Managed care organizations supposedly achieve these goals by simultaneously using health maintenance strategies and establishing contracts with a limited panel of doctors, hospitals, and suppliers. Many of us originally welcomed these innovations, and the various mechanisms HMOs put in place to provide incentives against overutilization of health care resources. HMOs are not all bad, and to dismiss all of their contributions out of hand would be disingenuous. Those who have major health problems are at risk of being shortchanged in managed care systems because there is so much emphasis on restricting access to expensive treatments or remedies.
Most patients assume their doctors are the final arbiters of medical necessity, but they are wrong.
In capitated managed care programs, doctors and hospitals are paid based on the number of patients assigned to them, not the amount of care they give. Under these contractual obligations, doctors are prohibited from discussing treatments with patients if they are not covered. This means that if a patient's only chance at life is an experimental treatment not covered by his HMO, he may never know about it. Even the patient's right to pay for this treatment out of his own pocket is taken away when doctors are forbidden from discussing these treatments with their patients. Establishing a provider network can allow HMOs to negotiate lower fees, but it is not always clear to consumers that even emergency care can be limited to in-network providers.