Playing the Hunger Games – HMO style

Dr. Kevin SmithOne 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 ENT surgeons in the area, physicians whose practices were already busy without having to deal with this outfit.

Even though many of the HMOs are long dead and gone from Oklahoma, this particular HMO has lingered on, only to crawl back to this partner of mine, asking him to make them an offer. They had, very simply, lost every single ENT surgeon from their “panel,” even the ones who were not well thought of and who needed more business.

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. To his surprise, they accepted.

Having made this agreement allowed the HMO to advertise his presence on their “panel.” The availability of quality ENT coverage made their product easier to sell to reluctant employer groups, most of which are by now familiar with the HMO hunger games.

Things seemed to be going well for about three months when my partner noticed a sudden change. The HMO had made it impossible to schedule a patient for surgery. He had to make phone call after phone call. He had to endure extended phone consultations with remote nurse manager-gatekeepers to review the indications and justify the need for surgery. Paperwork was lost, and needed to be re-filed. He would be kept 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 will have under “ObamaCare:” 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 has been said repeatedly, “coverage doesn’t mean care.” When will people understand?

The poor child with gigantic tonsils and adenoids, who could be spared much misery by a 20-minute operation, must continue to suffer sleep apnea and chronic ear infections. 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 who have been down this road, they will wind up at our facility, paying a fair price out of pocket for their child’s surgery, a price that is within their budget, and having their child’s surgery done immediately by the surgeon they have come to trust and respect. Afterward, they will wonder why they have “insurance” at all. They will wonder whether some “insurances” are really a black mark that actually prevents them from receiving care. Finally and angrily, they may conclude that this whole HMO idea must be good for someone—just not for the patients covered by “the plan.”

I think this case illustrates that while the central planners of HMOs or ACOs or government health care may boast that the payment rates 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.

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Keith Smith MD

Dr. G. Keith Smith is a board certified anesthesiologist in private practice since 1990. In 1997, he co-founded The Surgery Center of Oklahoma, an outpatient surgery center in Oklahoma City, owned by 40 of the top physicians and surgeons in central Oklahoma. Dr. Smith serves as the medical director, CEO and managing partner while maintaining an active anesthesia practice. More posts by Author