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.

Friday, July 11, 2003

Commentary by
Roger S Case, MD

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


This is the fifth 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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Each person has a right to know everything about their managed care plan, and they can, with their physician’s counsel, select that program which best serves their needs. It is incumbent upon each person to inform him or herself — to learn all that they can about this very important factor in their life — and to select their medical insurance very carefully… very wisely.

The move to a consumer-driven health care system will not happen without business leaders, health care providers, and the consumer all working to make this type of service and consumer accountability a reality. This is that ‘better way’ I spoke of in my second commentary in 1997. The consumer has always paid the bill… its time (s)he begins to direct the show. Don’t you agree?  

Its been almost 18 months since my last commentary on "managed care". . . which is really an access-to-medical-care issue. Unfortunately for more and more folks, this is becoming a real nightmare issue as the financial burdens for medical care providers is either forcing many providers to limit their services, limit whole segments of folks from their practices (are you a Medicare beneficiary?), or to even induce many providers to retire.

Until the general public and business leaders decide to force our legislators at both the state and federal levels to responsibly address two major issues facing the health care industry, access to care is going to continue becoming less obtainable for whole segments of our population, beginning with the less fortunate and/or the elderly of our communities. . . in fact, it is already a reality for these two groups, and only a matter of time before everyone will find themselves shopping for quality health care that just won't be available unless you have the personal finances to accommodate your needs. And by this, I don't mean health insurance — which is really no assurance for access to care).

The two major issues that must be responsibly addressed... and right now:

1.      Tort reform  Redress for having been wronged by medical practitioners has become a lottery which is encouraged by certain trial lawyers (and more are joining the feeding frenzy). Certainly it is appropriate to be able to recoup actual financial loss, and to effect some financial redress from the responsible party. Reasonableness, if you will, has all but disappeared, however. Remember the McDonald's hot coffee case? Anyway, the lottery effect of malpractice rewards from juries has caused malpractice insurance to skyrocket for everyone connected with health care... to the point that many practitioners are limiting their care or retiring early. Meanwhile, trial lawyers are becoming wealthy as they bring suit against providers, many of which are frivolous (but costly to defend), and sometimes even without the knowledge of the patient. (Historically, only about 20% of malpractice suits are won by the plaintiff. But all this drives cost up and up.)  

A cap on non-financial loss is absolutely necessary to stop this escalation. Recently introduced legislation recommends a cap of $250,000 as being appropriate. The House of Representatives in March 2003 passed such a bill that includes a $250,000 non-economic damages cap. . . and a more recent Gallup poll shows that 72% of Americans favor caps on non-economic damages.  Talk to your doctor... talk with your legislators.

2.      Uniformity in Medicare Payments    At present, payment for services for Medicare recipients varies across the nation. The same service in New York will be reimbursed at a considerably higher rate than in Washington State... higher in Seattle than in Oak Harbor... even though the service is exactly the same. Locally, the reimbursement rate pays only about 52% of the charges, not even covering the actual cost of the service. It is no wonder that an increasing number of providers do not take new Medicare patients when it costs more to see them than they will receive in payments. And reimbursement for Medicaid Recipient care is at an even lower percentage of charges!

Do you ever think about these things? Or does it only come to mind when you need medical care. How can your hospital remain in business if physicians leave the community or limit their practices? How can any office or hospital continue to provide care if they do not receive payments that cover their cost of providing that care? Your buying health insurance does not solve the problem, either . . . only lulling you into thinking you have access to the care you think you have "purchased". What if you cannot find a physician who will see you?

This country is facing a medical care crisis that only you, the public, can address. You can do so by becoming informed and then acting on that information. Much of what occurs today in health care is directed by the government and/or insurance companies... and will not change if the public remains uninformed/apathetic. 

If you don't clearly understand all this, you must take the time to inform yourself before you find you don't really have the service you think you have. Talk frankly to your provider of health services. Learn who will provide your specialty care. Does your physician actually know the folks to whom he might refer you? Is obstetrical care you want really available locally? Orthopedic services? How about dental care?

It’s your health, your health care dollar and your access to health care that we're talking about here. And one day you may find yourself in one of the two categories mentioned in the first paragraph. How you address issues 1 & 2 today will largely determine how you will obtain your health care tomorrow.

And again, seriously think about a single-payer system of medical care for at least our state, if not nationally… the efficiencies of such a plan far outweigh the multitude of “Health Insurance Plan” variations and inefficiencies that we must deal with today. After all, much of your premium dollar ends up paying for the construction and maintenance of insurance company buildings (ever see any of these in the city?), salaries for insurance company staff, corporate leadership, and stockholders... none of whom provide anything toward your health care. Don't you think your health care premium could be put to better use? I certainly do!

Roger S Case, MD, FAAFP, retired Family Practitioner

From Medscape Medical News 2003:
"Overhaul of Medical System Should Focus on Risk Assessment and Prevention"
also, please read
    by George C. Halvorson & George J Isham, MD

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