My experience with an HMO

When I first started working for Raytheon full-time, I had to pick a medical insurance plan. Since I never go to the doctor, I just picked the cheapest available plan, which was an HMO. When I married Joy, we decided to go for the slightly more expensive HMO, Kaiser, because her family had been covered by Kaiser as long as she could remember. We didn't spend very much time thinking about the options. We figured that if there was something we didn't like, we'd just change plans at the end of the year.

HMOs have a bad image in this country, because there is a feeling that they are huge companies, motivated almost purely by profit, and therefore resist as much as possible expensive tests and treatments, even at the risk of patient health. Perhaps the most gruesome, if not eloquent manifestation of that feeling, was a man who shot himself on an LA freeway in 1998 with a sign that said, "HMO's are in it for the money!! Live free, love safe or die." And of course HMOs are in it for the money.

But that's the way health care works in the U.S.; doctors, hospitals and insurers make money by selling health care to consumers. And no matter where you live, someone, somewhere has to look at the monetary cost of the health care you receive and decide whether or not the benefit is worth it. If you live in Canada, that person works somewhere in the government bureaucracy. If you live in Mexico, that person is probably you. The only difference with an HMO is that you (or whoever is paying your insurance) is paying the HMO to make those decisions.

Right now, my wife and I are getting ready to have a baby. Because Joy likes to do things right, and needs to know what's going on with her, we started taking a birthing class taught by a Bradley Method® instructor. In ten weeks, we are learning all sorts of details about bringing a healthy child into the world. Everything about the process is explained with stark honesty. We've seen many videos of women giving birth: some in the hospital, others at home, some in beds with stirrups, others in bathtubs, some with painkillers, other with their husbands sitting behind them.

The effect of this class has been to give Joy and I a lens through which to view our hospital, doctors and nurses. I think that it is a more clear lens than what most people use, though I could very well be wrong. From where we sit, our HMO is doing a lot of things right; some of which other hospitals are doing wrong. Let me tell a quick story to illustrate:

One of my coworkers congratulated me on our impending child and immediately afterward told me, "Children are expensive." When I asked what he meant, he told me that with his non-HMO plan he had paid a copay for each of the procedures done for his wife and child. Since I've been learning about labor and delivery procedures, I asked what happened. First his wife noticed she had lost her mucus plug, so they called the hospital and were told that they needed to come in right away because there was a risk of infection. Once they arrived at the hospital, they induced labor with Pitocin since she hadn't yet experienced any contractions. After several hours, she still hadn't started labor, so the doctor performed a Cesarean, which kept her in the hospital a couple extra days. The net result was that he paid a significant percentage of the thousands of dollars that this pregnancy cost over a more normal vaginal birth.

What makes this story tragic is that his wife probably could have had a normal birth. Women routinely loose the mucus plug (which is not the same as having their water break) days or even weeks before labor. It's like throwing out the ceremonial first pitch at a baseball game; it happens a shortly before the start of the game, but it doesn't signify much more than that. They shouldn't have even checked into the hospital at that point. Everything else that happened to them happened as a natural consequence of thinking labor had started before anything had happened. It would be as if the umpire had called strike one on the "first pitch", and, since no one else came to bat, canceled the game.

I'm pretty sure I know what would happen if Joy and I showed up at our hospital before her first contraction. They'd send us home. There's a strong financial motivation to avoid unnecessary procedures like inducing labor because the HMO bears the cost. I can't be sure, because I don't know the details, but I suspect that the hospital my coworker went to knew that inducing labor and performing a C-section were unnecessary, but did it anyway. There's a strong financial motivation to do extra procedures, because the patient and their insurance bear the cost, and the hospital makes a profit.

Sometimes our teacher brings in former students to tell us about their birth experiences. So far we've heard about a home birth and two women who gave birth at one of our HMO's hospitals. The woman who had her child at home told us that her midwife checked the baby during labor with a handheld Doppler stethoscope like our doctor does during prenatal visits. The women who went to the hospital were asked to get on an IV, be strapped to a fetal monitor and stay in bed once labor began in earnest. My wife, like most pregnant women, hates the thought of being put on IV and a monitor because she wants to be able to move around and find a comfortable position. Most hospitals like to have women on the monitors because one nurse can monitor multiple women from the comfort of the nurses station.

Both women were able to avoid being stuck in bed by refusing to get attached to the IV and asking to be monitored only 15 minutes out of the hour. This is the weakness of any bureaucracy—eventually policies have to be enforced by a real human. The nurses gave in to the women's demands because ultimately it was easier to bend the rules than to deal with an angry pregnant woman. It's instructive that both women reported having trouble with the doctor that took over when their nurse went on break. Doctors are higher up on the authority chain and find it harder to break the rules. Imagine if every pregnant woman demanded personal care!

Breastfeeding is, as we now know, the best way to feed babies. Lots of studies have shown that babies who are breastfed, even for a few days after birth, and their mothers are healthier than families that bottle-feed formula. But companies that manufacture and sell baby formula spend millions of dollars a year trying to convince mother to use their product. Private hospitals would deny it, but they don't have any reason to push mothers to nurse and at least indirect reasons to encourage formula. Not so with HMOs. We heard over and over that breast milk is best for babies. The HMO knows that in the long run they'll lose money if their patients don't nurse because healthy babies are much cheaper to provide care for than sick babies. Our hospital gives a little kit to new mothers that is provided by a formula company. A nurse told us that they are not allowed to remove anything from the bag, but that mothers who plan to nurse can throw away the formula sample since they won't need it.

What actually happened

It turns out that my son, Joshua, was born in Denver, Colorado about two weeks before his due date. Joy's water broke about midnight and she had a few contractions during the night, but we took our time getting to the hospital. Our HMO operates in Colorado, but they do things a little different than they do in California. They operate a small group of clinics and contract out to local hospitals for things like labor and delivery. I don't know exactly how this works, but the upshot is that Joshua was born in a private hospital associated with the Catholic church.

As we expected, once we got to the hospital, the doctors wanted to induce labor immediately because of the risk of infection. Joy kept telling them that she wanted to wait for the contractions to start on their own.

Jon Ericson
Last modified: Tue Jun 17 18:11:37 PDT 2003