HMOs and people with MS

HMOs and people with MS – includes glossary of health-care terms

Leon Sternfeld

These are samples of comments sent to us in response to our request in the Spring 93 issue of INSIDE MS, in which we asked about members’experiences with HMOs.

The health-reform plan proposed by the Clinton administration places great emphasis on HMOs and other “managed care” arrangements. (See the Glossary at right.) Our aim is to support those elements of the health reform plan that appear to benefit people with MS, and to advocate against elements that create problems.

Sixty-three percent of the letters we received were primarily positive about HMO care, 27 percent were negative, and 10 percent were mixed. A total of 180 letters came in from people with MS residing in 32 states. More women than men answered (a ratio of about 4 to 1), with both sexes primarily in the 30- to 50-year-old age group.

People who were positive praised the small patient co-payments, prompt referrals to specialists, approval of special treatments, minimal paperwork, and sensitive, supportive physicians and other personnel.

But the smaller group of people who were negative said there were limitations on their choice of physicians, particularly specialists; physicians were insensitive and lacked knowledge of MS; referrals were denied or made reluctantly; payments were made arbitrarily some were denied; and paperwork was much too complicated.

Because the letters were from people who wrote voluntarily rather than from a random sample, the comments can’t be considered representative. They can provide only general impressions and some leads for further study.

Nevertheless, we were impressed by the fact that most people who wrote to us were positive about HMO care. Conventional wisdom holds that people tend to report their negative experiences much more readily than those that are positive. The contradictory responses suggest that there are variations among HMOs as well as variations in the expectations people with MS have of their health plans. Several investigators have expressed interest in doing a more extensive, rigorously designed study and the Society is currently considering supporting such a project.

A GLOSSARY OF HEALTH-CARE TERMS

The following concepts are part of the current debate on health-care reform. We thought this glossary would help clarify the many proposals that are under discussion.

Free for Service: A system that pays doctors and other practitioners a fee for each service or procedure performed for a patient.

HMO (Health Maintenance Organization): A managed-care organization that provides a pre-determined ranged of health services or procedures at a fixed periodic price. Some HMOs have their own staff and facilities; others contract with individual providers or provider groups who work out of their own offices.

Managed Care: A health-care system that attempt to hold down costs by reducing or eliminating services that are deemed ineffective or unnecessary. An increasing number of U.S. insurance companies are moving more of their business into managed care.

Managed Competition: A proposed system that would permit managed-care health plans to compete against one another, and perhaps against more traditional fee-for-service health plans, in an open market. Managed competition would put health-care consumers into purchasing pools to give them the same kind of clout that large employer groups have.

PPO (Preferred Provider Organization): A type of health plan in which health-care providers agree to give care at a reduced cost to plan members. These plans are offered through employers and professional or fraternal organizations. PPOs allow consumers a choice: They may use the plan’s providers or go outside the plan but at a higher out-of-pocket cost.

Provider Group: A group of doctors and other practitioners who work together as a single administrative unit.

Single-Payer System: A system that designates one entity (usually the government) as the only purchaser of health-care services.

COPYRIGHT 1994 National Multiple Sclerosis Society

COPYRIGHT 2004 Gale Group