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The rise and decline of the early HMOs: some international experiences.

Consumer-controlled health insurance groups in northern Europe in the late nineteenth and early twentieth centuries resembled modern American HMOs in many ways. Fierceness of competition hindered European doctors' control of their own services, prompting them to organize physician-dominated insurance groups and to extend their power through means of licensure, boycott, and supportive government regulation. While patients thus gained the right to choose their own doctor, physicians were able to negotiate more favorable payment standards, including price discrimination by patients' income levels. The experience may foreshadow more ruthless operation of market principles among American HMOs, and raise questions about the HMO model's viability for Europe today.