The most restrictive form of managed care is the HMO (Health Maintenance Organization). An HMO promises to provide nearly all care at virtually no extra costs to the participant. But is the promise kept? Not really.

For instance, patients in an HMO are required to have all their care coordinated by a Primary Care Provider, or PCP. The decision to see a specialist and have it covered by HMO is taken out of the patient's hands and placed in the hands of a PCP. This is part of the HMOs' philosophy to limit the number of specialty referrals, tests, and hospitalizations. Their objective is cost reduction. But what happens to patient care?

The PCP/HMO relationship includes other roadblocks to quality health care. Most HMOs pay PCPs a monthly fee regardless of whether or not they see their assigned patients. Moreover, bonus money is often given to PCPs who come in below target on the number of patient specialty referrals, tests, and hospitalizations. On the other hand, penalties are commonly imposed on PCPs who go over target. The message appears to be--the less you do for your patient, the more money you stand to make.

Another common HMO practice is encouraging physicians--though financial rewards--to keep their practices "open"--a term which has taken on the meaning of allowing more patients per day than may be treated properly.

• You may have a medical condition that is more serious than can be realized during a rushed office visit.
• You may wish to see your PCP, but the wait is very long. Typically, you cannot see another PCP, just the one designated as yours.
• You may be limited to seeing a nurse or physician's assistant.
• Your PCP would like to refer you to a specialist, but the system results in prolonged waits or delays.
• Your PCP or specialist determine that further diagnosis/testing is needed, but the HMO may refuse. (You have limited ability to appeal this decision.) And, in most states, the HMO is not liable for this decision.
• Your doctors agree you need ongoing treatment, but it may not be allowed due to costs.
• Because you cannot get in to see your PCP when illness or injury occurs, you may go to an emergency room for something that is considered a non-emergency--and end up with an additional bill.

Some HMOs have responded to patient complaints by introducing a POS (Point of Service) option. Plan participants can opt to pay increased fees to see any physician without PCP approval. Patients may be responsible for increased costs for tests and hospitalization not recommended or ordered by the PCP.

Diagnostic Clinic does not participate in HMOs because they conflict with everything we believe about putting patients first. We are ethically opposed to allowing financial arrangements to influence medical care.

Another form of managed care is the PPO, preferred provider organization. In PPOs, patients may see physicians included on a set list for a set price. These physicians are considered "in network". This is different from the traditional deductible and copayment arrangements on visits to physicians of your choice, or "out of network".

Physicians agree with PPOs to accept a preset discount from their usual charges or agree to a predetermined rate schedule. Some physicians see more patients to offset the discounted rate. However, if physicians participate in too many PPOs and patient loads get too high, they may spend less time with patients, possibly compromising the level of patient care.

Diagnostic Clinic of Houston does participate in a limited number of PPOs--but only those which allow us to provide care that is consistent with our core philosophy. Because PPOs constantly change their fee schedules and ownership changes are not unusual, Diagnostic Clinic of Houston regularly evaluates these plans and our association with them. The needs of our patients will never be compromised and will always take priority in any decisions we make.

Click here for the Managed Care Glossary
Click here for Our Position on Managed Care
Go to a related article on Why We Are Different