HEALTH CARE FOR OLDER PEOPLE: THE HMO ALTERNATIVE

Tuesday, June 1, 2010 13:42

Increasingly, rather than selecting a private doctor, you may have another choice – joining a health maintenance organization or HMO. Rather than paying a physician for each appointment, if you join an HMO you pay a fixed sum in advance that entitles you to almost all (or all) of your medical care: checkups and routine care, laboratory tests, the services of specialists, hospitalization costs. There are two major types of HMOs – group practice and individual practice.

Group-practice HMOs provide all their outpatient services at a centrally located health facility, usually staffed by primary-care doctors, specialists (e.g., in eye care, hearing, surgery, gynecology), and additional personnel such as technicians and nurses. The clinic offers laboratories, X-ray services, a pharmacy, and perhaps ambulatory surgical care. On enrolling, a subscriber selects one of the primary-care doctors as a personal physician who is responsible for coordinating care. On routine visits patients may see a specially trained nurse practitioner.

Individual-practice HMOs provide primary care in the private offices of doctors under contract to the HMO. Joining this type of HMO may make getting to the doctor easier if you choose someone with an office near your home, but you may not receive the wide range of services you would get by joining a group-practice HMO.

A major advantage of joining an HMO is more financial peace of mind. Your medical bill is already paid. There are no large out-of-pocket expenses you might abruptly incur. There also is no economic deterrent to calling the doctor if you are ill, since visiting four times a month costs no more than once a month. And because HMOs have to operate within a fixed budget, they have an incentive to deliver services in an economical fashion. Studies show that, on average, people who use HMOs spend less for health care.

Does this emphasis on efficiency lead to poorer service? Although doctors opposed to HMOs reason that a system where people are paid beforehand no matter what they do offers a built-in incentive to provide minimal, cursory care, the reverse seems to be true. When researchers at Johns Hopkins Medical School reviewed the literature comparing HMO care with traditional fee-for-service care, nineteen studies showed that HMOs provided better care, a handful found the two types of care comparable, and only one or two found HMO care inferior.

On the other hand, the serious drawback to joining an HMO is the lack of freedom. HMO subscribers must use a certain hospital; when they need a specialist, they must visit someone under contract to the HMO. Many people decide against joining because they are not prepared to give up the right to go to the doctor or hospital of their choice.

Furthermore, only a fraction of HMOs accept Medicare. (Some HMOs not under contract to Medicare provide what is called Medicare “wraparound,” offering coverage for current subscribers, who then become eligible for Medicare.) Probably in part because of this, only a small minority of the elderly are enrolled in HMOs.

If you are interested in an HMO and able to enroll, use the same considerations in evaluating it as you would in selecting a private physician: cost (Does the HMO accept Medicare? How expensive is joining? What services are covered?); accessibility (How easy is it to get there? Will a doctor see you promptly if you are ill?); quality (Is the clinic overcrowded and unattractive? Are the doctors on the staff well qualified? What is the affiliated hospital like?).

James Doherty of the Group Health Association of America, a national organization of HMOs, also suggests finding out if the HMO is “federally qualified.” Federally qualified HMOs are approved by the Health Care Financing Administration. Your state insurance department will also have information about the quality of a prospective HMO.