Commentary on Managed Care
(licensed vs non-licensed de facto practice of medicine)



"Managed care is a social experiment involuntarily imposed upon a group of unconsenting subjects... the physician and his patient." Anon.

Monday. June 29, 2009

Commentary by
Roger S Case, MD

(Health Officer, Island County & Commissioner, Whidbey General Hospital)


This is the twelfth in a series of commentaries addressing the subject of the funding of (y)our medical care, and what we as wage earners (and businesses) can and must do to regain control of his/her/our healthcare dollar.


Friday, 18 April 1997

  Saturday, 26 April 1997

Saturday, 11 April 1998

Friday, February 15, 2002

Friday, 11 July 2003

Saturday, 7 January 2006

Friday, 10 November 2006

Sunday, 18 March 2007

Wednesday, 13 February 2008

Wednesday, 30 April 2008

Tuesday, 30 December 2008

Monday, 29 June 2009

Sunday, 16 August 2009

Monday, 26 April 2010

Monday, 15 November 2010


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It would appear that reform in the way medical care will be provided in the coming years is inevitable …but not in way most Americans are envisioning. The most superficial look at reform, and the area where everyone’s attention is focused, is in the financing of health care. And while that is an extremely important factor in any health care reform planning, there are fundamental changes in the way in which we will receive our health care over the coming five to ten years — largely due to the effect of these financing changes.

While the cost of health care is spiraling upward, the remuneration to hospitals and health care providers is going the opposite direction. Even now, the provider of health care loses money every time he provides a service to a Medicare or Medicaid eligible patient, and CMS has plans to reduce reimbursements even further. The effects of this is making it impossible for providers to keep recipients of these programs in their client base, making it nearly impossible for these folks to find a provider …so the Emergency Room becomes their "clinic" …and at what a cost (which is often written off as an "uncollectable")!  Are you nearing Medicare age? Is your retirement income enough to afford health insurance?

I spoke of the way that health care delivery systems would change. Here is what I predict will happen over the coming years …and it is not necessarily for the worse, just different.

Electronic Medical Records (EMR) are inevitable …everyone will have one someday. And it will be "portable", available anywhere/everywhere with your permission. This is good. But EMR systems are expensive, and right now they don’t necessarily "talk to each other". So the many EMR systems available on the market become "islands" of interoperability, adopted independently by the many provider clinics across the nation.

Enter the "Big Box storefront urgent care clinic", already existent in many places across our country. They have the big bucks to make a nation-wide EMR available in every one of their store operations, along with the capacity to provide (and growing interest to do so) same-day urgent care clinics staffed by mid-level practitioners with store-system physician oversight. This makes a lot of sense …your health record on tap at "Big Store" nationwide. Travel with the comforting awareness that you can get same day walk-in primary care anywhere "Big Store" conducts business. And they have reduced cost of pharmaceuticals right in the "Big Store" pharmacy.

This is not necessarily a step-down in quality of care — and may indeed yield an improvement in many cases …consistency, access to care, oversight of the quality of care (which does NOT uniformly exist in the private clinic care operations today), and insurance plans that "Big Store" can negotiate with the ever-consolidating INSURANCE INDUSTRY (all of which operate on the PROFIT basis for their stockholders.) INSURANCE is another issue about which I have written in previous commentaries.

Along with this movement toward "Big Box" urgent care same-day access to care will be the simultaneous disappearance of the private practice primary care physician. Finances will drive these folks to become employees of either hospital operated clinics or into specialty medicine. And specialists will organize themselves into Professional Service Corporations, contracting their services to the ever-growing "Big Hospital Systems" that will be buying up the slowly-going-bankrupt smaller hospitals across our country …slowly going bankrupt because of the ever-diminishing remuneration that I spoke to in the second paragraph of this commentary.

These "Big Hospitals" will survive because they have the financial wherewithal to negotiate effectively with "Big Insurance" for the remuneration necessary to provide the services of the specialists they are either able to hire or to contract for services …all ‘BIG BUSINESS". Small local hospitals are unable to compete in this environment, and will eventually become "feeder hospitals" to the "Big Hospital System". I foresee the small district public hospitals slowly being squeezed into nonexistence as local district hospitals because of the constraints of having to provide services to one and all, regardless of the ability to pay for services received, along with the continually diminishing remuneration from Medicare, Medicaid, and the Health Insurance Industry.

This is the larger issue about which I have been writing all the past 12 or so years. Financing of health services would not be the burden that it is today were the profit motivated INSURANCE INDUSTRY not part of the picture. As non-providers of health care, per se, they have absolutely no business in the medical care picture. They have a singular function — the transference of a portion of your premium payment to the providers of care. The rest goes into the pockets of folks who have no real interest in the patient or the providers of health services ...only in the finances (staffs, stockholder returns, etc.).

That is not to say that medical insurance is not necessary. Au contraire, the insuring function is absolutely necessary. It’s just that insurance should be provided by an entity that is uniform in their payment schedules, offering a series of plans to one and all with premiums based on the individuals age and health, with incentive discounts for those who chose to lead healthy lives. No expensive staffs to pay; no corporate CEO to siphon off unseemly huge salaries; no stockholders looking for "a Return On Investment" ...just premiums in, minimum overhead for administration, and payments out to hospitals and  providers of care.

This structure is the State-run (not Federal) single-payer type of insurance program — a form of "self-insurance" at the organizational/county/state level.  All health care premiums, all Medicare premiums, all workers’ health benefit premiums, etc. would be collected by the Single Payer Entity and paid out according to the plan level  purchased by the individual. The dollars are there, just not siphoned away as occurs in our current profit-driven INSURANCE INDUSTRY system. Extra medical benefits for the individual so inclined could be available by encouraging Health Savings Accounts.

Aren’t you tired of all this? It’s no way to run the show. And believe it or not, YOU run the show, if only you would.

Again, only an informed, concerned and enjoined public will be able to effect change. Change is afoot, it is an absolute certainty.  Make sure the change is not for the worse. You have a voice. Use it. Get involved.  It’s your health. It’s your money.  Why let THE INDUSTRY tell you how to invest it? Talk to your local leadership, your state senators and representatives.  Don't let this become a FEDERAL program!!! (Governors take notice! State Insurance Commissioners can require an absolutely level playing field.) "Managed Care" (i.e. Managed Financing) can be accomplished in far a better manner.

If we let this become a Federally run program, kiss it all goodbye! Too much authority in the hands of too few, too far from public scrutiny and/or control.

Roger S Case
, MD, FAAFP, retired Family Practitioner

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