One of the most enlightening experiences of my life was working for an HMO.  In 1993, I realized there was a change going on in medicine, where insurance companies and government health agencies were trying to get a grip on escalating health costs.  HMO's offered a system where tests and treatments ordered by doctors would be subject for review.   Any test ordered by a doctor had to be approved by a "gate-keeper," someone in the HMO company who should have been most knowledgeable, but usually, was not.

In the HMO I worked for, I found 2 major problems which interfered with my practice of medicine:  The first was that tests which I felt were absolutely necessary, were often not being permitted by the gate-keepers.  I once had a patient with new-onset chest pain in our clinic, which subsided with sublingual nitroglycerin.  His electrocardiogram showed changes consistent with cardiac ischemia (pre-heart attack).   My gate-keeper would not approve my request to send this man to an emergency room, nor would he fax me his refusal in writing.  I sent the patient to the ER, as I knew it was "bad medicine" not to do so.

The second issue I had with the HMO was their quest for me to evaluate and treat 5 patients per hour (12 minutes per patient !!! ), and posting monthly statistics on a wall in each office, the number of patients seen per hour by each doctor (much like baseball statistics).  I was asked by one of the employees why I wasn't at the top of the list.   I responded that this was a list where the best doctors were at the bottom.   I left the HMO soon after.