Without the White Coat
HMO...the healthy supports the sick and ill
The Filipino way of thinking is always so unique when it comes to health maintenance organizations (HMO) contrary to the main mission and objectives of the health maintenance organizations. The HMO had made its existence here in the Philippines for more than 20 years now, but deep inside "most" of HMO subscribers and members will never see the point, reason and purpose of its existence. If all the members of the HMO will have there ways, utilization cost will just hit the ceiling. The Filipino mentality may he deny it "always" believes that if he puts a peso in, then he should get a peso out. The HMO members or subscribers yearly pays a certain premium to the HMO and with this they are entitle to "some" basic benefits of the health organization like a "no-cash out" consultation in an accredited HMO doctor's office or in the emergency room of an accredited hospital. A "no-cash out" for laboratory examinations that are approved by the HMO provider, and the hospital stay in a room designated by the HMO as a private or semi-private.
Behind the set-up the Filipino HMO member or subscriber will never see the point for the purpose of an HMO. In the US of A the HMO set up works with efficiency and is highly commendable in some cases some HMO have already had set up there own medical institutions. With this a lot of US citizens have now opted to buy health insurance, this have paved for the HMO to dictate on the cost, coverage terms and reimbursement and documentary requirements.( Payments will come in late, with HMO assuring an influx of patients if the practicing doctors will just cut down its rates....consultation fees to 60 to 70%, this was just too good for the HMO ,but too bad for the doctor since he will be under the clutches of the HMO) The Filipino never thinks that as a healthy individual the premiums that he pays will cover those that will get sick or in some future day will pay for an emergency consultation in the emergency room of an accredited medical institution. As Filipinos we never see the purpose of an HMO, we deposit in forms of premiums then will collect later in form of a "yearly executive check-up" or some weird and "unnecessary" diagnostic examinations.
From the view point of the HMO members it is beneficial due to the "no-cash out" policy for consultations or laboratory examinations. For accredited HMO physicians dealing with some "demanding" members that thinks they are entitled to a yearly "this and that" without any medical basis or will need a battery of medical diagnostics just to consume there premiums or one way or another will get something out from there HMO from the side of the doctor and physician this doesn't make any sense. Imagine a hypertensive and diabetic patient, a member of an HMO demanding a 2D echocardiogram with no reason at all just for the heck of it.
In the losing end of the rope are the medical coordinators, since it is the HMO that will make the money.(remember they(HMO) are already paid(yearly premiums) for by the members, irregardless of our intentions as physicians to serve our patients we are used by the HMO as pawns in the world of business in medical practice). The belief among "true" doctors or physicians that will render there services irregardless they are paid or not will always become pawns of the games the HMO will be playing.
HMO which falls under managed-care practice will always make the big bucks living the accredited physician or doctors holding an empty bag, let us look on the side of curb reimbursements---- deny valid claims, delayed claims, undisclosed cost based criterias to asses medical claims, a power behind the HMO that dictates among practicing physicians to accept billing practices that is "only" beneficial to the HMO, and a no appeal process.
In the long run it is the HMO or any managed care institution that will be benefited, and the hopefully its members, but it is the accredited physicians and doctors that will end up holding the bag ......... an empty bag.