Supporting the patient

Article Abstract:

Banning ownership of health maintence organizations (HMOs) by for-profit insurance companies and other nonphysician businesses may be a way of reforming health care that preserves the doctor-patient relationship and minimizes a focus on costs. In the past, physicians may have treated health insurance as a deep pocket and performed unnecessary services. Physicians may have a moral as well as professional commitment to providing medical care for their patients, and they should remain their patients' allies as health care undergoes reform. For-profit managed care organizations may lack commitment to patients because they are run by nonphysicians who do not have the same ethical obligation to patients that doctors do. A ban on ownership of health maintenance organizations (HMOs) by nonphysicians may be legally upheld by state laws. Physician-owned HMOs may avoid violating antitrust laws by making sure they do not fix prices or control more than 30% to 35% of the market. Physician-owned HMOs may seek financing through commercial borrowing, where the lender is not involved in the management of the organization.

Column, Health services administration

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The growth of medical groups paid through capitation in California

Article Abstract:

The medical groups in California that are paid by capitation have grown, but continue to struggle to gain financial assets. Researchers interviewed administrators and reviewed records at six medical groups in California that have contracts with health maintenance organizations (HMOs). These groups receive most of their finances from capitation. Some of these groups are owned by the physicians, however many have sold their assets, such as equipment, to investors. Between 1990 and 1994, the number of enrollees in all the groups paid for by capitation increased by 91%. These organizations vary in the level at which they provide or contract others to provide services. In 1994, the average hospital use was 139 days/1000 non-Medicare enrollees, and 893 days/1000 Medicare enrollees. The average number of annual doctors visits was 3.4 for non-Medicare enrollees and 7.4 for Medicare enrollees. These utilization figures are considerably lower than the California and national averages.

Capitated payment systems (Medical care)

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A national survey of the arrangements managed-care plans make with physicians

Article Abstract:

Managed-care plans use different methods of choosing, paying, and managing their physicians, though the differences between various types of health maintenance organizations (HMOs) are not great. Researchers surveyed managers at 29 group or staff HMOs, 50 network or independent-practice-association (IPA) HMOs, and 29 preferred-provider organizations (PPOs). In choosing doctors, group or staff HMOs generally had more requirements than other managed-care plans, but all types of plans tended to investigate the reputations of doctors. Annual turnover of physicians was less than 5% in most plans, but slightly higher in group or staff HMOs. Sharing of financial risks with doctors was more common among HMOs than among PPOs. Most HMOs required that specialist referrals be made by a selected primary care physician. More HMOs than PPOs tended to use physician profiles and outcome studies to evaluate care. Most plans had systems of quality-assurance and patient-grievance.

Physicians, Medical professions, Managed care plans (Medical care), Preferred provider organizations (Medical care)

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