Letter: HMOs aren't all alike

To the Editor:

Your series on HMOs presented a limited view due to the generalization that all HMOs are identical. In reality, HMOs vary depending upon the mode of physician compensation.

To emphasize the difference, the Health Center Division (HCD) of Harvard Pilgrim Health Care (HPHC) is legally separating from corporate HPHC. The salaried physicians of the HCD want to concentrate on medical rather than insurance issues. Bonuses in the HCD are contingent not only upon financial targets, but also upon access, member satisfaction and clinical goals. Bonuses are so far removed from individual tests and treatments that they are not factors in decision-making.

Decisions about testing are based on patient needs and clinical research. (Example: Skull X-rays are seldom needed for children with head injuries because medical literature has indicated so.)

Cost impacts testing only in determining where to perform the tests. If the cost of tests of equal quality vary at two locations, we would naturally select the less expensive option.

If, however, the quality of the tests vary at two sites, we would choose the more accurate test, even if more expensive. (Example: Even though more costly, our pediatric patients are sent to one specific hospital for EEGs because its EEGs are the best on the North Shore.)

Medical "horror stories" abound regarding withheld services at HMOs. If you were to investigate, you'd also find a significant number of "horror stories" about non-HMO patients.

Individual decisions and medical outcomes depend as much upon individual clinician expertise and integrity as they do upon insurance status. Physicians, after all, are only human.

Having been in private practice, I've seen non-HMO clinicians order too many tests and see patients too frequently when such behavior resulted in personal profit. (How many children are returning for ear checks in 10-14 days when medical literature suggests follow-up visits in one to two months?)

Peer review at the Peabody Center focuses more on quality than on cost. "Journal Clubs" help update our pediatricians about the latest medical research.

The key to appropriate medical care is not HMO vs. non-HMO. The key to quality medical care is the specific HMO and the specific physician.

Patients carefully and wisely need to select both their HMO and their primary-care clinician.

Bob Krachman, M.D.

Co-Chief of Pediatrics

Harvard Pilgrim Health Care

Peabody