The HMO Fiasco
A doctor speaks out.
June 19, 2000 -- A young woman sits in front of me with tears in her eyes, so grateful to have finally gotten an appointment in my office. She has end-stage liver disease and will need a liver transplant. She recently moved to our community so that she could live with her sister and find a good doctor close to a transplant center.
After two months in our system, she has seen three different doctors, but none would spend more than fifteen minutes with her. When she heard that I had a reputation for spending extra time with my patients, she asked the health maintenance organization (HMO) to transfer her care to my office. During 30 years of experience in my field, I have cared for many patients like her. I will make sure she survives to receive a liver transplant.
What's Wrong With This Patient?
What is it about this perfectly nice young woman that aroused so little compassion from her doctors? Nothing about her would make her an undesirable patient -- except that she is sick and will need a lot of attention. In the past, when doctors assumed responsibility for complex cases, they were reimbursed in a manner proportional to the amount of their time required. Now, under the so-called "capitated" payment systems used by most HMOs, they are paid a small fixed fee per year for each patient, no matter how many visits, operations, or hospitalizations are needed.
In my community, this fixed fee is so small that if a patient needs to be seen more than two or three times a year, the physician will actually be working for nothing because the fixed costs of seeing the patient (including secretarial time and paperwork) are not paid for by the HMO, but come right out of the physician's pocket. It is not an exaggeration to say that this payment system makes every sick patient a direct financial liability to his or her doctor.