No Comments March 9, 2008 – 6:37 am

As the name actually implies, an HMO places emphasis on maintaining optimal health through regular visits to your doctor. The idea is that most major illnesses can be prevented through inexpensive testing and regular visits to physicians. Here are four basic facts about HMO’s that will help you better understand how they work:

1. All physicians and specialists are part of a network. Participants must choose their doctors from a list and only see physicians included in the plan. It is typically not possible to see any doctor’s outside of the list on an HMO.
2. Less expensive than PPO. Premiums are lower on HMO plans and so also are the co-payments which may even be waived on some plans.
3. More Restrictive than PPO. While less expensive, HMO’s typically have a “Gatekeeper” otherwise known as your primary care provider. This doctor will have to be seen before you can gain access to specialists on the network.
4. Networks tend to be overcrowded. Because emphasis is placed upon regular visits to the doctor, the HMO networks tend to get crowded making it difficult to get into to see your primary physician. In really severe cases of overcrowding, it can sometimes take a month or more to see your doctor for a regularly scheduled visit.

The “Gatekeeper” function of the primary physician in HMO plans really tends to limit health care options especially when a patient disagrees with the doctor’s diagnosis or treatment. You are not locked into keeping any one primary physician but it will often take weeks before the necessary paperwork can be processed and your choice changed. Then, if the other doctor still agrees with the original assessment, the patient will again need to switch physicians if they think they need to see a specialist but the doctors disagree. In theory, by having those in an HMO plan see their primary physician first, the propensity to drain the insurance fund with unnecessary specialist visits is minimized. This may very well help keep the costs down for those enrolled in an HMO plan but it can be very restrictive for participants and is often a source of contention for those enrolled when they disagree with the “Gatekeeper’s” assessment.