[laceylady]

Originally Posted by OCsun

Having previously worked for a large health insurer / health care provider, these kind of systems worked fine when they were first developed. The reason they were initially successful was their large popularity with young families looking for well child care with little out of pocket expenses. They were known as HMO's or in the sales department as, healthy members only (HMO).

Some HMO models included specialist which were on retainer or contracted for services. Referrals were made to the specialists associated with the health care plan. This model worked well until someone with a serious illness wanted to seek care from one of the top docs and discovered they did not have a choice. The response was you can see whoever you want to see, but we are not going to be financially responsible unless you see one of our specialists who we think is capable of treating your condition.

As people age they need more care and want to have some say in the medical care they receive. Staying healthy is certainly a key to needing less medical care, but age can not be ingnored.

The health model being described in this discussion reminds me of a Kaiser. Doctors are recuited to work for a salary and costs are paid for by Medicare through a Medicare Advantage Plan. A Medicare Advantage Plan is insured by a health insurer who agrees to cover the same basic medical services Medicare pays for. This model can work very well for many Medicare Eligible people, because it gives them access to medical care with less out of pocket expenses.

The initial concern of HMO's is still hiding in the back ground. The plans hire what they determine to be the best doctors and will refer you to specialists who they deem are capable of caring for your needs. I can't stop asking myself, why don't top docs join HMO's?

JMHO

Top doctors don't join HMOS because the HMO manages the patient's care, rather then the doctor and patient managing the care. Referrals, tests, surgeries, etc.all have to be approved by doctors and nurses who work for the HMO. The care is not quality care. Although patients have an 'assigned' PCP, they see whoever is available when they call for an appointment. There is a huge HMO in WA state that has been in business for over 30 years. Although the premiums are less than other non-HMO plans, the consistency and quality of care is lacking. I have been to the Villages Colont Care Center twice now, and I don't see it operating like an HMO. Just my opinion, of course.