Case Study 13 : HEALTH MAINTENANCE ORGANIZATIONS
Challenges
Patient is a 55 year old female, admitted due to multiple fractures of the left femur resulting from a vehicular accident. One week later, the HMO paying her bills advised discharge. They claimed procedures directly treating the fractures were already completed, and the physical therapy she still needed could be done on an out-patient basis. The attending physician, however, felt that the patient could recover more quickly with a few more days in the hospital.
Question
Given that a contract binds the patient, doctor and HMO, which side should the doctor support when the HMO’s contractual statement conflicts with the patient’s welfare (as judged by the doctor)?
Solutions
The physician must frequently go beyond legal limits to properly balance responsibilities to the other two parties (patient and HMO).
The physician must always act as the patient’s advocate. For example, when the patient needs tests not covered by the contract, or to stay in the hospital longer than allowed, the doctor has to seek reconsideration from the HMO.
Conversely, the physician should also act as the HMO’s advocate, by avoiding all unnecessary procedures, even those covered by insurance. Unnecessarily exploiting insurance coverage is unfair – this added burden will surely be eventually passed on to other subscribers, resulting in higher premiums and other fees.
HMOs frequently gain the upper hand in negotiations, since they could always employ legal provisions to their advantage, insisting on non-payment for additional procedures. Doctors should organize themselves to protect their interests and those of the patients.
