Friday, July 1, 2011

HMO: HOW REALLY ACCESSIBLE IT IS TO ASSIST YOU ON YOUR MEDICAL NEEDS

I watched a judicial drama in star movies cable channel this week. The title is "John Grisham's THE RAIN MAKER". It's about the major fallacy of a huge healthcare insurance provider "Great Benefit" who denied a terminally ill boy of support to his medical needs despite of his demand on a very complex intervention. The issue was brought in a court trial and  a former employee strengthened the complainant's case by stating the unethical practice (every first claim will always be denied, no matter how serious the disease). While watching the film, I got scared if there are still existing companies all around the globe like what is happening inside Great Benefit. First thing that cross into my mind was the people who have health insurance right now. I wish that everyone who has it was served well by these companies.

As early as 8, I'm already a policy holder. It was my parent's company benefit to the dependents of their employees. We were entitled for atleast 100,000php worth of hospitalization that time. My mom enjoyed it's benefit even for the simplest irritants that we encounter, hospitalization is always the first option which I grew up detesting such practice. When I had a chance to work as an on call PT of a healthcare provider for ex patriots. I worked with the PCP. I handled policy holders that fall to cases for Physical Rehabilitation. I learned more on how we have to document everything for further approval of the 3rd party payers. Denial happens, so we have to justify everything that we do. I understand why they (HMO) have to do this. They want to make sure that every intervention or visit is utilized well, and no unnecessary protocol was being done with the policy holder. Thus, maintaining the integrity of the whole healthcare system. I admire US policy in terms of controlling the utilization of healthcare services. I just hope they could see clearly who really needs the services badly.

In my country of origin, still needs further improvement on justifiable schemes for the involved parties. Some HMOs overlooked some aspects to be able to sustain the healthcare system well. Some would have amended rates for specific services, seem to be fixed regardless of your competency in the field (every clinician differs from one another). Some policy would allow unlimited consultation, which I presume, the affiliated doctors abuse by letting their patients go further for more consultation visits, which already deviating to the common goal of doing our best to make our patients well as soon as possible. Even your an ordinary or premium card holder, their is always a room for inflexibility. I experienced when I was a kid, we only go to doctors who were only affiliated to our insurance provider. We can't just go with any doctor. Some would cover for diagnostic tests but subject for approval, or depending on the diagnosis. Here's the logic, how can you make a final diagnosis without running some specific tests? These requested tests were necessary in order to pin point what's really happening and how come it has to be with approval despite of the evident cascade of symptoms? What if we need the doctor immediately? What if there is an affiliated doctor that is not competent enough to make us well? These are just few of the drawbacks that I hope they could address in order to strengthen the system. How I wish Philippines would adapt a system that will encourage Physicians to have a more patient-centered practice. SMART (Systematic, Measurable, Attainable, Realistic, Time Bound). Accurate, Fast track intervention, Less visits. In the US, there is this rule, the chances of the MD's to be paid well become slimmer the more visits they allowed on their patients. For example, I'm a policy holder, allowed for 500$ consultation a month. If I just visit you once and you made me well, you receive it full based on my policy. But if you made me visit a hundred times on your office, the payment will also be divided on the number of visits you require me. I'm pertaining to OPD. With people under long term maintenance (terminally ill or with permanent disability), I hope there is also a good policy for them but I'm not sure if this rule is applicable to them. See the difference? Something to enlighten practitioners. I'm not acting like a know-all-citizen, I'm just aware of what's really happening in the industry that I'm in. I just hope the government will strengthen the healthcare system favorable and justified on both parties. Patients and Healthcare providers.