How many reputable doctors change their name every couple of years? How many brand-popular industries like Coke would want to change their name after all the "brand-quality-recognition" and consumer trust that has been generated over the years? Brand recognition usually represents quality and visa versa? Then what kind of industry would ever want its companies to change their name with any degree of frequency? The health care industry ... especially the HMO industry. It is a common business tactic to shake off problems (in the health care industry usually this means death, injury, harm and the like). Remember ValuJet's crash into the Florida Everglades because a harmful, illegal and hazardous cargo caught fire in the baggage hold? Probably not, the airline renamed itself Airtran, problem solved. Aside from changing names to cause confusion, here are some things to watch for in the health care industry that often plague America(ns).

Ever wonder where that health insurance premium/benefit you work hard for is going to? Recently one of the website author's patients, an insurance salesman was flown up to the Kentucky Derby courtesy of a managed care company (that begins with the letter H) on a Lear Jet to attend some lavish parties and dinners as well as have box view of the Derby. I would guess the cost might be in the range of $10,000 or double that. What % of the remaining insurance premium gets kicked back to the salesman and how much goes into the pockets of Washington politicians to restrict patients' (who are forced to pay the premium) rights? Stories of HMO's stinginess toward patients are so old-news and commonplace that they no longer make it to TV or headlines unless there is a new twist or shock value. Every extra dime an insurance company makes in profit or gives away in executive perks comes at some expense to an insured patient's health care quality.

The type of health plan you have may have a big effect on the kind of care you receive for skin cancer and sun damage. Unfortunately, HMO's are almost always at odds with dermatologists on allowing patient access (the right to see the dermatologist and be covered) to dermatologists. In Florida and across the U.S., dermatologists have had to "donate" hundreds of thousands of dollars to politicians just to get laws allowing patients a choice of direct access just to see a dermatologist, avoiding the HMO gatekeeper doctor, who commonly said "no." Many respected, valid studies have shown that primary-care doctors (who can't possibly know everything about every branch of medicine) often fail to recognize many melanomas and skin cancers. Melanomas are frequently misdiagnosed (missed) by primary-care doctors, even when patients warn the primary-care doctors of the possibility of skin cancer! Unfortunately, many patient deaths have resulted because of restricted access to specialists by managed-care companies.

HMO's like to pay for screenings such as Pap smears (test for cancer of the cervix), mammograms (test for cancer of the breast) and vaccinations because these things are very inexpensively ($10-$20) and make for very good publicity (advertising). However, to save a life with skin-cancer screening, costs much more money. In states without direct access laws, most HMO's won't consider paying even for a trained skin-specialist doctor (dermatologist) to examine all the skin, the cost of taking a biopsy or biopsies or the cost of having the biopsies read by a trained dermatopathologist. HMO accountants know exactly how much skin-cancer screening of every patient member would cost the HMO (managed-care company) compared with how much money the screening could be expected save the HMO and cost to treat patients once the cancers are found. That is why HMO's pay lobbyists and politicians millions to restrict patients' access to dermatologists. This level of specialization (medical care) costs much more money than HMO's are willing to spend. HMO's know that the bottom line (profits) goes down when patients request to see specialists like dermatologists (direct access). In this case, cost simply outweighs saving lives. In a moment we will examine managed care in general, HMO's and PPO's, and how they may interplay with medicine and treatment.

The October 9, 1998, ABC Nightly News had a special segment on HMO's in which it was stated that 80% of Americans were happy with their current health care which is now largely managed care, i.e. PPO or HMO. What about the other 20% of Americans? Is the "other 20%'s" care much worse or just a little worse than in the 1980's? What percentage of the "HMO horror stories" that don't make it to TV lie in the "other 20%"? Also, HMO's advertise heavily on TV - why would TV put too many negative stories on about one of their big money customers. In this same ABC segment, it was mentioned that the happiest patients on HMO's are the state Medicaid patients. Many HMO's are finding that Medicaid patients are "too sick to make money on." These HMO's are now considering opting out of certain state Medicaid plans, leaving behind the patients who like them and need them the most. An HMO is a business. Most are run by politically powerful insurance companies. A business is in business to make money. Quality health care is usually costs money to have the best tests and medical materials. Don't count on an HMO being generous and forgetting that they are in business to make money and not lose it on giving you the best possible health care.

Managed-care companies are great at "spinning" or "bending" the results and meanings of studies, so the 80% satisfaction figure should be looked at carefully. There are good and bad aspects of managed care. Again, like 'em or not, managed-care companies will probably be around for quite a while. Managed care is capitalism (Wall Street) and politics (Washington, DC) at their best. Understanding this connection may help you take a more aggressive role in your or your loved one's health care. If you or your loved ones are never sick, then read no further regarding managed care. But if you think you may ever become ill or that someday you may need to use a managed-care health plan, perhaps you should look through the remainder of this section.

Managed care implies that some company or group will control, in advance, a portion of a certain patients' health care delivery. Many plans or types of care are referred by three-letter acronyms, i.e., PPO, PPC, HMO, etc. If a certain plan or three-letter combination, such as an HMO, gets a bad reputation in a particular state or region, then a managed-care company can give the plan another name that the public will not recognize as easily. We will first discuss PPO's, which are a step above HMO's and probably make less money for insurance companies. PPO's and HMO's differ mostly in how they easily make doctors available to patients.

PPO doctors can be primary care, e.g., internist, family practice, pediatrics, or specialists, e.g., dermatologists, eye doctors, etc. PPO's usually contract with a number of doctors who are bound to charge the managed-care company no more than a certain amount of money to see a given group of patients. PPO contracts may restrict these doctors to the use of only certain procedures. To put the screws down further, PPO's may subject their contracted doctors to managed-care company panel reviews. These reviews are frequently conducted by doctors who are specially hired by the managed-care companies for the sole purpose of claim denial. These same reviewers may even be paid based on the number of claims they reject. The "review doctors" are allowed to "determine" whether or not the service, which may have been performed months or years before, is covered.

HMO's usually work a bit differently, with much of the definition in the contracts the HMO doctors sign and in the contracts patients sign. HMO doctors are usually primary care doctors and only sometimes specialists. HMO doctors may get paid a lump sum like $50,000 to be responsible for one year for, say, 100,000 people signed up in the HMO in a particular geographical area. If the HMO doctor does not understand a disease or cannot handle the treatment and sends a patient to an outside specialist, that HMO doctor may have a financial penalty subtracted from the $50,000 for which he/she contracted. If most of the 100,000 insured HMO patients show up to a HMO doctor's office in a given year, do you think the doctor can pay his/her overhead (employees, rent and supplies) at 50 cents per patient? What most Americans do not know is that even after negotiating these tough contracts with doctors, many managed-care companies try not to pay the doctors the agreed-upon amounts. The cases eventually wind up in courts with the doctors "winning the case" but paying much of their winnings to lawyers while the offending insurance companies were benefiting form holding on to the money and making investment income on monies improperly withheld from the unwitting doctors.

In the late 1990's Prudential Insurance was defending a class action lawsuit by many South Florida doctors because of nonpayment. Also in the late 1990's Oxford Health was successfully sued by the New York State Attorney General's Office for not paying doctors and hospitals billions of dollars while Oxford executives pocketed big stock gains. This frustrates many managed-care-doctors and interferes with and undermines the health care of innocent patients. Aetna had to pay up in first years of this millennium.

As of 1998 about 80% of Americans (not of Medicare age) were enrolled in some type of "managed-care" health insurance plan. Today, fewer than 20% of Americans have some type of indemnity insurance, in which the patient pays the doctor and is reimbursed by the company, or the plan pays doctors' fees a portion of the reasonable and customary rates. These percentages are a complete reversal of the situation in the 1980's. Managed care was conceived and came into being long before the 1980's, but the government and business aggressively pushed managed care into prominence as medical costs and their rates of increase, which were indeed out of proportion to background inflation, spiraled. American business was hampered by skyrocketing medical costs in the late 1980's and federal and state government budget deficits ballooned. The choices before government (politicians) and business (wealthy people who place and pay the politicians) were difficult and included socialized medicine, such as that in Canada, keeping the then-current system, managed care and a combination of choices.

American business and business school graduates, as well as some shrewd doctors and politicians, formed a good portion of today's large managed-care companies. Many managed-care companies were formed from scratch, many by merger with other smaller managed-care companies. Many managed-care companies went public, earning profits and money almost from the start. After all, there was a lot of fat in the system (i.e., doctors making too much money in the public view, waste, fraud, etc.). Many big, traditional insurance companies also saw a chance to make even more money than they were already making and entered the managed-care game.

Insurance companies are not, and never were, primarily in the business of helping people. Most insurance companies are publicly traded and are designed to make a profit so that the stockholders and top brass can more money. Remember the movie The Rainmaker! The key to making a profit in managed care is controlling costs, which translates into paying doctors and health-care providers less so the managed-care company can keep more money. Just think of HealthSouth and their fleet of jets for the executives ... and yes those executives who were in trouble for pulling Worldcom like stunts with the HealthSouth books while paying themselves tens of millions of dollars per year while some of their patients had to make do with what money was left over for their care.

As we discussed, managed-care companies control the doctors with very restrictive contracts that give the managed-care companies tremendous power over doctors and almost obscene power over patient choice and patient care. Unfortunately, managed-care companies have "managed" to pay off the politicians with money and stock so that when a managed-care company makes a decision that blinds a baby girl or kills a 60-year-old man by ignoring his chest pain, the managed-care company can not be sued. This little-known law is called ERISA. See Tricks Insurance Companies Play on Doctors and Patients. The author thinks that it is necessary to have the option of managed care, as well as many other health alternatives, including medical debit-card systems, semi-socialized medicine units, like county hospitals, fee-for-service, etc. However, it is extremely unfair and dangerous to Americans to allow the current managed-care companies to unfairly manipulate politicians and use ERISA as well as contract "gag" clauses to interfere with patient care and patient's rights.

Managed-care companies are great at hiring Madison Avenue advertising firms to make warm and fuzzy commercials that talk about "saving CO-pay money," "flying a rare patient to Johns Hopkins Medical Center for heart treatment," "finding early breast cancer," "paying for medicines," etc. However, every one of these "good acts" has much more benefit for the managed-care company than the ordinary person would guess. For example, low CO-pays are used to lure patients into the plan. Let us look at some other examples.

Flying a patient with a diseased heart to a major medical center to create a treatment plan will likely save the managed-care company big money, because the HMO doctor "back home" could waste thousands of managed-care dollars just figuring out what is wrong or how to treat a special heart problem. Additionally, the managed-care company gets to make a warm and fuzzy television commercial showing the patient riding in a private plane to a world-renowned medical center courtesy of the health plan. With the proper background music, and a soothing woman's motherly voice narrating, the managed-care company can sell thousands of policies, or perhaps even keep some their current patients from complaining about care.

Paying for routine Pap smears and screening mammograms are great ideas, but these are done only because managed-care accountants have discovered by crunching the numbers that finding cancers early means that the treatment is much, much less expensive and that the company will save money. Further they can market (advertise) the free screening idea! And market this screening success, they do. After all, there was no competition with which to compare screening successes before the current managed-care system. Large numbers of Americans previously had no incentive to show up for screening because it was rarely covered by the old insurance that many of THESE SAME COMPANIES wrote in the 1980's. If Americans did not get screened properly then, it was partially the fault of the insurance companies in the 1980's for not creating the incentive or mailing out alert notices early enough.

However, the author must complement the managed-care companies on promoting early screening, even if their true motive is to make or save money. Just why do HMO's pay for immunizations of babies? Immunizations (vaccinations) are cheap and work well, at almost a 100% success rate, to prevent serious and very costly diseases. Immunizations are truly a great example of the old adage that "an ounce of prevention is worth a pound of cure." In addition, because of legal constraints from ERISA, managed-care companies cannot be held liable (and they really should not be) when a child has a rare bad reaction to one of the vaccines resulting in death or paralysis. This is one of the few issues where money is saved and patients are being well served. Managed-care companies have chosen the right track although not necessarily for altruistic reasons, in this instance.

For many managed-care health plans, especially the HMO's, "paying for medicines" is a charade. A formulary is the list of medicines that your managed-care doctor is allowed to choose from if you need a drug. Most managed-care formularies are composed of cheaper generic drugs rather than the brand names. This may not always be bad, but it can be. Sometimes the active ingredient is not the only trick to making a good pill. In some cases the coatings, binding and releasing agents that are mixed in to form the pill play an important roll in how the medicine will act. Many times, the appropriate drug is not on the formulary either in brand or generic form because some insurance company official has chosen the next best thing (in his/her mind) to be on the formulary. The real issue is almost always cost. Often, the managed care contract forbids the managed-care doctor to tell you of the problem. You may never know that your heart medication isn't the one your doctor would like to have prescribed, because there is a "gag rule" in the doctor's contract that forbids the doctor to say anything negative about the managed-care company. And guess who defines negative! Watch out for this problem. If you are lucky, you live in a state where lawmakers have made managed-care gag clauses illegal. In any event, you can and must ask your doctor about such potential managed-care conflicts.

The website author believes that the managed-care companies' slogan for health care should be caveat emptor, or "let the buyer beware." Television commercials promoting managed care, most likely to be aired just prior to elections or near times Each year the US Congress Considers ERISA and each year amazingly the Republicans side with the HMO's (remember the days when the Republican Party was the party of the doctor). Be concerned and be informed about why your employer is adopting a particular managed-care plan. Being aware of potential problems is your best defense. If HMO's spent as much money on patient care as they do on executive salaries, executive jets, executive perks, executive stock options, executive vacation houses and television advertisements telling the public how great HMO's are, then maybe there would be an improvement in patient care. If managed-care companies aren't doing anything wrong, then why do they spend millions to keep the ERISA shield up so that they can hide behind it when patients are maimed or die? Managed care means someone else chooses what patients can and cannot do; that necessarily means a loss of choice and freedom. In this respect, managed care seems so anti-American, but it is what the TV ads tell us that we have asked for. However, managed care is very American in that the bottom line rests in Wall Street and money is the main deciding factor.

Although managed care will be with us for some time, the author believes that laws should be passed requiring businesses to allow employees the choice/right to opt out of any HMO plan that the business has joined and take cash or another negotiable asset instead. Because health care is an earned benefit the employees should be given in cash or as a medical card disbursement, the same money that would have been used to pay for the HMO yearly insurance premium. Businesses may say that this approach is impractical because many healthy employees would opt out, choosing to care for themselves, leaving too little money to make the contract practical for the managed-care company, which would probably find itself caring for the remaining employees who may be sicker. The question for the politicians and businessmen is, which is more important, lives or money?