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, November 10, 2006

Commentary by
Roger S Case, MD

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


This is the seventh 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



This is number seven in a series begun in April 1997 to focus attention on the changing world of health care in America… and more directly, here on Whidbey Island, Washington.

Over the past several years we have seen the gradual erosion of the health care provider’s ability to price his services according to the patient’s ability to pay. Now all services have an insurance plan’s designated amount to be paid for a service that has a specific number attached to it, and only a percentage of the listed payment will actually be paid. And there is no uniformity among the insurance company payments, although they all seem to be merging toward the two major payers in America — Medicare and Medicaid, along with Tri-Care, the uniformed service’s payment plan for services obtained in the civilian economy. All these agencies pay pennies on the dollar of services charged, with the latter paying the health care provider in the range of 35% of the billing rendered.

As I reported in my last commentary, insurance carriers are nothing more than a transfer agent for funds from your premium payments to those providing services to you — with a significant amount removed for their doing so for their stockholders, their staffs, and the costs of transferring your premiums (administrative overhead). While this may be convenient for you, the premium payer, it is an exceptionally inefficient (expensive) way of obtaining an increasingly difficult-to-obtain range of services from a rapidly diminishing pool of privately practicing physicians.

All this is prelude to the crux of an ever-growing problem… the changing environment of medical care in America — especially as it relates to the primary care provider (the person we all knew as ‘doctor’ 30+ years ago). The Family Practice physician shortage is estimated at around 20,000 today, and will become even more critical in the coming years. Some FP residencies have closed, and the growing trend for medical students is to go into higher paying residencies and practices. It is becoming increasingly difficult to recruit primary care physicians to rural communities, and a growing number of primary care practitioners are electing to have office practices only — no inpatient hospital care.

There are pluses and minuses to this situation. The pluses may include the trend to have hospitalists — health care providers that practice only in hospitals. While this may provide a more uniform quality of service to inpatients, recruiting such practitioners to small hospitals will be difficult. Specialty practices will thrive, but the primary care environment will drastically change.

The minuses include the gradual disappearance of the physician from the suburban and rural communities. Midlevel primary care providers, Nurse Practitioners and Physician’s Assistants, will replace them, and gradually, the "doctor’s office" will be replaced by large store-front operations that will hire mid-level health care providers to augment their pharmacy operations, making it convenient for patients to shop while awaiting their appointment, and to pick up their prescriptions immediately after their appointments. Electronic medical records will make it convenient to maintain continuity of care in such a practice environment, and perhaps computer-assisted kiosks will provide much of the routine question-and-answer dialog required in diagnosis. While the latter may perhaps be more inclusive in arriving at diagnoses, much will be lost in the uniqueness of the doctor-patient relationship.

All this goes to alert everyone that the "non-system" of medical care in our country will soon be changing in a rapid sequence necessitated by the economics engendered by the growing numbers of the uninsured, the under-insured, the higher costs of the biologic medicines coming on the scene, and the failure of the premium payer (that’s you and I… and business) to formulate a more efficient and effective system of health care for everyone.

A word to the ‘boomer’ generation. You will soon be reaching the Medicare age. You are used to having things your way… but medical care is not Burger King. Be prepared for the change.


Roger S Case
, MD, FAAFP, retired Family Practitioner

Addendum: Please read this article from the 4 June edition of the LA Times entitled "Physician Shortage Looms, Risking a Crisis as Demand For Care Explodes"

(Can't find this file? I have it in a pdf file ...or Word file)

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