SENIORS NEED HMO FACTS

I've been getting a lot of ads from HMOs lately. So have my neighbors who are seniors. All of a sudden those of us who have Medicare look like potentially profitable customers for the HMOs, so they're out to recruit as many of us as possible.

By now most everybody knows what an HMO -- or, to be more formal, a health maintenance organization -- is. It is, to put matters most simply, a health care rationing outfit. An HMO gets paid a fixed sum in advance for each member and tries to make a profit by spending less than that fixed sum for the care of its average member. The incentive is clearly to do as little as possible, since the less that's done the more profitable the HMO becomes.

That isn't the way HMOs sell themselves of course. Here's how one HMO that wrote me recently put the matter. The HMO wrote me that "it gives you ALL of your Medicare benefits and MORE without charging you a monthly plan premium."

It stressed again that there was no monthly plan premium, though they had the grace to admit that my Medicare Part B payment will continue to be deducted from my monthly Social Security check. Then they promised in boldface type: "Unlimited Hospitalization as Medically Necessary...Unlimited Primary Care Physician visits...Prescription Drug Benefit (up to $500 per year.)"

Then they had a sentence about what great doctors they have and added, almost as an afterthought, that as an HMO member "you receive all your care through this network (except for emergencies and urgently needed care.)"

Some of this sounds great. Note, for example, the double use of the word "unlimited" in reference to both hospitalization and physician visits. But that's where the scam is, since the last thing any HMO wants to do is to provide "unlimited" hospital or doctor care for anybody.

But it takes only a little thinking to see that they're talking out of both sides of their mouth. Take that "unlimited hospitalization as medically necessary." But who decides what's medically necessary? The answer is the HMO does, and the HMO always wants you to get out of the hospital very quickly, even if you think you need more time there.

And what about those "unlimited primary care physician visits?" But senior citizens tend to get serious diseases, heart failure, cancer, stroke, Alzheimer's. In short, most of our serious medical needs are for specialists who are trained to handle serious illness. What the HMO wants is to stick us with a general practitioner who may be fine for a cold but is virtually useless for any really serious, life-endangering disease.

In any HMO, as millions of patients have learned to their sorrow, you can't go to a specialist unless your primary physician -- who is openly called the gatekeeper -- allows you . Unfortunately your primary physician's incentives, even his ability to hold his job, depend upon his giving you as little contact with a specialist as possible. Specialists are expensive, after all. But notice not a word of this appears in the HMO propaganda.

Finally there's that famous $500 prescription drug benefit. If you're seriously ill, your drug bill can easily run into thousands of dollars. Many generally healthy younger people spend over $500 a year for drugs.

I want to make plain that there are different HMOs in this country, some better and some worse. But if they were dealing honestly with us, they would discuss openly the issues I've raised above. At what stage of an illness will they want to evict us from a hospital? How often will they let us see a specialist, and how long do we have to wait for such a consultation? Does their drug benefit cover the costs of the newest and most effective drugs which also tend to be the most expensive?

Would you buy an automobile from a salesman who gave you the kind of misleading pap this HMO sent me? If an HMO wants my business it has to talk cold turkey to me, laying out accurately and fully the advantages and disadvantages of HMO membership. But the HMO propaganda I've seen assumes we seniors are idiots who don't understand the potentially crucial importance for our lives of whom we turn to for medical care. Truth in HMO advertising is what we need, and the full truth.

Harry Schwartz is a former member of the New York Times editorial board.