My first HMO experience was working as a staff physician for a hospital. Patients on the HMO had special stickers attached to their charts, and were intentionally treated differently. The sticker meant a fast discharge from the hospital. Startled surgical patients awoke from anesthesia to the news that they would be going home in a few hours; with a new collection of surgical wounds, drainage tubes, IV lines, wires and pain.

Later I worked for a group that repeatedly lectured me on the necessity of minimally treating their HMO patients. They told me to let the patient return at least three times for the same complaint before spending any money on them. They told me to avoid taking lengthy histories, or doing any tests, or getting consultants. The HMO patients were only allotted a very small fraction of the available appointments. I was told that they could wait a few weeks to be seen. Only on the non-HMO Medicare patients would I be allowed to treat as I saw fit.

I learned that they found medical money comes from different sources: and the sources, not the patients, needed to be considered. Especially where the business of HMOs was concerned.

My dad, who was a doctor, predicted the day when doctors would make hospital rounds with an accountant and an insurance actuarial. I have lived to see it. I have seen HMO medical directors and their financial / insurance experts making rounds early in the morning, before the doctors, to say who should be discharged that day.

This is called "case management", or managed health care. I call it a travesty.

HMOs were first the domain of the working person who was offered a health insurance benefit that was cheap for the employer. The families were young and didn't have too many medical needs. If there were problems the patients were unsophisticated as consumers and nobody spoke up.

Later the government decided to take the Medicare system down the same lines. Bidding on fixed-price medical care on whole populations would limit costs. Remember the logos and the baseball caps? This is where the real triumph of marketing to seniors comes into play. Turn the Page