and angrily they may conclude that this whole HMO idea must be good for someone, just not the patients covered by “the plan.”  

I think this illustrates that while the central planners of HMO’s or ACO’s or government health care may boast that the reimbursement levels they have arbitrarily concocted are sound and fair, they will always retain the powerful tool of rationing-access-by-bureaucracy, an incredibly cruel way to balance a budget or book a profit.

G. Keith Smith, M.D.

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