Opinion: Stop Blaming HMOs

[Dave Baker]

(Jonathan P. Weiner, in the Baltimore Sun, 7/21/2000)

Excerpt: "And yet, in our attempt to regulate and litigate HMOs and other health insurance plans into submission, we have once again side-stepped the two real U.S. health-care issues: the more than 40 million Americans who have little or no access to services and--election promises and contingency fees aside--that health-care resources are finite. Neither of these two issues are the HMOs' fault. In fact, quite the opposite is true."

http://www.sunspot.net/content/archive/sto...d=1150370207105

Please take a look at this piece and post your comments here!

[Larry M]

I agree with most of the writer's opinions and comments.

The arguments against insurance companies and hmo's seem to be based upon the contracts entered into between the buyer (an employer or an individual) and the carrier. These contracts specify the benefits which are to be provided and the premium which is to be paid for those benefits.

If the employer wants a greater benefit, then the carrieer will oblige - but for a greater premium. Lesser benefit packages can be had for smaller premiums.

Perhaps an analogous situation can be seen in the profit sharing field.

For example, an employer, with limited funds, can only provide a 1% or 2% profit sharing contribution every other year.

An employee with a vested benefit terminates his employement with the employer after having been in the plan for a few years.

Should the trustee of the funds be required to deliver a higher benefit than that based upon the account balance? Must he distribute an amount equal to that which would have been in the account if the employer had been making maximum contributions every year, and the investment yield was equal to the S&P 500 for each year of the plan?

Of course not. He must deliver a benefit equal to the vested account balance for that plan - no more, no less.

And, yet, that is not the rule to which health plans are being subjected.

Suppose the same employer can afford only a limited health plan for his employees. He will provide the full cost of any tonsillectomies or appendectomies required by his employees or their spouses or dependent children. So, he contracts with an insurance company to provide these benefits and no others and pays the appropriate limited premium for that limited benefit.

When a spouse discovers the pain in the abdomen is caused by a debilitating disease which may be terminal if not treated, but having nothing to do with the appendix (or even a swallowed tonsil), should the carrier be forced to pay for the treatment - even though it was never intended to be covered by the contract?

Again, the answer should be, "Of course not." And, yet...

It seems as if we are forgetting there is absolutely no requirement that every employer provide every employee with every medical benefit which may or may not be necessary to preserve that individual's health. [beyond the fact that there is no such requirement, there isn't enough money available to provide such a benefit for everyone.]

Does this mean the individual can not have the non-covered illness treated?

NO!! It means the individual has the right to have the illness treated and he can pay for any expenses out of his own pocket or through the aid of others.