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Healthcare fallacies

By Dr. Philip S. Chua

Cebu Daily News First Posted 14:11:00 10/20/2008

Filed Under: Health, Healthcare Providers

I just returned from the 94th Annual Clinical Congress of the American College of Surgeons
held in San Francisco, California, October 12-16, 2008. Among the hot topics during that
convention, besides the various new trends in minimally invasive and robotic surgery, was
healthcare delivery system.

Thirty-five years ago, the United States enacted the Health Maintenance Organization (HMO)
Act of 1973 as a solution to the massive (billion dollars a day) healthcare expenditures. The
Americans thought it was the panacea to their healthcare dilemma, and helped pushed for it. But
as it turned out, HMO has led to poorer quality of medical care and a lot of bureaucracy and
great delays in access to medical care, especially where surgery was concerned. The Americans
now realized they made a big mistake and are vehemently complaining to their legislators about
it. HMO has now been proven to be “the deadly treatment that is more fatal than the disease.”
Today, the US Congress is revisiting the HMO issue.

What is HMO?

In the traditional patient-doctor arrangement that all of us are familiar with and have been
accustomed to, and which is still the predominant existing force in the United States and the
Philippine healthcare arena, the patient freely chooses the physician he/she wants to consult. In
the HMO system, the patient can only see the physicians who are members of the HMO, even if
he/she feels there are other better physicians around, or there is one he/she prefers to see. In
some HMOs, the patient cannot even see a specialist directly. He/she has to be referred by the
HMO (“Gatekeeper”) doctor to a specialist who also belongs to the same HMO. The patient's
freedom of choice is sacrificed. In many cases, even the quality of healthcare, besides the good
doctor-patient relationship, suffers. The insurance premium may be cheaper, but it is now
apparent to the Americans after that bad experience that indeed, “you get what you pay for.”

How was HMO supposed to work?

The idea was to cut cost by various methods: requiring pre-certification before a patient is
admitted to the hospital, using strict admission criteria; discouraging patients from going to
emergency rooms or seeing specialists; mandating physicians to prescribe and use the cheaper
generic medications; forcing physicians to use less expensive, and less, diagnostic tests;
requiring physicians to discharge their hospital patients sooner, sometimes too soon; decreasing
reimbursement to hospitals and physicians by 30 to 50%; refusing to cover and pay physicians
and hospitals for certain medical care, illnesses or hospitalization that the company deems “not
covered,” etc. It also instituted dozens of “strict and somewhat punitive” rules, criteria, and
policies for physicians and hospitals to follow in providing healthcare to patients “if they want to
participate in the HMO and be paid at all.”
Did HMO help the people?

No. As a matter of fact, the quality of healthcare has suffered and access to care more difficult.
Patients feel they have lost their freedom of choice of family physicians and specialists. The wait
in the doctor's office is much longer, and the care much less personalized, since HMO doctors
are salaried and are assigned too many patients. Since they get paid the same whether they see 20
or 40 patients anyway, the incentive to do their best is not the greatest. More sophisticated tests
(CT Scan, MRI, Heart Angiogram, etc.) are considered “too expensive” by HMOs, whose main
concern appears to be their financial bottom line and not the quality of medical care. In subtle
ways, they discourage the use of what they consider “too costly tests or medications,”
handicapping the physician in his service to his patients. Unfortunately, it takes years before
people find out the painful truth and complain about it, and another 2 decades or so to have the
mistake corrected thru legislature, as in the case of this American experiment with HMO.

Has HMO invaded the Philippines?

Unfortunately, yes, but fortunately HMO in the Philippines is still in its budding stage. The
traditional healthcare delivery system is still the major force in the country, and the people and
our medical care are the better for it. Hopefully, the Filipinos, our political leaders, our
businesses, hospitals and physicians can unite and prevent the growth and catastrophic onslaught
of US-style HMOs on the healthcare system in the Philippines. HMO has adversely affected
medical care and healthcare delivery in the United States. The US Congress is now re-discussing
the HMO issues and exposing the adverse effects of HMO and the resulting deterioration of the
healthcare delivery in the country.

Let that painful and inhumane national “experiment” in America be a warning for us Filipinos to
be vigilant to protect and preserve our most fundamental privileges: quality medical care, easy
access, and the freedom of choice, at a most affordable cost. HMO, as it stands today, is more of
a health menace organization and, if allowed to take root and flourish in the Philippines, will
clearly be hazardous to the health and well-being of our country and its people.

Since the United States experience with HMO is a catastrophe as the Americans have found out,
and most eager to throw it out, wouldn't it be stupid for us, Filipinos, to adopt it for our country.