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.
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!
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 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?
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.
We can sustain recent successes that increase the number of insured, improve the value of health care, reduce waste, and entitlement costs. [Ref.–the Accountable Care–Act (ACA)]. In addition, "healthcare costs can be controlled if we focus on and implement adequately risk-adjusted payment incentives* for a small number of outcomes. A small number of outcomes is critical for consumer understanding and will facilitate healthcare delivery change.
Accountability is the key ingredient in managing and ultimately reforming healthcare.
Who's not anxious to improve health care's Cost/Quality/Access, lest they be left out? Ans: anyone but concierge practitioners, i.e.,all the rest of us–hospitals, insurance companies, health care workers and drug and medical device manufacturers. The hospital association, for instance is one of six groups that went to the White House on May 11, 2009 to announce they have made a commitment to accountable care with quality, accessibility and reasonable cost as its mainstay.
The health insurance and managed care industries are strange bedfellows. Health insurance, however, seems to work better for health insurance companies than patients, by and large. They, the insurers "like to cite figures showing that 87 cents of every dollar in premiums is spent on medical claims. But a new Senate analysis suggests that for-profit insurance companies are spending much less than that, especially for policies sold to individuals and small businesses.
To make health care reasonably profitable for private payers and more affordable for patients, those who manage health care must focus on reducing cost, which is far easier than increasing the health benefit or medical loss ratio.