New Page 2

10 DIRTY TRICKS YOUR HMO
DOESN’T WANT YOU TO KNOW

HMOs don’t want patients to know that they force doctors to play a game called HMO HARDBALL that wrongly denies medical tests and treatments. The game is unfair. HMOs and HMO doctors use dirty tricks to control the game.

My book, How to Play HMO HARDBALL, identifies the 30 dirty tricks that cause HMOs to win the game. The final score is always: Profit and Power for HMOs v. Disease, Disability and Death for patients. I have selected 10 HMO dirty tricks that hurt patients the most. These dirty tricks were all played on my family, especially on my wife, Jackie, who suffers from polio.

1. Mystery Contracts.

HMOs have legal contracts with doctors that are written by HMO lawyers. These contracts control doctors’ diagnostic and treatment decisions through financial incentives. The more medical care they prescribe for the patients, the less money for the doctors. HMOs and medical groups reserve the right to offer or deny doctors financial incentives such as bonuses, stock and profit sharing, if they order too many tests and treatments, too many referrals to specialists and too many prescriptions. HMOs can also fire doctors by terminating their contracts. When HMOs have doctors by their paychecks, usually their hearts and minds will follow.

The contracts allow HMOs and medical groups, not doctors to determine:

· What healthcare services are medically necessary.

· Where “medically necessary” healthcare services are provided.

· When healthcare services are “medically necessary.”

· Who provides “medically necessary” healthcare services.

· How “medically necessary” healthcare services are provided.

· How long “medically necessary” healthcare services are provided.

2. Secret Police

HMOs and medical groups maintain a “profile” of doctors’ practice patterns. This means that whatever medical decisions (see above) your doctor makes are tracked by bureaucrats. Periodically, doctors receive a report card that either compliments them for making decisions to maintain HMO profits at levels defined in HMO business plans or threatens them for busting the budget by treating patients compassionately and properly instead of impersonally as “cost units.”

Doctors have limited autonomy and cannot be patient advocates without risking retaliation (payback time) from HMOs and medical groups. The HMO secret police are always in exam rooms to watch what doctors do. It’s just the patients who are unaware that there isn’t a third party (the HMO medical group) to the doctor-patient relationship that calls all the shots.

3. Ration the Compassion.

HMOs force doctors to ration their compassion in treating patients. Otherwise, HMOs will ration doctors’ salary increases, bonuses, perks and profits. HMOs make sure that doctors understand that “managed care” translates into “managing money and rationing healthcare.”

HMO doctors base patient care on “outcome studies,” which are presented as objective, scientific measures as to whether tests and treatments are effective in producing a positive “outcome” for patients.

Outcome studies are usually rigged to show that cheap or none is better than expensive and more. Doctors tell patients that a test or treatment may only extend their lives by hours. An HMO bureaucrat actually made that statement regarding a new (and more expensive) type of Pap smear to detect cervical cancer.

The corrosive influence of money on the objectivity and integrity of highly regarded medical institutions has been widely reported and include the American Medical Association and the New England Journal of Medicine. Patients must verify what HMO doctors tell them. Use the Internet. Use the library. Use your brain. Question, question, question!

4. Health Depot.

Doctors must meet “production goals” or face an HMO or medical group bureaucrat for a “counseling” (reprogramming) session. Doctors must get patients in-and-out without worrying what they do and how well they do it. Although patients are legally required to take “responsibility,” patient initiative, including asking questions, is discouraged, because it takes too much time.

Patients are given a self-care manual and an “800” number to get healthcare from pre-recorded tapes or to speak with someone who is insufficiently qualified to diagnose and treat them. HMOs shove “Handbooks” at patients that preach and demand patient responsibility without giving patients authority in medical decision-making.

Patients must know and enforce their rights and protections. Nobody’s going to do it for them. Patients must enforce their rights over and over again. HMO abuse is not confined to one time only problems. The need for healthcare is continuous, not static, involving many areas at various times. Playing HMO HARDBALL has no time outs and has unlimited innings.

5. Death is in the Details.

A quick death is a cheap death. HMOs imbue patients with HMO “values” so that they reject expensive treatment that may help when medical intervention may very well cause patients to lead fulfilling lives.

HMO “Bioethics” bureaucrats teach patients about Advance Directives and Living Wills. Patients are made to feel guilty about being an emotional and financial “burden” on their families. Patients are tortured with the possibility that they will be forced to endure uncontrolled pain.

After a session of brutal HMO bioethics, the bureaucrats hand out the (Advance Directive and Living Will) documents to be completed, to be given to next of kin/agent and to be placed in their official HMO medical record. Patients will write that they not be resuscitated, not put on ventilators, not provided with hydration and nutrition.

HMO profits are protected, not the rights of scared, sick, or potentially sick patients.

HMOs know that hopelessness discourages patients’ will to live and the will to use treatments to prolong life.

6. Blame the Patient.

HMOs know that the best defense is a good offense. When patients assert their rights, HMOs and HMO doctors blame patients for protecting themselves. They are very good at using labels to demoralize patients. Patients who have figured out how and why HMOs are mistreating them are called “HMO bashers.” Patients who are vocal and proactive (especially women) are bashed with labels such as “hysterical, neurotic, complaining and demanding.” HMO doctors write these labels in patient medical records.

Patients are threatened with being “blackballed” by all the doctors in the medical group, if they “burn their bridges’ by demanding quality care. My wife and I were. We were also told that we wanted ‘favoritism” and had ‘unrealistic standards.” We were told to find another HMO or use another health plan.

We replied that the facts showed that we were not to blame, that we demanded appropriate standards of care and that if HMO doctors didn’t want to fulfill HMO advertising promises and abide by the terms and conditions of our contract with the HMO they should quit the HMO, not us.

7. Get ‘Em Out

HMOs and HMO doctors believe that HMO healthcare is warfare. In fact, an HMO doctor referred to himself as a “foot soldier” and patients as “pawns.” Patients who demand medically necessary healthcare and learn how to play HMO HARDBALL are enemies. HMOs and HMO doctors must get ‘em out of the HMO, before they drain profits or cause losses.

How do HMOs get ‘em out?

· Send them to the worst doctors in the medical group. Rudeness and incompetence work wonders.

· Set up an obstacle course to cause difficulty in making appointments. Cancel appointments. Frustration is a magic bullet. (Hopefully, patients won’t download and use HMO HARDBALL’s “Appointment Scheduling Complaint Form.”)

· Terminate their care. My wife’s gynecologist wouldn’t see her, after she had caught him in lies and medical mistakes. He claimed that there was a “serious erosion of trust.” We documented that he had caused it. The Chief of OB/GYN is now my wife’s doctor.

· Trigger the “involuntary termination” clause in the contract. Patients’ HMO contracts state that patients can be kicked out of the HMO, if they have “failed relationships” with their doctors. We showed that HMO doctors caused failed relationship, not us. This term was deleted from the 1999 HMO contract.

8. Gotcha!

HMO doctors keep patients on a short leash to show them who’s boss. GOTCHA helps control patients by undermining their self-confidence. My wife used my book’s “Patient Pressure System” to obtain out-of-plan referrals for DEXA testing to diagnose osteoporosis. The referring HMO doctor was mad as hell about having to approve the tests.

He called with the test results. Yes, she had “some” osteoporosis (However he failed to inform her that she was at 26 x normal lifetime risk of fracture). She asked about drug therapy and other solutions. The doctor’s answers:

· The solutions is wearing low-heeled shoes, not bone-building drugs. GOTCHA!

· You don’t meet HMO “guidelines” for further testing. GOTCHA!

· Your condition is “nihilistic.” (Worse than hopeless) GOTCHA!

We used the Patient Pressure System to convince the HMO’s Chief of Internal medicine to refer her to the medical group’s expert in osteoporosis diagnosis and treatment. The result? Drug therapy, further diagnosis and careful follow-up.

9. The Records Racket.

Medical records justify everything doctors do or don’t do. They include documents, electronic medical records and tape recordings (“for quality assurance purposes only”). Medical records are the key to winning appeals, arbitrations and lawsuits. HMO lawyers teach HMO bureaucrats and doctors how to use the HMO poison pen to write medical records that favor them, whether the statements are true or untrue.

HMOs maintain files on patients in addition to their official medical records. Patients have no idea what the contents of these files are, because they are classified as “administrative,” or some other category, not medical and not subject to patient access. HMOs maintain medical records under the auspices of HMO lawyers. Legal privilege prevents patient access.

If records are incriminating, they are intentionally “missing” and patients are told that the records aren’t “important.” Patient calls (e.g., to the HMO hospital emergency room) are taped, but HMOs refuse to produce the tapes unless patients initiate legal action.

State laws exist to force HMOs and HMO doctors to produce records. Enforcing these laws is virtually impossible, because HMOs often co-opt regulatory agencies that by law are supposed to protect patients.

10. Sounds Fair, Seems Fair, Isn’t Fair.

HMOs produce warm, fuzzy ads to lull patients into a false sense of security to discourage logical thinking. These “infomercials” are hype, but are vital to enrolling new patients (i.e., producing new business revenue). At least one court has found that these fraudulent representations aren’t fraud at all. They are simply “puffery.” Patients must wake up and understand that the standard for honesty in what is represented to be the best healthcare system in world is no higher than what one might get when buying a used car.

Patients are told that their care is “in the hands of doctors.” That’s the ‘branding” slogan of our HMO, Kaiser Permanente. We found a document in which our HMO’s lawyers instruct HMO doctors not to approve emergency room care for patients. Doctors in our HMO are not able to approve payment for ER care. That’s done afterwards, by an HMO Committee.

Seniors shouldn’t believe for a second that Medicare protects them from HMO dirty tricks. HMOs defraud vulnerable Medicare recipients to enroll in the HMO. For example, Foundation Health sales representatives take the old folks out for breakfast at CoCo’s to lure them into signing up for the HMO. The enrollment application states that the applicant has reviewed the contract (the Evidence of Coverage) prior to signing the application.

What’s wrong with this picture? The Evidence of coverage isn’t distributed for the applicant to review. It’s not distributed until after the enrollment occurs. (To view more Patient Rights Violations, visit my website at www.hmohardball.com. Click on HMO Violators to read authenticated violations.)

There are many secret dirty tricks that HMOs don’t want patients to know. Learn the secrets and the solution. Don’t wait! Don’t be an HMO sob story.

The Author

Robert D. Finney, Ph.D. was Manager, Health Care Cost Containment at the Hewlett-Packard Company. He helped to devise and implement the first employer sponsored Preferred Provider organization in America. Not one patient complained about quality of care. The company saved almost one million dollars in the first year of operation.

Dr. Finney and his family have been Kaiser Permanente members for over 10 years. He has used his time and experience in managed care to learn HMO dirty tricks and to devise a solution for patients to stop them.