Wednesday, July 1, 2009

The ABCs of HMOs

Awhile ago, I mentioned that I would address the topic of HMOs and why they are not necessarily the enemy of quality medical treatment. This is the topic of this posting.

Disclaimer: I can only speak from my experience and about my particular HMO, and I am not a paid promoter of HMOs.

OK, now that we got that out of the way, let's delve into the world of managed care, as well as how you can best make the HMO work for you.

Advantages of HMOs over PPOs

As one of the people lucky enough to have medical insurance, I am very happy with my HMO. Some primary care physician groups do not have quality doctors, I'm sure, but I selected my primary care physician based on a group affliated with a first-rate hospital.

Unlike the horror stories you hear in the media, my HMO doctors are outstanding.

Through my HMO, I was able to get all my cancer treatment -- chemo, surgery, radiation, etc. -- free of charge. Trust me, I saw the statements of all the charges I would have owed -- enough to give anyone heart trouble and a new set of specialists -- and I know that with a PPO I would've had to pay a certain portion of it, and a small portion would've still been a ga-zillion dollars.

Also, what PPOs don't emphasize is that they have a ceiling, where they won't pay anymore after a certain amount of funds are exhausted. The cap is a high amount, so it's not a problem for routine problems and conditions, but cancer treatments and reconstructive surgery would have driven a sledgehammer through a PPO's ceiling, and expenses would've gone through the roof.

HMO: That's A-Okay

Another little-known fact is this: many HMOs will cover a medically necessary procedure done by out-of-network doctors -- if the primary care physician, also known as the gateway doctor, advocates on your behalf. That is why it's so important to have an excellent relationship with your gateway doctor and to hire the best one for your needs.

When you have an excellent gateway doctor, the HMO experience can be wonderful. That's the key: finding and hiring that gateway doctor to help you help the HMO meet your needs.

In my situation, I needed a double mastectomy with reconstruction. Because I was young, fit, and active, a double tram flap procedure was not an option because too much abdominal muscle would be removed, and I might not ever be able to sit up on my own. According to my doctors, the procedure I needed to reconstruct both breasts was a Diep flap, a more cutting-edge surgery (pun intended), designed to preserve as much of my abdominal wall as possible.

One doctor of reconstructive surgery who was recommended to me by many medical professionals was out of my HMO network, although affiliated with my hospital. I wanted him as my surgeon, but as he was out of network, my gateway doctor said that in order to make a case to the HMO that I needed the skilled Diep flap surgeon, I had to first see the in-network plastic surgeon to ask his recommendations. While I dreaded this pain-in-the-butt step, it had to be done, explained my doctor, as she and my oncologist were drafting their letters on why I needed the Diep flap procedure.

Here was the key on which my fate would turn: If the in-network plastic surgeon could do the Diep flap, then he would be my surgeon. However, when I saw him, he said I needed the Diep flap, but he is not skilled in this arena, and I'd need to go out of network. He drafted a letter on my behalf to the HMO, stating that I needed this procedure that he did not perform.

A few weeks later, the HMO came to its conclusion: It would cover the ENTIRE cost of the Diep flap, hospital stay, and all followups as needed. And, because my surgeon needed a doctor skilled in this type of surgery to help him (also out-of-network), the HMO paid for that additional surgeon as well.

Cost to me: 0 cents. Cost to my quality of life: priceless.

Whether you have an HMO or PPO, though, the key is to have the right doctors in place, so if a time of medical need arises, they will advocate for you.

Beth L. Gainer is a professional writer and has published an essay on her breast cancer experience in the anthology Voices of Breast Cancer by LaChance Publishing. She teaches writing and literature at Robert Morris College in the Chicago area. She can be contacted at and She also blogs on the adventures of her cats, Hemi and Cosette, at



  1. Thanks for a positive perspective on HMOs. My MIL is a nurse and thinks they're the devil. She'd seriously disown us if any of us accepted an HMO plan.

    And then there's the line from the film As Good As It Gets (Jack Nickelson and Helen Hunt): "Fucking HMO Bastards Pieces of Shit."

    Isn't that a mouth full?

    Another detailed and insightful post.

  2. Yes, there are two sides on the HMO debate. It really depends on the HMO; some are just criminals and only care about the money. We always hear about them on the news. And they are reputed to have doctors see as many patients as possible within an hour.

    To be fair, however, there are kinder, gentler HMOs. I have Blue Cross Blue Shield of Illinois, and I have gotten Cadillac (or the luxury car of your choice), state-of-the-art treatment. My doctors spend LOTS of time with me and do not rush me out of the office. They are quality, and I consider myself blessed.

  3. This was a VERY informative post! Thank you :)

  4. Thanks, Alicia, for your comment!!