How are medical services affected? This is where money and care collide. Appointments are long-awaited blessings, often with a nurse or other non-physician. If a "real doctor" can be seen, the quality may be highly variable. The goal is for 5 minute appointments in many HMO practices: thats 12 an hour. The AMA actually has a book to teach the art of 5 minute visits.
Cheap and sometimes out-moded medications are approved by HMO committees, and deals are cut for the best wholesale prices for generics. Specialists aren't consulted, or are made difficult to obtain by permission of the company and bureaucratic obstacles. Or maybe you just get stuck on hold, or reach their voice mail, and you can leave a message. Sometimes you may get a call back. There are often paperwork hurdles for permissions to treat.
The patient is not admitted by an ER, but sent home because of the plan. One HMO locally uses a strategy that requires permission from the physician to treat. But the physician only authorizes an evaluation and a second phone call to him to explain the test results before any treatment is authorized. Imagine you needed a pain shot, and the ER doctor has to wait for all the test results to come back, and then has to track down the physician a second time before he is empowered to give you the medicine! The patient who is unlucky enough to have merited hospital treatment may have fewer specialists, less testing, less expensive treatment and an earlier discharge.
The doctors' and directors' incomes (and even their length of employment) are based on profits. These are production bonuses from unused profits. The doctors are tracked by computer for cost-effectiveness (or face unemployment.) In regular office-based practices there may be end-of-year bonuses for a percentage of the unused pile of money. There are even special bonuses for those who send the least patients to the hospital. Everyone's loyalty to the company, and their own livelihood and survival, is tested with every patient, every day. Even hospital staffs are being assembled along these lines.
Loyalty to the organization has begun to supercede loyalty to patients. And the patients are supporting this change.