Word: hmos
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Dates: during 1990-1999
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Health Net is typical of "network-model" HMOs that contract with large medical groups and networks of physicians--called Independent Practice Associations--to provide the actual medical care. New subscribers choose or are assigned to a particular medical group, and in turn choose a "primary care provider" or "gatekeeper" who controls access to other services and outside specialists. Even his or her recommendations often must be approved by the group's own utilization-review managers or by Health...
...becomes most evident. The new medicine, by its nature, abhors complexity and innovation. Health Net, for example, won't cover any treatment it deems to be experimental or investigative, even though its contract with MediCal, California's Medicaid program, does cover visits to acupuncturists and faith healers. Like other HMOs, it spends nothing on research to hunt for new treatments for disease. In fact, it feels bound by law and competition to avoid such research...
Under the old medicine, research hospitals paid for clinical research through billing surpluses; grants from the National Institutes of Health tended to pay only for big-ticket basic science. Colorado's Dr. Jones accuses HMOs of placing medicine in a double bind. "Is it reasonable," he asks, "for an insurer to demand the gold standard of proof and simultaneously refuse to pay for patients to enter a trial to get that level of proof?" Dr. Jones is convinced that women who once would have come to him for a transplant aren't coming because their doctors, operating under tight managed...
...HMOs arose and have flourished in the U.S. largely in response to the runaway medical costs engendered under the fee-for-service approach, in which doctors have an interest in doing everything their patients might require, and possibly more than that, provided an insurer is paying the tab. But Himmelstein and other physicians believe the bottom-line philosophy of for-profit HMOs has pushed the pendulum too far in the opposite direction...
...join the type of organization he had previously criticized? "If you want to treat patients these days," says Himmelstein, "you have to become a part of HMOs." Other physicians have felt these pressures and become similarly, if less vocally, disillusioned with HMO practices. One Los Angeles doctor worked dutifully for three years as a neurologist for CIGNA HealthCare, a large HMO. When she advised the mother of a brain-damaged boy that a muscle biopsy might help diagnose the extent of his condition, she was chided by her bosses for suggesting the test. "I was told it was a mistake...