Managing Managed Care

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

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Health Insurance Isn't; Nor is It Health Coverage

Does the insurer really know if it was medically necessary? The 'cheapest' plan may not be.  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] are propelling us away from the bench or the bedside. No one ever goes into medicine do unnecessary testing, but this sort of behavior is now commonplace. 

Ref.: "10 Things Health Insurers Won't Tell You" [pdf] by Elizabeth O'Brien, WSJ, Oct. 12, 2014 [Saying insurers are focused on "ensuring affordability, stability and accessibility."

  1. They have no idea what to charge you.
  2. If you can figure out the math, you might get a tax break.
  3. Regarding the individual market, shop around.
  4. Out of luck if out of network.
  5. Who's in network, anyway?
  6. Are the really good hospitals, specialists, procedures covered?
  7. The 'cheapest' plan may not be.
  8. 'Where did those charges come from?'
  9. Does the insurer really know if it was medically necessary?
  10. Do the high deductibles make the Affordable Care Act less affordable?

An Insurance King comes out from under a rock and declares:

“We need to move the system from underwriting risk to managing populations," said Aetna CEO, Chairman and President Mark Bertolini. A fortune 100 health care insurer's CEO recognizes the "imminent demise of his venerable, profitable business model.…"  [click for the source of his quote]

Align incentives; improve quality/reduce costs

Being an informed consumer or an empowered patient won't get the costs down, the diagnoses upheld or the quality improved.  'Doing the right thing' should be our motto and we should be rewarded for doing that, however, without incentive alignment, health care reorganization or reform is merely a shell game - apply pressure in one place and like a balloon, it pops out somewhere else.

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