Managed Care is a business operation premised on controlling access to “providers” and setting rates for medical services available to patients. We, so far, agree that consumers are in the dark about how a given third party payment program will affect them in the face of personal health care needs.
Yet, given 2014 IT capabilities, there is no technical reason why health care consumers, employers, brokers, physicians, governments or anyone should be(technically) unable to instantaneously know the “rules of the road” for access to specific health care “providers,” the costs of such services, and what a designated third party or patient will actually pay for these services. We all agree there is no such thing as free health care. Someone pays. So who decides who pays, for what, and how much?
A key policy question: Who controls access to this information, and (at what price and for what reasons) is this information systematically withheld from or offered to consumers (patients and their families)?
Patients and insurance plan enrollees must have accurate and timely information for there to be a true health care marketplace.
Some argue that a medical care marketplace is neither possible or desirable (See Arrow, K., Uncertainly and the Welfare Economics of Medical care. American Economic Review 1963;53(5);141-149) Others hold that there is a market for coverage when health plans compete for clients. And others, such as MPPA, want a marketplace for both provider Direct Pay and insurance coverage protection.
Theses are themes of the political season’s health care debate.
Sent: 7/25/2014 1:29:55 P.M. Central Daylight Time
Subj: Fwd: Health Care Empowerment: Lessons and Needs
From Kip Sullivan:
I’ve commented before on the impossibility of strong competition at the insurer level as long as insurance companies restrict patient choice of doctor and type of treatment.Comparing the quality of insurance policies prior to the advent of managed care was not easy, but it was possible. With the advent of managed care, it is now impossible for anyone — including brokers — to divine in advance which treatments are actually covered by a policy, which doctors are subjected to which incentives, and which clinics and hospitals are “in network.” I have actually tried to get HealthPartners to tell me how “managed” their policies are. It’s like asking a mule for directions to the nearest gas station. It’s just a waste of time.I’m willing to state very clearly that a single-payer system with managed care grafted onto it is a severely compromised single-payer system, perhaps not one worth fighting for. Why can’t you do the same for your market-based proposals? Why can’t you get in the habit of warning readers that competition between insurers can only be possible if managed care is rolled back, and if it isn’t, competition is severely compromised?Kip SullivanOn Thu, Jul 24, 2014 at 12:30 AM, Dr. Robert W. Geist <email@example.com> wrote:Lee, fine post. You have all the right questions. We need the answers!Complexity in buying insurance is a problem, but that’s why we have professional insurance broker expertise—Mike Myers missed this.Complexity is a problem in medicine, but that’s why we want a professional doctor expertise for our care.On another level you noted that one serious threat to patients is when a 3rd party can coerce doctors into being bedside corporate gatekeepers, who are paid contingent on the volume of care ordered—bonuses are paid when they “spend” less corporate money on patient care. This is behavior pay and not pay for patient services.And what is behavior pay? It is, “money or favor given or promised to a person in a position of trust to influence his judgment or conduct”: that’s the definition of a bribe [Webster’s New Collegiate Dictionary. 10th edition. “Bribe.” Springfield, MA: Merriam-Webster Inc.; 2000:142.]. The managed care industry even brags about changing behavior! Docs paid for behavior pleasing to a 3rd party are no longer professionals. They are only double agents playing the dual roles of corporate underwriters carrying stethoscopes.What is of interest is that most players in a corrupt system have no insight and are personally not corrupt. This happens when the corruption of language comes first. The ‘New” system is justified as the necessary means (“bonuses” for decreased “utilization”) to achieve some glorious end (cost control). Language is corrupted when sophistry, such as “value” or “quality” pay, is used to cover up 3rd party bribes to double agent gatekeepers at the bedside.A system is corrupt when 3rd party incentive bonuses for volume of referrals are legalized. Fee splitting “incentive” bonuses for increased volume of referrals amongst providers have been illegal for over 100 years—the public recognized the threat of bribes, when their life was at risk. Would they be referred just for the money or to the surgeon paying the biggest split fee rather than the most competent?However, since the HMO Act of 1973 and ObamaCare after 2010, “incentive” bonuses for decreased volume of referrals (and increased self-referrals) have been legalized. “Incentives” failed to control costs the 1st time, because they address the problem of cost-price inflation by rationing care supply, when the problem is tax-subsidized “free” care demand. Nobody ought to trust fatuous economics and the subsequent fatuous inflation “cures” that depend on “payers” (corporate or government barons) paying “bonuses” to bedside gatekeepers to protect their treasuries. There is a way out of a corrupt system, but the corruption must be recognized first.Thanks, Lee.BobRobert W. Geist MD
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