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Health

"Managed" Care

A euphemism for rationed or denied care.

The Physician is literally punished financially, and often emotionally, by utilization committees whose job it is to review each and every expenditure for a diagnostic test, a specialty physician consultation or referral, and for treatment, itself! See the Health Law Site for definitions of different types of payor arrangements.

Hospitals are being forced to cut back on vital services and nursing care in order to stay solvent due to financial pressures from all variety of governmental (Medicare, Medi-Cal, Medicaid) and private (Blue Cross, HMOS, PPOs, EPOs, IPAs, etc.) payors who grind-down contracted reimbursement to levels which do not allow clearing the overhead of even routine care. Hard to believe, but true! If Physicians or Hospitals get together to fight the insurers, they are accused of violating anti-trust laws; the insurers are exempt from these laws, however--NOT FAIR, but reality!! In the final analysis, only the patient truly suffers! The patient is not generally educated in medical matters , and has to trust in the System, while the insurers steal the premiums and minimize expenses by not giving appropriate care, not paying the Physicians, and retaining huge sums to pay million dollar executive salaries, and donate even larger sums to pet charities and to political organizations (to help garner support for this new standard of non-care).

The patient no longer owns an insurance policy. The insurance company now owns the patient's life and welfare. In fact, when contracts are made with health providers, physicians and hospitals, the terms and language used reveal their contempt for the humaness of the patient, for example: "we bought 2,000 lives" or "we are contracted for 10,000 bodies."

Some Quotes from our Readers:

David C. Murphy, Ph.D.: "I think the real way to break the powerful grip of the insurers is through massive political organization of both patients and doctors."

Paul J. Sheya, M.D.: "We are a rural, medically underserved area...and have been faced with insurance mechanisms which steer patients out of their own town for health care (the nearest facility is 90 miles away). To counter this, we've begun an employer education seminar series to educate the employees and employers in the reality of insurance marketing, the various types of insurance (many of which are drying up) and what steps can be taken by the employer to improve local access to health care."

Lee Carter, VP & Chief Information Officer, 150,00 member mid-west physician-owned HMO serving "over 1 in 3 people in our community.":
"As a consultant and now an executive, I have NEVER been involved with a case where the best interest of the patient was not primary. The patients are, after all, my friends and neighbors in many cases."
"Do we limit services? Yes we do. I care about how much health care costs. Many people struggle to make the payments for their health care. There must be a balance between reasonable health care expenditures for proven treatments and excessive costs for experimental treatments and over used tests and procedures. We CANNOT pay for every service for every person-no one could afford this."
"I have attended grievance committee meetings where people can appeal a denial. Very very rarely do denials get overturned. Most denials relate to purely elective surgery, coverage that THEIR EMPLOYER chose not to cover or the simple cases of people not going to a 'plan' physician as it is clearly stated in their handbook."

Managed Care Definitions:

  1. Organizations:

    Health Maintenance Organization (HMO)

    An organization which offers a comprehensive set of health benefits on a prepaid basis (premiums). Unlike traditional insurance, HMOs provide services DIRECTLY to patients either by employing or contracting with physicians, hospitals, and providers of ancillary services. They often own their own hospital and outpatient facilities with everyone within its walls being an employee-such as Kaiser Permanente. Here, the organization that collects the premium from the individual patient, controls whether or not a service is "necessary," and then renders the service-a clear conflict of interest; the organization keeps the premium, and makes a larger profit only is less or less expensive care is rendered. Often, physician services are provided by non-physicians to further save on cash outflow.

    Independent Practice Association (IPA)

    An association of physicians practicing independently, usually in their own offices, and who provide services to HMO members. The Physician, in this case, contracts only with the IPA which in turn contracts with many HMO organizations. The Physician has no direct contract with the HMO itself, only with the IPA; it is the IPA who pays the Physician a set, agreed upon amount, for each service. The IPA makes a profit by making profitable contracts with the HMOs, and then restricting care in the same way that the HMO does, only, here, the patient gets to keep the same Physician they have been seeing for years--the same deal, but cozy, and less threatening. It is here that the "Gatekeeper" concept evolves. All patients are essentially owned by the IPA thru the "Gatekeeper" who makes all health decisions for the patient: whether or not a visit ot the Hospital Emergency Room was justified, whether you need that hernia repaired, whether you need to have a treadmill-"Maybe, I'll do it in my own office, before we send you to the Cardiologist," and procedures which are performed by Specialists with long years of training, and real experience, are now done in the office of and by the "Gatekeeper," who is, invariably, a family practice Physician/entrepreneur.

    Preferred Provider Organization (PPO)

    This is a "discount for volume" arrangement wherein Physicians, hospitals, and other providers contract with an insurer, third party administrator, or employer medical group, to provide health care services for a negotiated payment level. Often, patients are punished financially, if they go to Non-Particpating Physicians or hospitals. Usually, as well, the Physicians and hospitals work together to generate these contracts, to bring patient volume ot a particular hospital or medical community, with financial arrangements which are generally more favorable to them than the IPA or HMO arrangements. You, as a patient, will generally get a better quality of health care under this arrangement than with the other, HMO, or IPA choices.

    Point of Service (POS) Plan

    May be referred to as an "Open-Ended HMO". These plans enroll patients, referred to as "beneficiaries," as in an HMO, and contract with a network of Physicians and hospitals who give them a favorable fee structure. There is more freedom of choice, here, since the patient can see Physicians and go to hospitals which are "out-of-network," but, of course, at an increased out-of-pocket expense to the patient.

 

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All materials are the opinion and exclusive property of Frederick G. Schechter, M.D., 
OnPump Copyright© 1995-2004. All rights reserved.
Revised: July 20, 2004 .