If the patient tries to get medical care from a doctor other than the PCP or does not receive a referral from the PCP to see a certain specialist, the insurance company will not pay for any of the costs except in cases of life-threatening emergency. If the patient follows the rules and sees his or her PCP and gets referrals to approved specialist and hospitals, he or she will generally only have to make a small copayment to the doctor for each visit. Many HMO doctors have more patients than they know what to do with. Many physicians have so many patients from HMOs that they can no longer accept new patients, and it is often difficult for current patients to get a timely appointment. So, sheer patient volume is one way that doctors make money on HMOs.
Capitation refers to the financial arrangement between the doctor and the insurance company.
For each person that chooses a certain doctor as his or her PCP, the insurance company will pay the doctor a certain fee each month, whether that patient sees the doctor during that month or not. This arrangement has been criticized because some charge that in order to maximize profits, the doctors are motivated not to see patients and care for them as often and as well as they should. Furthermore, some arrangements have also been set up to penalize doctors financially for referring patients to specialists because the referrals add to the costs for the insurance companies. Regardless of how you feel about HMOs, they are a pretty good deal, on the whole, if they are available in your area. Their major drawbacks are rigid rules and lack of free choice in physicians and medical facilities.