Managing Managed Care

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

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Physician Compensation

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Reform will fail when practitioners are not getting paid for legitimate work they do. Here follows a cadre of recent situations that sought, outside of contractual obligations to get payment: "After 7 months of claims for a certain procedure being denied, and resubmitted, to be denied again, the practice finally read the EOB and checked out the reason – the plan instituted a new pre-authorization requirement.

Doctoring All Of Health Care At Once

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The U.S. practices of medicine and surgery aren't as cost-effective as other countries. We suffer intolerable costs (poor value) and huge variation in our practices, the way we fail to coordinate care and communicate, health care reform is vital. Why are we not doing the right thing?

Practices Must Change for Cost Effectiveness Research to Work

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It is unclear in the U.S. if Cost Effectiveness Research (CER) studies are compelling enough to overturn insurer's coverage decisions or reduce well-established procedures--Beware the status quo

Duh! Better Health Care Coverage--Better Health Care; Better Results

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Much of the work on health disparities and inequities in access focuses on comparisons between the insured and those without coverage. It should come as no surprise that the uninsured come out wanting and “Uninsurance is associated with mortality.”  Furthermore, Uninsured persons have less access to services, suffering worse health outcomes than that of the insured. Breast Cancer patients seem to have a 30-50% higher mortality rate then those without cancer.

Care Mgm't, Communication Curriculum Tools and Diagnostic Coding

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Coding systems that support clinical decision-making, 'measurement and management,' communication, especially about transitions of care and outcomes (acuity-adjusted) become the modus operandi of the new Managed Care.

Managed Care Organizations Practicing Medicine (Without a License)

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Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs.  Not long ago, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered! Mental Health Parity; Let the HMO's Be Damned!

The Managed Care Method

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Healthcare reform is really about managing the care so that it is optimally accessible, reasonable and reliable quality (esp. less variation), and is more efficient and cost-effective. A fellow Medical Director and I wrote in 1994:

The EHR—on the Road Where a Cottage Industry Lived

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Improving doctors' quality, effectiveness and cost-benefit requires meaningful communication at all levels and settings. To cure health care's ills, there's an obvious remedy that is difficult, but not impossible to implement—make cogent information* available at the point of contact with the patient, regardless of setting and within HIPAA constraints. 

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