Managing Managed Care

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

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When Practitioners Collaborate, It Can Clinically Help, Financially Hurt or Both

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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

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]

What's Non-emergent?

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Non-emergent? There are 2 schools of thought in health care cost-efficiency management: One is benefit limitation and the second is managing "non emergent" presentations with a triage payment for screening the patient. The following is a snippet from Charita Harmon, her LinkedIn MCO Executive discussion:

"But, My Patients Are Sicker!"

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The Commonwealth Fund contends that: reforms physicians could champion to eliminate waste and duplication (inefficiency) include, but are not limited to: "integrated systems of care,""shared savings, bundled payments, or global fees" and "performance measures that promote care coordination." I say that docs aren't happy about any of that.  I can hear them now.... Here's what i hear docs saying with regard to Affordable, Accountable, or Managed Care:   I'm too expensive?

Protecting Practitioners With Compliance Programs

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When addressing possible administrative sanctions, an effective compliance program (CP) can protect physicians, so long as it was in place predating any investigation.  The burden, however, is on the physician practice to demonstrate that their CP is operational, effective and meaningful. 

Health Care Reform at the Office

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Francis J. Crosson, MD seeks "a rationale designed to influence the physician microenvironment so as to support physicians in developing patterns of clinical decision making that result in better health outcomes and lower costs."  

In computerized med. records, ignorance is bliss ….

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The electronic health or medical record (EHR/EMR) can be a technological advance, but only if it tells "who" got "what," "where," and "when."  IOW, it establishes a database that is, for all extents and purposes, more complete, accurate and available.

Delayed Everything

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Charlene Maurer Finerty, owner of Plans and Profits, a business plan writing and implementation service, speaks of the opportunity cost, delayed gratification and indebtedness that characterizes the long-haul of medical training. You'd think once you hang a shingle, your problems are over—but, actually they're just beginning.  For example, there's the hopeless bureaucratization of health care, the need to document every step and then some all along the claims trail and the lack of digital proces

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