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HMO Regulation

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HMO Regulation

Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
HMO’s are groups of doctors hired by insurance companies and are usually controlled or regulated by the hospitals who facilitate them. The majority of this limitation is due to pressure from within the organization or government pressure. The government influences hospitals into denying treatment in order to cut federal costs. These government actions generally result in a revision of private employee health care claims, and in turn certain businesses can no longer afford to provide health insurance for their employees. Consequently, approximately 50 to 60 million people go without insurance for at least one month each year. Many HMO’s constantly evaluate their services to "ensure" the best care and coverage. But in many cases, what is happening is the exact opposite.
HMO's can and do conduct their business quite ruthlessly. Patients are continuously unable to receive the necessary treatment due to the insufficient HMO coverage. Many HMO's actually make more money if their doctors see or treat fewer patients. According to the Associated Press, “Consumers who have been denied a treatment that the HMO says is not covered, or who inadvertently fail to follow HMO guidelines in seeking treatment and are therefore denied reimbursement, will continue to have little recourse.” (2) Many people must drive for hours, generally sick or injured, simply to receive treatment from a doctor that will be covered by their HMO.
Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their...

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...ts to cover their mistakes. This is the exact opposite of what the country needs. Why should costs go up because of denied treatment? The big concern is whether or not government really understands the great difficulty in trying to control HMO’s and other health care programs without a nationalized program. Since there are some 6 million people using Medicare in HMO’s something needs to be done to ensure these patients the treatment that they need.
In conclusion, there still needs to be a lot of work done to health care in the United States. Other nations provide universal health care to their citizens, but this would cause dilemmas in balancing two often conflicting policy goals: providing the public with equitable access to needed pharmaceuticals while controlling the costs. Universal health care probably would not work in the U.S. because our nation is so diverse and our economy is so complex. The system we have now obviously has its problems, and there is a lot of rom for improvement. HMO’s will still create problems for people and their medical bills, but they definitely should be monitored to see that their patients are receiving just treatment.
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