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August 28, 2005

Just like that old time HMO

Tufts Health Plan says forward -- into the paaasssst ...


Tufts Health Plan is trying to revive the company by returning to old-fashioned managed care: The insurer has put its own nurses into hospitals to monitor patient stays and is requiring doctors to get permission to perform hysterectomies, back surgeries, and certain other procedures.

Ugh... yeah, we've seen this movie before. The moral-hazard cops  manage to piss off patients, doctors, politicians, you name it. Tufts wants to cut costs and offer lower rates, but I can't imagine many more people are going to want to sign up for it unless they've learned something from the mid-90's HMO horror stories. If so, I hope they share it with the rest of us.

Posted by Charley on the MTA at 10:29 PM in Massachusetts | Permalink


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God, I hate that I'm taking the side of the HMO here, but back surgeries are way overdone. They rarely help and often make the problem worse. A little scrutiny and patient education by someone who won't be getting paid to perform a procedure might be worthwhile.

Posted by: Abby | Aug 29, 2005 6:48:44 PM

Abby, of course you should take their side if they're right. :)

Back surgery and hysterectomies may well be performed way too often. The question is who makes that decision, and based on what information? Doctors should be made aware of the latest research, but as an insurer, the HMO has a conflict of interest in deciding what's medically necessary.

Posted by: Charley on the MTA | Aug 29, 2005 9:25:16 PM


Here's the rub. The insurer has a conflict of interest, but the doctor does too. The surgeon wants to do more back surgeries, because he'll get paid more that way. I trust doctors more than HMOs when it comes to deciding what's medically necessary, but they're hardly saints themselves.

If a back surgeon told me that I needed surgery I wouldn't necessarily trust him. That's like asking a barber if you need a haircut.

Posted by: Abby | Aug 29, 2005 10:06:47 PM

True... but at least the docs are closer to the situation.

OK, here's the solution (as I wave my magic wand):

1. have a blue-ribbon commission of wise and impartial people do regular audits, updates, and best-practice research on necessity of all manner of practices;

2. somehow make health care more stable, so that the health plan will have a long-term incentive to make sure that procedures will have a preventative effect without incurring unnecessary costs.

I think the success of the program will depend on its implementation ... but it sounds like the same old HMO thing that folks pilloried Hillarycare for (RATIONING!), and then the private sector did the same dang thing anyway.

Posted by: Charley on the MTA | Aug 29, 2005 10:50:57 PM

Yeah, that's why I support single-payer long-term, and I want to be able to access good data on my own.

Posted by: Abby | Aug 30, 2005 1:15:24 AM

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