HMOs and Smoking Gun

  1. Does anyone else visit www.calnurse.org on a regular basis? Some of the articles they carry knock my socks off. If you scroll down to New Articles section there is one about a HMO accountant who has begun to talk. Some of the things he tells us about HMO exectutives is quite damanaging. Like for instance if you suspect that your HMO is holding back on paying your bills on purpose your are right. It is a tactic they use to push up profits. Another thing that irked me was a CEO refuring to MDs as being too emotionally involved with their business. If these people are contemptuous of MDs for caring about patients you can guess what they think of nurses.
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  2. 6 Comments

  3. by   Mijourney
    Hi oramar. Unfortunately, I don't have the time I want to read all the interesting articles in calnurse or other sites. I did take a peek at the article you recommended on HMO and smoking guns.

    I think this article validates why I feel that the industrial approach to health care is the wrong approach. I agree with those experts who feel that profits have undermined patients and their families to receive the best and most objective care possible. It has also prevented us from moving beyond the limited-focused medical model.

    Unlike the HMO executive in the article, I don't have a lot of pity for physicians as a group. As a group, they made the choice years ago to steer clear of working as salary and wage employees like nurses, therapists, and other health care workers do. The insurors, other corporate, and governmental entities enabled physicians and other for profit health and medical vendors such as pharmaceuticals, laboratories, medical service business owners to wreak havoc on the health and medical system causing this public health threat we now have in patient care.
  4. by   nursedude
    Oramar and Mijourney... How are you gals doing? It's been a while but good to see you two are still around.

    Oramar, I did not read the smoking gun article but I did read your post and Mijourney's as well. You know, there is currently and has been much "hype" about "HMO horror stories": The executives are stealing all the profits, the people who answer the phone don't have any medical experience etc etc etc....

    Oramar, I know you live hear in the Pittsburgh area and I want to ask you if you have ever seen one of those billboards for UPMC Healthplan? The one I am talking about is the one with the motto about "your doctor making the choices not your HMO" or something like that. Anyhow, I guess my point is "Who do you think runs the HMO's?"

    I like Mijourney, don't have an ounce of sympathy for MD's. Do the names Milliman and Roberts ring a bell? Both of those guys are MD's who are partly responsible for making managed care what it is today. They gave birth to the guidelines that determine hospital lengths of stay and that kind of evolved into DRG, CPT, HCPCs and ICD9's. Thanks to a couple of DOCTORS patients now get the boot in 24 hours for something 10 or 20 years ago would have kept them as an inpatient for a week.

    Oramar, I have worked at several managed care companies. Highmark BC/BS, CIGNA and a company called Intracorp. They all were responsible for determining/enforcing how long people stayed in a hospital, how much $$$$ was paid for medical care and treatment and guess what? All those decisions were made by folks with an MD after their name.

    Mijourney, I don't disagree with you on the statement of "industrialized" approach, my opinion is that we are now in a phase of healthcare called "commercialized healthcare" The only thing worse would be government sponsored or socialized healthcare...

    PS Oramar- "Choose a hospital (or an HMO) as if your life depended on it!
  5. by   Mijourney
    Hi nursedude. Appreciate your response. You always provide food for thought and tend to generate strong responses from posters.

    I worked in the hospital setting when we kept patients in the hospital for diagnostic testing long after their symptoms or disease process had stabilized. I believe that this was done for several major reasons:

    1. Technology and biotechnology was advancing and doctors needed time to play and assess the new toys.
    2. The legal profession like the medical profession was looking for profit, so physician's became their meal ticket in the form of litigation. Many physicians became caught up in practicing defensive medicine because of this.
    3. Insurance companies as intermediaries and direct payors paid all claims of physicians and other vendors for a long time, no questions asked. The insurors, in particular, were happy to say as they do today, they have a large number of physicians in their network.

    Physicians use to do mostly pro bono work. They got tired of seeing other occupations forge ahead economically and wanted a bigger piece of the pie. I can't blame them for that. But, the problem is is that they have been a part of what I feel is a corrupt system involving the government and private entities where in the U.S, the richest country on earth, we have 25% of the population, mostly children, that can't get quality access to health care or good education, because they have no or inadequate insurance.

    What happened with HMOs is that the intentions may have been worthwhile, but the designers went to the extreme in trying to control costs and combat the corruption. They are also in the profit making business. I personally would like to know if M&R are lawyers? I also would like to know what possessed them to make deliveries of babies and mastectomies outpatient? I want to know why a global assignment for length of stay has to be assigned to every case?

    I think a combination of the best of private entities and governmental entities working together to try to get the healthcare system balanced is what is needed. The problem is that so many people involved in health care as well as other areas have profit motive ingrained in them to the point where they can't see beyond the trees.

    [This message has been edited by Mijourney (edited February 25, 2001).]
  6. by   oramar

    Oramar, I know you live hear in the Pittsburgh area and I want to ask you if you have ever seen one of those billboards for UPMC Healthplan? The one I am talking about is the one with the motto about "your doctor making the choices not your HMO" or something like that. Anyhow, I guess my point is "Who do you think runs the HMO's?"

    [/B]
    Is UPMC health care plan a Provider Owned Plan? If it is, there is a article over on www.healthleaders.com saying how most of these types of programs are not the big money makers that the people who invented them thought they would be. Matter of fact most Provider Owned Plans are loosing money. Seems to me someone told me about that a month or two ago, anybody you know NurseDude?
  7. by   rncountry
    A good book on the subject is "Making a Killing" by Jamie Court and Francis Smith. This book identifies Milliman and and Robertson as a Seattle based accounting firm. It identifies them as the actuarial company that sets the health care standards for the nation.
    from the Book "Milliman and Robertson Sold more than 20,000 copies of its guidelines through the enod of 1997, affecting the treatment of 50 million Americans. The company's West Coast offices have expanded to 120 health-care experts from just four in 1991, and its partners charge upwards of $450 per hour for their services. In 1995 had $150 in revenue"
    I think this is the firm that you are referring to Nursedude. The book identifies them as an accounting firm, but as the paragraph above states, they have health-care experts on staff. These "experts" are not identified as to what type of "experts" they are though. This area of the book does go on to quote a Dr. John Vogt from Kaiser about cutting utilization , droping referal rates and hospitals utilization as a way to balance budgets.
    It's an interesting and eyeopening book, my only reserve on it would be it does not explore well the reasons that HMOs can into being as mijourney pointed out. The need was there, but the system ran amok.
  8. by   rncountry
    oops, a $150 million in revenue! and my spelling was bad too, LOL, middle of the night, Oh well. And Oramar, thank you for your post in another thread.

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