Providing Management Consulting
and Internet Services
Under Florida Corporation
Comad Property Management LLC

Email: George Makrauer, President
Web: www.comad.com

Internet and Traditional
Management Consulting.
Founded 1972 in Ohio
as Comad Corporation.

1327 Beasley Terrace
Lady Lake, Florida 32162
Phone 352-753-9289
Fax 352-753-9648

Re: Doctors' plan to start HMO is struggling, Dec. 14.

If the idea behind a physician-owned HMO is to "give doctors more control," it's not surprising to hear that raising the start-up capital is a tough sell. But saying "HMOs create bureaucracies" (which is as accurate and balanced as saying, "Doctors' patients die") has nothing to do with it. All businesses of two or more employees create bureaucracies. Name one hospital, one physician group, one medical lab, one drug company or one newspaper that hasn't created its own bureaucracy. The key issue is how members of the health care delivery system work to improve outcomes and the quality of care at affordable cost.

HMOs - both for-profit and not-for-profit - are popularly blamed as the force behind cutbacks in health care that, at best, inconvenience patients and, at worse, diminish outcomes (which, in health care doublespeak, means "kills people"). The fact is HMOs do not operate in a vacuum but respond to two other major influences of the health care system, both of which were omitted from your article and from my list above: employers and patients.

Who pays the bills to the docs, hospitals, et al? It ain't the HMOs; it's employers.

Who determines medical procedure utilization? Without responsible oversight, first and foremost, it's patients who believe someone else pays the bills and they, therefore, have no personal stake in the cost or the process. So, patient behavior is often poorly directed - for example, emergency room visits for a weekend illness, doctor visits rather than phone calls, requests for prescriptions rather than over-the-counter pills (which aren't paid for by "insurance"), irresponsible use of tobacco and drugs and other decisions which drive up the employers' - not the HMO's - costs.

Patients beat up HMOs for more service; employers beat up HMOs for lower costs. When docs and hospitals respond to a patient's request or need, their motivations are complicated, too, most times well, sometimes poorly.

Patient care and outcome have to be primary. But avoiding lawsuits is close behind. No doubt, an occasional bad apple will try to take advantage of his or her own bureaucracy for an unfair financial advantage. And so, too, will an occasional patient. But, if patients want better service, they have to become better informed decisionmakers, too, just like all the other components of the U.S. health care system who want to see improvements for themselves.

Physician-sponsored HMOs that "promise more freedom of care without cut-and-dried rules for patients and bigger fees for doctors and hospitals" are always going to have trouble attracting investors for one simple reason: They're going to have an even tougher time attracting bill-payers.

George A. Makrauer, Treasure Island

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