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HMO Model in Indian Healthcare Delivery System: Panacea or Poison?

Posted on April 18, 2012 in Health and Life

By Bhavna Mittal:

The USA has one of the highest expenditures per capita on healthcare among the OECD countries and yet it lags behind most of them with regards to a number of healthcare indicators which doesn’t say much about the healthcare delivery models adopted by them. However, there are certain merits of the Healthcare Maintainence Organization model adopted by them as part of “Managed Care” that can be replicated in a developing country like India.

Firstly, the system of primary care physician acting as a gatekeeper to enable access to specialists is already common among the Indian middle class who tend to approach the family doctor before approaching a specialist.
And yes, the HMOs allow access to only a limited list of doctors and a fixed list of prescription drugs but isn’t that better than no access at all? The staff model particularly can be implemented in the rural areas and serve as an incentive for doctors to practice in these regions; in a similar way, payment via capitation can also be used to rouse the interest of doctors.

HMOs also have an advantage over indemnity plans that tend to concentrate more on secondary and tertiary care rather than primary care, an area in dire need of attention. With the HMOs there would also be no problem of exclusions. Despite growth of the health insurance companies, 80% of expenditure is still out of our pockets, clearly showing that insurance may not be the solution.

But HMOs have received considerable backlash, time and again, and there is no guarantee the same won’t happen in India. This model will work only if it is supported by the government and NGOs and not run as a profit making venture. Unfortunately, corruption will probably ensue as it has in other healthcare schemes. In fact even in the United States, the HMO Act of 1973 was politically motivated to a large extent and not completely in the interest of the citizens, hence exporting such a model may not essentially be the best choice.

Premiums of the HMOs tend to be lower than those of Insurance companies but HMOs interfere with the authority of the doctors to a greater extent, a move that may not sit well with the egos of the Indian doctors. Doctors in India are not used to being instructed as to how many patients to see per hour or which treatment plan to opt for.

The best option in my opinion would be to replicate certain elements of the HMO model as being done in forming the ACOs (Accountable care organizations) rather than discarding the entire system, because when it comes to managing health, there is no panacea and the poison in one case can be a life saver for another condition.