Controversial Facts and Questions Regardings HMOs

Part 2, Chapter 7: Managed-Care Plans Page 5

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Another major controversy revolves around the question of whether HMOs can offer patients as effective a system of medical care as traditional plans, particularly for people with disabilities or special health care needs. For example, some people have expressed concerns about the degree to which HMOs are likely to be prepared to offer the kinds of services needed by patients with disabilities or conditions such as MS (multiple sclerosis), Down syndrome, autism, post-polio syndrome, or unusual types of heart conditions. In many cases, patients with such illnesses or conditions may require treatment by highly trained specialists, and they may also require a wide range of services. Of course, concerns have been raised, as well, about the degree to which such needs are generally met for patients enrolled in traditional health insurance plans.

Questions have also been raised about the degree to which HMOs are prepared to offer effective treatment for patients with serious mental and emotional illnesses. Those concerns have focused on such issues as requirements for pre-authorization prior to outpatient treatment, limitations on the number of outpatient sessions that may be allowed without additional authorization, and the process of obtaining approval for admission to a psychiatric hospital in an emergency situation.

It's difficult to evaluate these issues, since the rules under which Health Maintenance Organizations operate may differ significantly from one plan to another. Eventually, information on the effectiveness and the economic benefits of HMOs may become available through research. That research may focus on the number of illnesses and conditions experienced by participants in HMOs as compared to patients in traditional plans, the degree to which individuals with serious mental or emotional illnesses require hospitalization, and the long-term costs of medical care in each type of plan. However, it may be a number of years before definitive answers to these questions are available.

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