Pros and Cons of HMOs


Authored by Sylvia Cochran in Health Care 
Published on 11-12-2009

Upheaval and changing trends in the way America understands healthcare notwithstanding, the majority of insured at this point still have to choose between a preferred provider organization (PPO) and a health maintenance organization (HMO). HMOs have been getting a bad reputation for the tightfisted way in which they conduct business. That being said, there are pros and cons to any healthcare plan and HMOs are no exception.

Will I Lose My Doctor?

In the discussion of the pros and cons of HMOs, nothing is a jarring as losing one’s physician. This may be a professional who has seen the family through years or even decades of ailments. Unless the doctor is part of the HMO, you may only see him at your own expense. On the flipside, the requirement of choosing one primary care physician ensures that you have a close working relationship with a healthcare provider, who will be your chief contact for all problems and ailments.

Can I See a Specialist?

Another bone of contention in the discussion surrounding the pros and cons of HMOs is access to specialists. While there are copious specialists who belong to the recognized providers employed by the health maintenance organization, access is barred unless your primary care physician issues a referral. One subspecies of HMO, the open access organization, allows unbarred access to specialists but also requires an increased copayment or coinsurance percentage to offset costs.

Will I Receive the Same Level of Care?

Depending on your regular physician’s proclivity for ordering tests, you may actually receive fewer tests. HMOs are fiscally viable because medical administrators oversee the number of tests ordered by a participating physician. Although it is not generally expressed, the understanding between HMO and doctor outlines that physicians, who order too many tests, will eventually be excluded from the HMO. Generally speaking, the medical administrator oversight is one of the biggest disadvantages that are usually also the deal breaker for patients exploring the pros and cons of HMOs.

Adding insult to injury is the oftentimes mandatory arbitration clause to which patients agree prior to receiving care. Thus, even if malpractice or lack of due diligence is alleged, there is little fiscal remuneration for pain and suffering.

What is the Bottom Line?

If you are currently debating whether to sign up for a PPO or HMO, there are pros and cons of HMOs just like there are to PPOs. Consumers in good health enjoy the emphasis on preventive care and the low health premiums they must pay on a monthly basis. Considering also that the list of doctors participating in the HMO is usually quite substantial, there is no shortage of available medical professionals.

It is only the consumer who anticipates health problems or has family members with looming health issues, where the cons will weigh in heavier. In addition, the requirement of obtaining a referral each time a specialist is to be seen makes this a nuisance for those suffering with chronic conditions. There is no universal advantage to either a PPO or HMO and it truly depends on the individual consumer’s family history of illness, anticipated illness and willingness to pay higher monthly health premiums that governs the decision.


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