THE GOVERNMENT would like to see more Medicare patients enrolled in health maintenance organizations. In exchange for a fixed, per capita payment, HMOs provide a range of services that include physician's care and hospitalization. The patient must agree to use the plan's doctors and hospital facilities, but in exchange almost all costs are covered. The system is particularly efficient for the federal government, which is saved the cost of processing individual claims for service when predetermined Medicare payments for thousands of patients can be made to a single HMO each month.
The largest Medicare HMO -- and the third largest HMO of any kind -- has been organized in Florida by International Medical Centers. Using celebrity television commercials and newspaper ads, IMC has enrolled 147,000 Medicare patients in South Florida and the Tampa area in the last five years. But allegations about its operations have prompted a congressional hearing, an FBI fraud investigation, actions by the state to correct financial problems, an investigation by the Department of Health and Human Services and, just last week, a letter of noncompliance from HHS giving the firm 30 days to produce a plan for improvement.
Senior citizens complained of long delays for appointments, unsatisfactory emergency treatment and other serious deficiencies. Doctors and hospitals complain of late reimbursement. As a result, they are reluctant to care for IMC patients, who are not, the doctors point out, indigent, but supposedly covered by an HMO paid by the government. The company, whose president was paid $1.3 million last year, employs a number of former high officials of HHS, some of whom worked on IMC matters in the government. Medicare payments to this single HMO come to $30 million a month.
Medicare officials report that they have agreements with 130 HMOs across the country and that IMC is unique in its problems. This may stem in part from the fact that a temporary waiver was granted to IMC and one other organization in California allowing them to contract with the government even though more than half their enrollees are Medicare patients. Federal officials usually require a higher percentage of younger participants in order to provide some stability to the enterprise. No additional waivers have been granted in this program, and if this experience is any indicator, none should be.
Similarly, the government has an obligation to hundreds of thousands of senior citizens enrolled in HMOs to monitor these organizations carefully, to weed out the bad ones and to see that quality care is provided for this taxpayer investment.