Managing Managed Care

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

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Saying "No!" (In the Style of Managed Care)

Managed care (or a reasonable facsimile) is "still with us….its role is certain to grow" and its "appeal is financial." Tyler Cowen, a professor of economics at George Mason University, in "Managed Care: Get Used to It" writes that national bankruptcy would be considerably worse that managed care, even with all of its warts and "that’s where we’re heading if we don’t rein in health costs."  Clearly, "third parties — the government and insurance companies — won’t be able to pay for all the care t

Docs To Take a Big Pay Cut

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Dear Doctor, "They're just kicking your Medicare fees further down the road." Attached to a bill that extends unemployment, certain other benefits and subsidies for another month is a reprieve* to this October on a threatened 21% cut in Medicare physician reimbursement.  Thus, Congress again has failed to address a known flaw in the Medicare rate setting formula--the annual planned rate reduction that is deferred yearly at the last minute. 

Obesity's Massive Impact

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In a given year in the U.S., 1/4th of US men and 2/5ths of US women attempt to lose weight or keep it off. These are sobering statistics that we see all around us, particularly poignant in my office as a pediatrician. 

Possible Approaches to Spending Reform

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Clearly spending reform is not only part and parcel to "affordable insurance but also as the preeminent long-term threat to the economy and the competitiveness of American business."  The article referenced below discusses policy options and various approaches to cost containment.  1) Bundled Payments as in episodes of care, 2) all-payer hospital rate setting, 3) Disease state management programs, 4) Infrastructure-related options that form the foundation for other efforts or options.  Included

Access Problems

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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.?

Saying No, Well

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Clearly, not fulfilling patients' requests diminishes their satisfaction, but patient-centered communication can enhance that. So what is one to do? Being adept at saying "no" is an art; it should preserve, if not amplify a practitioners' interest in and concern for their patient. This article describes ways of negotiating with patients about specific requests for diagnostic testing, treatment, on-going or changing care.

Watch a Doc's Pay Drop

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You're getting squeezed and want ideas.... The recession has eroded health insurers' profits; they then lower practitioner reimbursement. Layoffs mean fewer enrollees in company-sponsored plans and less premium revenue for insurers. Reimbursement for E&M services declined by 7.3% on average; 99213, the bellwether CPT Code, fell to $65.49.  E&M reimbursement for private payers declined, esp. in the Mid-Atlantic region, however it improved in Medicare. 

Horse Poop or Fertilizer

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With the story: "Democrats consider dropping insurance ban on pre-existing conditions," we learned that kids under 19 years of age wouldn't be denied coverage for preexisting conditions.  Why? Because everyone over 19 will be denied coverage! The following is a particularly poignant blog extract: January 25, 20102:04:30 PM EST, Fredrick H (a triple doctor) comments:

Singulair v. Steroids

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Observation: children with mild to moderate acute asthma had been stabilized in the ER; upon discharge they received montelukast (Singulair] or oral prednisolone; those receiving the latter, the oral corticosteroids after discharge did better. Study Abstract Objective  To examine whether outpatient post-stabilization therapy with montelukast produces more treatment failures than prednisolone.

'My Patients are Sicker' Bias

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The common retort when confronted with the escalating cost of care and unexplained variation is: "But, my patients are sicker! Southerland, Fisher and Skinner in "Getting Past Denial — The High Cost of Health Care in the United States," are again observing their mentor, Jack Wennberg's dictum, written about extensively at the end of the last century and earlier, that the cost differences between regions and practices may be unwarranted.

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