Essay Sample on Health Maintenance Organizations

Introduction

Health maintenance organizations (HMO) are a health insurance plan which limits health coverage of the patients to care from doctors working for the HMO. The patients may also receive from doctors who have a contract with the HMO. The HMOs provide health care that is integrated, and they put more focus on prevention of illness and maintenance of wellness. The healthcare coverage may vary for different HMOs.

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In the 1990s for-profit HMOs came up with ways to increase their profit margins. This involved creation of rules that controlled the relationship between the doctors and patients. The rules forbade doctors from providing information to their patients on better healthcare that was not offered at their organization. Notably, this was to ensure that the patients only sought healthcare from the HMO they registered to (Gray, Lowery and Godwin, 2007). Besides this, referral of patients to specialists for further treatment was also quite costly to the HMOs. Thus the doctors were forbidden from educating their patients on alternative treatment options which would necessitate referrals. The doctors were also provided with monetary incentives to provide the medical care to their patients which would cost the organization least. The healthcare providers were forbidden from disclosing the large bonuses they were receiving for their work in avoiding the high cost of providing health care. The doctors who had made a contract with the HMO were not allowed to criticize the organization to the patients and any failures in the system were left to go on harming the clients. These rules were commonly known as the gag- rules. The patients received less care than they deserved, and were left in the dark about treatment alternatives that they could find in other organizations.

These rules posed a threat to destroy the confidence of the patients in the organization if they were to be known to the public. They were therefore kept a secret, shared only between the doctors who worked or the organization and the leadership of the organization.

The physicians working for HMOs had to comply with the rules. According to Neel Shah in a paper written in 2013, the writer elaborates that the health care providers have a major role to play in ensuring that health care costs are kept down. Presumably, this is for the sake of the patients, to make good healthcare affordable and available to all (Shah, 2013). For this reason, doctors had the best interests of the patients at heart when they complied with the gag- rules made to keep health care costs low for their organizations. By avoiding costly referrals to specialists, and providing only the most basic healthcare required by the patient, his was achievable. A conflict of interests between the need to keep the cost of provision of healthcare low and the ethical duty of the doctors arose when these efforts hampered the provision of quality healthcare. Low quality of healthcare provision was accentuated by the provision of incentives by the HMOs to their doctors to ensure they continued in the practices which kept their costs low. By agreeing to receive the monetary incentives the doctors allowed themselves to deny patients the best healthcare available which was unethical, and it was also against the main goal of a doctor; to provide the patient with the best healthcare needed to alleviate their suffering

Therefore the HMOs continued to gain at the expense of their patients. As this practice continued placing the patient in a compromised position, the government had to create regulations that guided the payment of the doctors who worked for HMOs. Their payment plan also had to be made transparent to curb the problem of secret bonuses for cutting costs.

The other gag- rule prevented physicians from educating their patients on better healthcare options that were unavailable from their organization. They were also not allowed to discuss with their patients about the shortcomings of their organization. The goal of this was to ensure all clients of one organization were maintained. This rule greatly conflicted with the interests of any doctor as mentioned earlier. According to Hafemeister and Spinos in an article that was written in 2009, doctors must inform their patients on any risks to their health, and advise them on the best way to go about restoring good health. The other reason why doctors were not allowed to provide information on treatment options is to avoid extra costs resulting from making a referral. By preventing doctors from giving information to their patients on other treatment options, the organizations maimed the doctors from performing their ethical duty.

The physician has a role of fully informing their patient about all treatment options available for their ailment this is done so that the patient can choose their best-preferred mode of treatment out of all the options (Gray, Lowery and Godwin, 2007). As time passes, the patients are getting more ways of gaining information on their ailments. It, therefore, becomes imperative that healthcare providers fully inform hem of what is happening to them. This way they consider the patients as people who can understand their illness and the various treatment options available for them. Provision of adequate information to patients and involving them in decision making has been shown to improve the quality of healthcare provided. It has also been found to have benefits in improved outcomes in the patient. There may be some social and psychological factors that contribute to the improvements. Therefore in the overall role of a doctor, patient education on all matters that pertain to their illness is crucial. Providing proper information to patients is however not without challenges to the doctors. It requires a more significant time input from the doctor to find out the patients preference in the myriad of options available. Sometimes the doctors may face the challenge of their patient preferring a mode of treatment that differs from the doctor's professional point of view, or from guidelines that are evidence-based. Therefore it may be difficult for the doctor and patient to align their opinions. In spite of the challenges that may come up, conscious failure by the doctor to inform the patient about all options of treatment is unethical as it denies them the opportunity to have the best treatment possible.

Conclusion

In conclusion, the health maintenance organizations independent organizations which are put in place for prevention and treatment of illness. The organizations that are set up for profit came up with some rules that would increase their profit margins. These included ensuring their patients did not leave the organization to which they were registered, and they received the least costly healthcare. The organizations made sure that these rules were enforced by providing monetary incentives to doctors involved in the treatment of patients. This step, however, created a lot of conflict of interests between the organizations and their doctors. The doctors who acknowledged their ethical duty to the patient knew that most of the stipulated gag- rules worked against the patients. Notably, this was later resolved when the government made regulations that controlled the activities of an HMO. The doctors have a great role in providing proper information to their patients on their ailments and the methods of treatment available for them. Presumably, this is very important since the patients can participate in decision making for their treatment, which is reported to improve the outcomes after treatment. There are challenges associated with informing patients fully, such as a time barrier and the patient choosing to have a method f treatment that is not in line with evidence-based guidelines. These pitfalls should not, however, dampen the spirits of the healthcare providers in providing all information that a patient needs to have concerning their treatment.

References

Gray, V. Lowery, D. and Godwin, E.K. (2007). The Political Management of Managed Care: Explaining Variations in State Health Maintenance Organization Regulations. Journal of Health Politics, Policy, and Law, Vol. 32, No. 3

Hafemeister, T.H., and Spinos, S. (2009). Lean On Me: A Physician's Fiduciary Duty to Disclose an Emergent Medical Risk to The Patient. Washington University Law Review, Vol. 86, Issue 5.

Lin, S. (2007). Bush's Stem Cell Veto: Ideology Before Science, Politics Before Patients. The Stanford Medical Student Clinical Journal

Shah, N. T. (2013). A Role for Physicians: An Observation on Cost Management. American Journal of Preventive Medicine. Elsevier Inc.

The New York Times, (1996). HMO Gag Rules. The New York Times Company.