OK, I agree people should be responsible for preventing illness, but that can be quite expensive to do. This would be feasible IF the HMO's were willing to assist in getting people well. For example, what if someone really wants to quit smoking, but can't seem to do it. Why doesn't the insurance compnay pay for patches? Or pay for other assistance via preventative programs??? If someone is overweight, why don't they have a company sponsored weight management program? Pay for a gym membership or discount, or cover the expense of a medically managed weight loss program?
If it was easy and cheap to loose weight and quit smoking, don't you think people would already be doing it???
As far as the HMO's needing to make a profit, I am sorry, I don't think so. The employees get bonuses for saving the companies money, this may one day be at your expense. HMO's don't pay bills in a timely fashion, and then the patient's get on bad credit lists for unpaid bills. I did work for a Medicaid HMO, and though the company was very generous, they had to allow what was laid out in the states Medicaid program, they made a $19 million dollar profit one year. From what I hear from other nurses, some companies make WAY more than that!
I just spoke with a nurse yeterday about my difficulites getting auth for home health visits. The pt had stasis ulcers on her LE's. The doc ordered an una boot, to be changed once a week, he then upped that to 3x a week due to copious drainage, so in the meantime, the nurses used up the allotted visits earlier than planned. So, here it is saturday, and the nurse says I don't have auth, there are no more visits. I call the insurance company, the person on the other end gives me such a hard time because apparently, the nurses had not re-measured the wounds, so I had no measurements to give her. After a 10 minute inquisition on the phone, I finally said, look I don't have time for this, if you're not going to give me auth, let me give you the patient's number, and you can send her to the hospital to be admitted for this care! Suddenly, we got auth! Why? It's more expensive to send the pt to the hospital. The bottom line was, there was COPIOUS drainage from the wound, which required increasing the freq of care, it would not matter what the measurements are, though I admit, it was embarrassing to find none of our nurses measured the wound in a week and a half. Getting back to the nurse I spoke to about this, her M-I-L worked for HR for a major insurance co, and she said they gave personality tests on hire to find people who had defensive and mistrusting personality traits, so that God forbid, they wouldn't allow more than what was needed.
I also agree that when HMO's came into existence, there was a lot of misuse and frivilous medical care, and fraud happening, but just like any system, eventually, people learn to "work it", so that if someone really wants to get one over on the insurance company, they still will. The probelm is still, that if particular individuals doctors or patients are the problem, they need to be addressed, or dropped form the plan. The idea should not be to punish everyone. I have had some very depressed patients tell me that were not allowed to have Open Heart Surgery until they failed PTCA 3 times, per the insurance company. Who the hell is someone sitting behind a computer screen to tell another human being and their cardiologist that they cannot have this needed surgery?? Because they are overweight? Did they offer to send him somewhere or do anything to help the pt with that problem? It burns me up!!!
And in my experience with this company, I can tell you, if the state came and reviewed our paperwork, they would be very impressed with all the wonderful things that were done for the pt's. Problem is, it's all on paper only!! They paid big $$ to give asthma programs to members, but the High-school grads, non-professionals, who were in charge of this effort forgot to mail out the invitations to the members, so 3 people were there, only one of them was a member of our insurance company (It was at a health fair.) Yet, we did community education, wooohooo!! What a JOKE!
There were a lot of hard working nurses there, but unfortunately, they were in the minority. Many left out of disgust.
Sorry, didn't mean to go off, but this subject really bothers me. Fine, hold people accountable, but help them to prevent illness then. THEN, if they are non-compliant, you can say, we tried to help them in every way, NOW we are dropping them.