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.

Saturday, 26 April 1997

Commentary by
Roger S Case, MD

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

This is the second of a series of commentaries that will speak to the subject of the funding of medical care, and what the average citizen (and businesses) can and must do to regain control of his/her 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


  Top of Pg.


“It’s time for a change. The individual paying the bill should be the one directing the show.”

That’s the charge I left with you at the close of my recent commentary on Managed Care. Have you thought any more on the subject? You had better. The changes facing you today regarding who will see you, how and where you will be seen — even if you will be seen — are almost totally in someone else’s hands. Yet you are paying the bill. How does that set with you? Very poorly, I suspect. So what is all this concern I have with Managed Care? Let me expound. You, too, may be concerned.

Employers have experienced spiraling costs in providing medical insurance for their employees, due in large part to the increased expectations for the best medical care available at all times for every insured individual. This means state-of-the-art service at all times. And that costs dearly. So what has happened on the way to providing this level of service for everyone? Managed Care has happened, that’s what. But this is a misnomer… it is more appropriately called Managed Medical Expensing.

Insurance “Plans” have been enrolling clients into their ‘programs’, promising an array of benefits to entice folks to join their Plan. They keep costs to a minimum by reducing payments to hospitals and physicians, setting payments so low that many physicians face losing money by seeing the very patients who need most to be seen. Plans like to sign up everyone, but the medical system can now afford to see only the healthier individual, losing money on those requiring frequent visits. How healthy are you?

This is compounded by the Plans’ acquiring a panel of primary care and specialty physicians whom the Plans will reimburse. Other physicians and providers not on that panel will not receive payment by the Plan for seeing anyone. That is why you may occasionally be referred to a physician whom you do not know… and who may even be unknown to your referring physician! Is this good medical care? It may be, but I don’t think so… I don’t know. Does your doctor know? Is this what you want? I certainly don’t.

All this happens in the name of managing the cost of providing care. But I say again, “Cost to whom?”

The major participants in all this — the patient and the physician — are being dictated to by the Managed Care Plans, none of whom have any stake in the game except to take in premiums and to pay out fixed payments, regardless of the amount of care required by the patient. And of course they keep a sizable portion of the premium for the work incurred by managing the financing, all the while absolving themselves of any risk. And if they don’t make enough, they either raise the premium or reduce payment to the hospital/ provider. Seem fair to you? It doesn’t seem so to me!

There is a better way of doing this, folks. It’s time to really get involved before you find out too late that what you have is not what you thought you were buying with your medical premiums. Speak with your employers, your medical providers, the hospital you support, and your family. Decide what it is you really want, and then demand it. You’re paying the fiddler — both financially and health-wise — so you should be calling the tune. Remember, insurance companies are really in business to earn money for their stockholders… they make profits for their investors with your premium payments.

You and your health care provider are the only ones truly involved. Talk to him/her and learn how best to get what you want. Talk to your employer/union and insist upon what you need. Talk with your elected representatives to demand an end to the rip-off being run by the Managed Care insurance industry that has taken themselves right out of the risk business by placing it all upon you and your providers of care.

Is someone’s hand in your pocket? Do you hear someone laughing? … it’s the Managed Care industry (i.e., Health Insurance Companies).

Roger S Case
, MD, FAAFP, retired Family Practitioner

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