Managing Managed Care

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

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Reform Issues

The EHR—on the Road Where a Cottage Industry Lived

Improving doctors' quality, effectiveness and cost-benefit requires meaningful communication at all levels and settings. Read more Tags: interoperability, electronic health record, EHR, FHIR, EMR, episode, meaningful use, cost, quality, value, value-based care, feedback, communication, health information exchanges, HIE Read more articles about: communication/knowledge

Doctoring All Of Health Care At Once

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.   Caveat: The means to a desired end – A truly integrated electronic medical record with acuity or case-mix assessment, point-of-service alerts and patient tracking (process and outcome) is necessary.... Read more Tags: MACRA, Clinically Integrated Networks, MIPS, Care Information, ACI, Resource Use, Clinical Practice Improvement, CIN, ACO, aligned incentives, process, quality of care, accountable care organization, health care reform Read more articles about: Reform Issues

When's "Good" Quality, Good Enough?

A payer judges a physician or a practice organization by the proportion of patients for which the physician adhered to one or more abstract practice measures. Read more Tags: health status, engagement, AI, value-driven outcomes, potentially preventable events, PPE, information, quality, empathy, actionable, patient welfare, access, value, shell game, shared decision making, artificial intelligence Read more articles about: quality, cost and/or access

Enhancing HealthCare's Worth

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 Read more Tags: quality of care, home care, population analytics, outcomes, teaching, teach-back, silos, affordable, affordability, health literacy, analytics, transparency, acuity, incentive alignment, informatics Read more articles about: communication/knowledge


"Up to 30% of Medicare spending is wasted on needless care." Read more Tags: quality of care received by Medicare beneficiaries, quality of care, Wenberg, waste, lab, cost center, more effective care Read more articles about: waste

Billing Beyond Customary

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] Read more Tags: billing, customary, appropriate, fair, balanced billing, profit Read more articles about: cost-sharing with patients

Ways That Effectively Transform Primary Care

Accountability is the key ingredient in managing and ultimately reforming healthcare.   Policymakers try to reform health care and on the top of their worksheet are ways to accelerate transformation to high-value models of advanced primary care practices. In so doing, "they are challenged by two things: the lack of a clear definition of the clinical model they are trying to create and the transformed practices [and] a business case for... Read more Tags: interoperable, Population Health, Value-based Health Care, disability, accountable, healthcare, meaningful use, relative risk, primary care practice, incentive alignment Read more articles about: accountability

Data Science Strategy; the Managed Care Method

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.  Here's what a fellow Medical Director and I wrote about this in 1994, still very relevant: Read more Tags: care redesign, accountability, incentives, data science strategy, leaning in, categorical, predictive analytics, managed care, quality, cost, outcome, efficiency, effectiveness Read more articles about: measurement & management

Waste Less; Add Value

To make health care reasonably profitable for private payers and more affordable for patients, those who are responsible for managing the care must concentrate on reducing cost (which, by the way, is far easier than increasing the health benefit or favorably affecting the medical loss ratio).  Read more Tags: waste, triple aim, value-based, over treatment, care coordination, outcomes, Population Health, risk adjustment, fraud and abuse, ​Coordinating, Communicating, comprehensive care Read more articles about: waste