THE HMO INSIDE AND OUT

To understand the prison HMO one must first have a working knowledge and understanding of the HMO as it exists in general society. With that knowledge as a foundation, only then can one understand the bottom line for healthcare in this country, inside and out.

The HMO "Outside"----- Some Background

     Managed health care in the United States has grown by leaps and bounds in recent years. According to a 1996 Consumer Report article, How Good Is Your Health Plan (August 1996, at 29), half of all Americans at that time (1996) who had health insurance received their benefits through some form of HMO. That number has since increased.

     Problems arise because of the incongruous elements of an HMO. HMOs are neither 100% "health care provider" nor are they 100% an "insurer". Statutes governing HMO operations vary from state to state. Realize also, that state statutes that deal with deceptive and unfair trade practices may apply to an HMO case; and while medical malpractice and negligence laws are usually pertinent; the laws that govern how insurance companies do business equally are applicable.

The HMO Behind Bars

     The HMO behind bars takes advantage of the publicís ill will toward offenders to give poor healthcare while making a profit. Patient inmates die as a result of negligence, indifference, inadequate training, and/or cost cutting. Encounters with an HMO behind bars can become a death sentence, even for offenders whose cases havenít yet gone to trial or who have been convicted of relatively minor crimes. Many are people with curable conditions.

     The attitudes of the HMO doctors turn the Hippocratic Oath upside down, which states "practitioners must keep free from all intentional wrongdoing and harm" no matter where they work.

     In the free world, a sick person has choicesóeven an HMO patient. He can switch doctors or health plans if unhappy.

     A patient in prison has no choice. HMOs have a captive audience literally and figuratively.

Understanding the HMO

     Generally speaking there are three types of HMOs: the staff model, the group model and the contract model.

Know the Difference

     Staff Model : The HMO owns and operates its own facilities. The doctors are employees of the health maintenance organization who receive bonuses and incentives linked to the profits, revenues, and goals of the organization.

     Group Model : The HMO contracts with a physician group that, in turn, pays individual doctorsí fees. Itís a relatively complex model that may involve, for example, a contract between the HMO and an individual practice association (IPA).

     Direct Contract Model : The HMO maintains a network of health care providers by contracting with doctors. Fixed or percentage fees are often established on the basis of the number of subscribers the doctor sees. This is known in the industry as capitation.

     HMOs more oftentimes than not, operate under the direct contract model. And within this model, a group of primary care doctors serve as Ďgatekeepersí-- to coordinate the health care services and treatment provided to their HMO clients.

What Do Those Gatekeepers Do?

     The gatekeepers attempt to limit costs of providing health care in two ways:

    1. By the designing and application of a plan that limits benefits,

      uses strict underwriting tactics or eligibility screening, and controls the quality of care; and

    2. Shift patient care to less expensive locations and minimize the frequency of treatment by aggressively applying direct cost containment tactics that reduce service options.

     The primary tactic to limit costs and increase profits is called "utilization review," medical lingo referring to concurrent review of a patientís needs.

     For outpatient care, utilization review is accomplished when the gatekeeper submits all referrals for diagnostic tests for further consultations to the HMO for approval. And to that end, specially trained nurses or doctors that are employed by the HMO approve or disapprove these referrals on the basis of appropriateness and necessity.

     Realize that the typical HMO contract does not spell out what utilization review is. The person looking for health care only knows that certain tests and specialized treatments were denied.

     For inpatient care, the HMOs normally require that registered nurses or medical directors on the HMO staff conduct the utilization review. Decisions, like plans for a patientís discharge from a hospital are made on the basis of appropriate and necessary care.

How They Control Costs

     HMOs will try and control costs by linking doctorsí payments with the organizationís goals. Whatís that mean? For instance, the organization may establish a desired limit for the number of patients admitted to a hospital or their length of stay. By utilizing these measures it forces the use of outpatient procedures as alternatives to hospitalization. Some HMOs have been known to withhold 30-50% of care providersí fees until the end of the year to determine if goals have been met.

     HMOs too, often use third party peer reviews to evaluate treatment in controversial cases. This review essentially determines exactly what treatment the patient should or should not get.

     When HMO staff or consultants look over proposed treatment plans, they use standardized treatment plans, standardized predetermined criteria. What dose this mean? For instance, diagnostic related groupings (DRGs) are normally consulted to determine treatment for a specific diagnosis. Some of these "standardized" criteria are actually developed by independent companies that then market the criteria to the HMO industry. Two companies that do this are Milliman & Robinson and Interqual.

     HMOs will also develop and use their own quality review reports and databases to monitor the utilization patterns of doctors and hospitals. To say the least this is questionable data and is used to force changes by threatening to drop a provider from the HMO list.

Tricks and Traps of the HMO

On the Inside

     Tricks and Traps are deadly tools and tactics utilized by the HMOs and their doctors and used against their patients [offenders] to wrongly and premeditatedly deny medical tests and treatments; or perform unnecessary tests and treatments for a non-existent condition. These tactics rely on secret, ruthless rules and dirty tricks. These tricks and traps are played to insure the survival of the HMO business that produces and protects their money, power and profits.

     HMOs make unfair rules and use dirty tricks to control the game. HMO doctors and nursing staff deny that the game exists, but patients are learning the truth---as are their families -- the hard way. Patients are angry and fearful, because they donít know how to win the game. And losing the game results in needless disease, disability, and death, and no answers.

     How do the HMOs and their contractors deny patients medically necessary healthcare? HMO insurance policies, or contracts, are written specifically to justify denial of healthcare. For instance, some family HMOs define healthcare to be "medically necessary" while others are given an HMO contract containing a "Memberís Bill of Rights and Responsibilities". In the former, for example, you might find "Öonly if a Plan Physician" determines that its omission would adversely affect your health and that itís a medically appropriate course of treatment for you." Bottom line: The HMO isnít going to pay for any healthcare service listed in the insurance policy unless the HMOís doctor decides that the health of the patient would be adversely affected and that the services are medically appropriate.

     In the latter, for instance the Bill of Rights included in part the following:

Members have a right to:

And Members Have the Responsibility To:

 

    Inside: Patients in prison are summarily ignored. It can take anywhere from 3 days to 3 months to see an HMO doctor. Medical emergencies arenít; unless youíre in the process of dying; be it by heart attack or end-stage liver disease.

     Patients [offenders] state their concerns only to be met with apathy and non-treatment by the HMO doctor. Their requests for detailed information about their condition(s) are met with disdain and disgust. If a doctor doesnít like the questions or inferences of questionable treatment and healthcare, that doctor can (will) retaliate against that patient. From administering the wrong medications, to denying medications, to forcing that patient to lockdown, administrative segregation, etc.

     Patients [offenders] can request tests for specific conditions and be denied those tests. They can be forced to succumb to other medical tests for conditions that donít exist. If they refuse the unnecessary tests, they are Ďwritten up" for refusing treatment; and are not treated for any current or future conditions.

     They are lied to about health conditions. Individuals can be dying of cancer and told they have the flu.

     People can have bleeding ulcers and are treated with antacids.

     Individuals can be told that their blood work and enzyme levels are Ďnormalí when in fact they are in end-stage liver disease, and eligible for medical parole.

I     t is this defiance by the HMO ÖInside and Out that becomes the capstone for any liability.

     Outside:: Individuals on the outside who are aggressive in pursuing their rights and responsibilities by seeking explanations regarding diagnostic tests and treatment; who attempt to participate in decisions about their healthcare, who join support groups, request medical information be provided to them, and demand prompt responses to their concerns and questions, are summarily ignored by the HMO.

What Can You Do?

     For all those who are patients of an HMO inside or out you must know what your rights are. Those on the inside must be effectively more knowledgeable then their counterparts on the outside. Why? Limited access to information; retaliation techniques used against them; inaccessibility to lawyers; the illegal denial of the right of informed consent.

     For both groups, as well as, taxpayers of those States that contract with HMOs for their prison systems, you must find out the following:

     For patients inside or out who are being denied adequate medical treatment, itís imperative that you apply pressure to the HMO and its staff. In applying pressure it will empower you to make HMOs and their doctors feel that pressure, when they make dishonest decisions about the medical necessity of tests and treatments. Systematic pressure is a necessity.

     To apply that pressure one on one , first ask your doctor to work with you. . Confrontation occurs when patients are wrongfully denied necessary healthcare and information that governs healthcare decision-making. Patients inside and out must learn how to protect themselves. Remember, HMO doctors are not your friends. These doctors are businessmen. You, as patients, must replace must play smart and convert your frustrations to methodical, strategic thinking. Control, discipline, and constructive problem-solving skills are crucial to your holding the HMO and its staff accountable all the way down the line. If the pressure you apply fails you will then be able to apply pressure by contacting regulatory agencies that can order HMOs and their doctors to do whatís right.

     HMOs and their doctors as well as, other staff members, do not welcome individual patient involvement that results in power-sharing. Especially in a prison setting. This fact alone is raised to an all-knew level within the prison system. Challenging HMO authority can turn deadly for an offender. Medical care can be out and out denied and medications withheld or administered inconsistently.

     However, whether inside or out you must challenge the doctors. You must make them uneasy. Family members, friends and advocates must get involved. You must persuade them to do whatís right. If the HMO doctors intentionally do whatís wrong, patients have a systematic method to contact outside authorities en masse.

     Realize how the contracts for managed care influence a doctorís decisions and how you as patients can pressure those doctors to do whatís right. Patients, families and friends of offenders, must demand that managed care organizations show them the contract up-front. Why? Because all decisions will be based upon the fine print. Itís not what they do; itís what they donít do.

Up Front and To The Point

     The way HMOs and physician management companies do business guarantees that HMO doctors and staff are going to play dirty. No one group understands this better than offenders that are on the receiving end of a prison HMO. That prison HMO will fight over what "medically necessary " healthcare means in terms of diagnostic treatment and decisions. In real medicine these fights should be resolved according to who has the best facts and analysis; and how they relate to the maintenance of the patientís health. Not so on the outside, not even remotely so on the inside.

     Patients [offenders] should analyze relevant facts when your HMO doctor isnít providing adequate healthcare or questionable healthcare. You must attack the doctorís facts, not the doctor. Unfortunately within the prison system, this can only be done with formal written appeals and regulatory authorities. Through Medical Services Requests (MSRís) and Informal Resolution Requests (IRRíS). It is a documentation war. And you must know how to play.

     These formal appeals for wrongful delay and denial of medically necessary healthcare is the Achilles heel of the HMO; itís their insecurity button. Especially the prison HMO. The HMOs and physician management companies force their doctors to disregard facts, logic and simple human decency in their medical decision-making. And they punish doctors if diagnosing and treating patients decreases profit beyond business plan forecasts. If it comes down to "them" or "you", the HMO doctors will not help you. Their income and employment mean more to them and they will not fight on a patientís behalf. Inside or out. And remember, patients in prison donít have a choice.

     Logic follows then, that because HMOís and their doctors revere money and power over their patients, so as to protect themselves from patients who demand medically necessary healthcare that they wrongfully deny, those patientsí must take away the HMO doctorsí obsessionóthat of money and power. They must cause extreme insecurity when HMO doctors intentionally do whatís wrong. The ability to do so will empower you, as patients, and your families, to cause regulatory authorities to overrule wrongful healthcare decisions and to punish HMOs and their doctors on a grand scale.

     Know too, that patient complaints become public. Publicity causes insecurity and corporate nervousness. HMOs and their doctors may not only be ordered to provide healthcare, but also may be punished for their bad intentions. Deliberate indifference is very much a legal cause of action. And itís the added threat of punishment that causes additional corporate nervousness. Patient appeals (MSRís) and (IRR"s) serve as a document trail of what has happened and it all too often catches the HMO off guard.

     Pay attention to the HMO titles; whose job it is to do what; the titles and explanations of their policies and procedures; it will be these same policies, rules and regulations that they will implement against the HMO and its doctors when they do whatís wrong. Public shame and ridicule serve a vital purpose in holding the HMO accountable, be it through the media or written word.

     Never forget that HMOs and their doctors do not hesitate to unfairly blame patients (especially offender patients) for everything. It will become imperative that you as patientsí, refer to their own rules and their own titles in all your HMO communications with them. By doing so, the HMO and its doctors will know that you are acutely aware of the inner workings and tricks that they utilize. There is no need to suffer in silence, beg or feel apologetic for requesting healthcare, or to be retaliated against for refusing treatment that is substandard. Take responsibility for yourselves. Families and friends must advocate for offenders who are forced to succumb to inadequate or non-existent medical care within the prison system. Taking responsibility for yourselves (others) will force the HMO and its employees to an accountability standard that is far overdue.