Managing Managed Care

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

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When patients require specific therapies and an insurance company makes the frail or sickly patients jump thru hoops, denying or delaying care, it's time to move away from the insurance model.  

How furious should we be when the insurer uses technicalities to refuse coverage, makes patients wait incessantly on the phone, transfers calls to G_d knows now many departments and then, after seemingly hours, the connection breaks, etc.?

In my own experience getting post-op wound therapy, I was stuck with huge out-of-pocket expenses, I later learned from the Wound Center that patients more needy and less well off then I were refused vital therapy. 

(It is this kind of crap that motivates me to write this column.)

Anyway, we all know that these refusals, delays and denials are mostly in the interest of maximizing corporate profits at the expense of patient's lives or limbs.

Is that any different than a doctor ordering the wrong test, wrong specialty consultation or wrong med and then making the patient pay for the wrong care?

Can we excuse fractionalized care where one hand (err, doctor) doesn't know what the other is doing?

Is that different from predictable, repetitive, avoidable mistakes in the hospital setting?


  • This happens daily, for example, when patients use the ER rather than a medical home (their doctor's office) for routine or non-urgent care.
  • This happens when insurance companies, in the guise of increasing patient accountability, levy co-pays and deductibles (which we all know have more to do with revenues than making patients think twice about visiting a doctor or ER, especially in a time of (perceived) need or anxiety.  It's the old parable about the balloon:  when you squeeze it one place, it pops out in another place.
  • We note: "increasing copayments for ambulatory care reduced the use of outpatient care among elderly enrollees in managed-care plans, but this decline was offset by an increase in hospitalizations, particularly among enrollees with low socioeconomic status and those with chronic disease. Increasing copayments for ambulatory care among elderly patients may have adverse health consequences and may increase spending for health care."

Trivedi AN, Moloo H, Mor V. "Increased Ambulatory Care Copayments and Hospitalizations among the Elderly." [Free text] N Engl J Med 2010;362:320-8 [Brown University]

 The ACA Coontinues, Unabated: High Cost Sharing and Narrow Provider Network Update

"[Even] for people who gained insurance under the ACA and the tens of millions who already had coverage, substantial barriers to timely access to affordable medical care remain. Two features of exchange-based coverage — high cost sharing and narrow provider networks — can limit access and are increasingly common in employer-sponsored plans as well. The average deductible in 2015 was just under $3,000 for silver-level exchange plans and $5,200 for bronze-level plans. Deductibles can reduce costs by discouraging the use of low-value care, but they may also drive patients to skimp on necessary care. Insurance designs could instead reduce financial barriers for high-value care while maintaining cost sharing for remaining services. The ACA takes a step in this direction by requiring evidence-based preventive services to be covered without cost sharing, but sensible plan design would similarly encourage ongoing management for chronic conditions such as diabetes, heart disease, and hypertension, without patients first having to exhaust several thousand dollars in out-of-pocket spending."

Sommers B.D. "Health Care Reform's Unfinished Work — Remaining Barriers to Coverage and Access." N Engl J Med 2015; 373:2395-2397<a [] style="margin: 0px 0px 0px 3px; padding: 0px 0px 0px 3px; border-width: 0px 0px 0px 1px; border-left-style: solid; border-left-color: rgb(153, 153, 153); outline: 0px; font-style: inherit; vertical-align: baseline; color: rgb(0, 104, 146); text-decoration: none;">December 17, 2015DOI: 10.1056/NEJMp1509462