HMOs and Companies as Hospital Clients and Partners and Most Common Concern of HMOCs
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
August 31, 2013 / September 4, 2013 / September 5, 2013
HMOs stands for Health Maintenance Organizations.
HMOCs as clients of a hospital refers to health maintenance organizations [HMO] and companies [C] that can and have established an agreement with a hospital for the healthcare services that may be needed by the client-patients of HMOs and workforce-patients / client-patients of the companies.
Healthcare services of hospitals in the Philippines are usually delivered directly to any patient from the community at large who goes to the hospital or through physicians or through health maintenance organizations and companies who seek accreditation with the hospital. Thus, there are basically four sources or categories of patient-clients of a hospital, namely: community-at-large or walk-in patient-clients; referrals from physicians accredited by the hospital; HMO-client-patient base; and company-workforce-client-patient-base. All business development programs of hospitals should have strategies to cater to these four categories of patient-clients to utilize their services.
In this paper, I will focus on HMOCs as hospital clients. I will share my thoughts, perceptions, opinions, and recommendations (TPORs) on how hospitals should regard HMOCs. In the process, I will point out some issues and concerns that I am familiar with, either derived from personal experience as a medical practitioner or hospital manager or from hear-say.
HMOs are usually corporations financed by insurance premiums whose accredited or employed physicians and professional staff provide curative and preventive medicine within certain financial, geographic, and professional limits to enrolled members. The insurance entitles enrolled members to services of participating hospitals and clinics and physicians.
In the Philippines, there is an association of HMOs – Association of Health Maintenance Organizations of the Philippines, Inc. (http://www.ahmopi.org.ph/members.html)
The member-HMOs are the following (note: this list may have to be updated):
Blue Cross Healthcare. Inc.
Caritas Health Shield, Inc
Cocolife Health Care
Fortune Medicare, Inc.
Health Maintenance. Inc.
Insular Life Health Care, Inc.
Maxicare Healthcare Corp.
Medicard Philippines, Inc.
Medocare Health Systems, Inc
Metrocare Health Systems, Inc.
Philhealth Care, Inc.
Prudential Healthcare, Inc.
Star Healthcare Systems, Inc.
Value Care Health Systems, Inc.
Companies establishing hospital affiliation
Companies that usually establish hospital affiliation can be categorized into 2 categories: manning and non-manning companies or agencies. The more common type of manning companies affiliating with hospitals are the maritime agencies. The non-manning companies that usually establish hospital affiliation can be divided into two groups based on the type of stakeholders the companies want to or are obligated to provide healthcare services. The first group consists of companies providing healthcare services for their workforce in conjunction with hospitals. The second group consists of companies providing healthcare services for clients who may suddenly need hospital services in the process of the business interactions and transactions.
HMOCs as Potential Clients and Partners
HMOCs are sources of patient-clients that hospitals can tap. Thus, the HMOCs should be considered clients of hospital. Since the HMOs and Companies and the hospitals are all concerned with the health of patients, whether client-patients or workforce-patients, they, the HMOCs, can rightfully be also considered partners of the hospitals in healthcare.
How do or should hospitals establish meaningful and excellent client-partner relationship with HMOCs?
There are three (3) big steps that hospitals should do in establishing a meaningful and excellent client-partner relationship with HMOCs. These are, namely:
- Hospital X looks at its catchment community. It looks at the population who are potential patients, existing companies and HMOs in its catchment community with the perspective of how to improve the health indices of the community with the assistance of the companies and the HMOs.
- Hospital X communicates with HMOs on how they can have shared goals and objectives as regards health indices of the catchment community and on what partnership they can establish business-wise and patient-management-wise. Business-wise, both should have agreed programs that will be mutually beneficially in terms of financial viability and sustainability. Both should collaborate to maintain, if not to enhance, their respective market share. It goes without saying that professionalism in interaction and transaction should be practiced. Patient-management-wise, HMOs expect accessible and cost-effective patient care which the hospital should be able to provide and assure.
- The same processes mentioned in No. 2 apply to companies. Hospital X communicates with Companies on how they can have shared goals and objectives as regards health concerns of workforce-patients and client-patients and on what partnership they can establish business-wise and patient-management-wise. Business-wise, both should have agreed programs that will be mutually beneficially in terms of financial viability and sustainability. It goes without saying that professionalism in interaction and transaction should be practiced. Patient-management-wise, Companies expect accessible and cost-effective patient care which the hospital should be able to provide and assure.
Most Common Concern of HMOCs
Based on my experience with HMOCs, at least 25 years now, the most common concern of HMOCs in their relationship with hospitals is how the latter can provide and assure cost-effective management of the former’s workforce-patients and client-patients. The main strategy that HMOCs has been using since time immemorial in an attempt to promote cost-effective management of their workforce-patients and client-patients is to designate or appoint physician-coordinators and a team of doctors. With this designation or appointment, they somehow have influence, if not to use the word, “control,” on the cost-aspect of the medical management of their physicians. With this strategy, they have achieved certain degree of cost-containment but not the honest-to-goodness cost-effective management that all HMOCs, and even the World Health Organization and the Department of Health would like to have as part of the advocacies on Health for All and Universal Health Care.
My TPOR on how to achieve cost-effective management of the workforce-patients and client-patients of HMOCs? All the members of the team of doctors affiliated and to be accredited by the HMOCs must formulate health-process-evidence-based clinical practice guidelines* (HPE-CPG) that promote cost-effective management. The coordinator and/or the medical director of the HMOCs should initiate this program. At the moment, I don’t think any hospital has this program for the HMOCs. After formulating the HPE-CPGs, the coordinator and/or medical director of the HMOCs should ensure alignment, integration, and coordination in implementation.
As I said, at the moment, I don’t think any hospital has the HPE-CPG program for the HMOCs. If hospitals want to establish and maintain meaningful and excellent client-partner relationship with HMOCs, they can be proactive and work on the HPE-CPGs. The latter will be most welcome to HMOCs. Also, the HPE-CPGs will not only be used for HMOCs but also for all non-HMOCs’ patient-clients. They can help achieve the WHO’s Health for All Movement and the DOH’s Universal Health Care Program.
*Health-Process-Evidence-based Clinical Practice Guidelines (HPE-CPG) are clinical practice guidelines based on the concept of health of WHO, patient management process and evidence-based healthcare and medicine.