Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Billing Beyond Customary

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Your health plan or doctor's office seems to see your heart attack, broken leg or laceration differently than you do.  They may want you to pay for that which one would ordinarily believe is covered.  In general, that is what consumer advocate, Ralph Nader calls "The Crime of Overbilling Healthcare." [Pub online August 31, 2014]

"Health Care" and "Insurance Companies"--Oxymoron

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"I don't understand why health care and insurance companies keep appearing in the same sentences." (Fisher, W. Truthout 10/25/09) Isn't it frustrating to have to live under employment based health care insurance?  If you lose your job, your employer wants to cut back, or you are a peasant, you're screwed!  Also, as a result of the way we are paid and the insurance model itself, there are many forces today that steal us away from the exam table or bedside.

Enhancing HealthCare's Worth

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It's disheartening; the cure for the ills of U.S. health care lies within our grasp, yet it eludes us.  We cannot answer basic questions–What works?  What we are paying for? Are we getting what we need?  Are we getting the right care at the right time and place? QI and UM: Strange bedfellows, but both need data to communicate

Autism and Autistic Behavior

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Autism Spectrum Disorders (ASDs) From the American Psychiatric Association's Diagnostic and Statistical Manual-IV, Text Revision (DSM-IV-TR), which provides standardized criteria to help diagnose ASD. Diagnostic Criteria for 299.00 Autistic Disorder A. Six or more items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): 1. qualitative impairment in social interaction, as manifested by at least two of the following:

Real Reform

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Health Care Will Be Organized (and Paid For) Differently Say Porter and Lee in the Harvard Business Review (Oct. 2013) The strategic agenda for real reform lies in creating a value-based health care delivery system. As stipulated by Porter and Lee, six critical steps in reform as as follows [modified]: Separate primary from preventive care; reorganize care around patient medical or surgical conditions, forming what they call “Integrated Practice Units” (essentially team work);

Collaboration Amongst Practitioners

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Is it the patient's fault when they end up getting needed care out-of-network, i.e., from physicians who aren't part of the managed care network, the referral list is too thin or restrictive, the right specialist is elsewhere (or so it seems), or simply because there was no opportunity to choose an in-network doctor? Referrals Tell Us a Great Deal About Collaboration Among Practitioners

Barriers: Poor Value; Prohibitive Out-of-Pocket Cost; Priorities

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Be careful! 'What you sow, is what you reap.' A health plan's primary responsibility is ?? (should be the patients they insure).  But, they have policies that "restrain prescription medication spending by shifting costs toward patients. It is unknown how these policies have affected children with chronic illness."  Here's research that proves that cost control may not be about managing care--worse, it can adversely affect your health.

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