This week's theme is HMO's and nursing homes.  HMO's are Health Maintenance Organizations, and they are a method of holding down costs.  The government pays the HMO a set amount every month for each patient enrolled, and the HMO is also given bonuses for getting good grades and extra money for the super expensive patients.  Plus they receive grants for other stuff like upgrading equipment, teaching, etc.  Yet in many areas, HMO premiums have sky-rocketed. 
     But does all that money translate into better care for the patients?  Nah.  
     Let's take a look at nursing homes and HMO's.  If a patient who has Traditional Medicare A&B is admitted to a nursing home, Medicare pays in a very bizarre way for the patient to receive rehabilitation services and medical care.  That's another story for another time.  However, It's substantially easier to be admitted to a nursing home under Medicare Part A than it is to be admitted with an HMO.  Nursing homes have the freedom to provide as much therapy as they can for as long as they believe that the patient is benefiting.  I've seen this abused, but for the most part the patients benefit from the care.  
     HMO"s require preauthorizations and weekly updates for each patients - and they funnel their patients to contracted facilities rather than ones that are convenient to the patient and family.  If the patient isn't doing well enough in the case manager's opinion, HMO's terminate the services.  I've seen HMO's force patients to be discharged home even though there was no caregiver available, with little or no notice.  But that's not all.
    Nursing home patients with HMO's who are there for the long run are often required to go out to medical appointments even though there is a doctor willing to see the patient in-house. They micro-manage patient medications and make it difficult to receive ongoing therapy to keep the patient at their level of functioning (provided by Medicare Part B on the Traditional Plan).  
     And patients can only go to nursing homes that are contracted with the HMO. In small towns that might not be a problem - but in a larger town, the nursing homes that contract with HMO's are often the ones that are least desirable.  In my city, the company that contracts with HMO's has the very worst of care (as reported by Medicare).  They smell like urine (my observation), are not as nice as the other facilities and the care is left to be desired.  The company rakes in profits but rarely do they trickle down to paying for upgraded facilities and better trained staff.  The buildings are elderly and the air conditioning systems barely work - but patients continue to be shoveled there by HMO's.
    Patients who have HMO's have a tough time being admitted to the better nursing homes (even if they have a contract) because of the hassle of dealing with the HMO's.  
     HMO's might be the right choice for the senior who wants to save money, but limited physician choice, facility choice, less than desirable care and denials for services might make you think twice before you choose to enroll in one.