Chapter 1.C.3--Managed Care and Consumer-Driven Health Care
The Community Tracking Study issues very useful reports about current marekt
developments, at www.hschange.com.
Health care reform has launched a major rethinking of the fragmented structure of health care delivery organizations and institutions. Rekindling interest in managed care, this movement adopts different acronyms to promote what policy advocates hope will be more "accountable care organizations" and "patient-centered medical homes," along with reformed payment methods that reward better care a lower costs. According to the always pithy Jeff Goldsmith, “The problem with this movie is that we’ve actually seen it before, and it was a colossal and expensive failure.” The Accountable Care Organization: Not Ready For Prime Time.
One important difference this time around is that ACOs are being conceived of in a “virtual” as well as “actual” form. A virtual form allows various unaffiliated providers to be held jointly accountable for a group of patients without their forming an actual corporate entity. Providers are linked based on naturally existing referral patterns among primary care physicians, specialists and area hospitals, and they receive incentive payments based on their collective performance. The structure is invisible to patients, who may still go to any doctoror hospital they want.
The new Center for Innovation in CMS and the Independent Payment Advisory Board (IPAB) are expected to lead the way in developing, testing and disseminating new forms of provider payment that reward higher quality and lower costs. Both are focused on Medicare and Medicaid, but private insurers are expected to adopt the more successful approaches, and the structures that form for purposes of public insurance can also be used for private insurance. See generally Symposium, 29 Health Aff. 1284 (2010); Stuart Gutterman, et al., Innovation in Medicare and Medicaid Will be Central to HealthReform’s Success, 29 Health Aff. 1188 (2010).
Various aspects of this managed care revival are discussed in later chapters. For general overviews and analyses, see: Francis J. Crosson and Laura A. Tollen, Partners in Health: How Physicians and Hospitals Can Be Accountable Together (2010), which is excerpted here; Einer Elhauge, ed., The Fragmentation of U.S. Health Care: Causes and Solutions (2010); Kim H. Roeder, The New Healthcare Delivery System: What Are Medical Homes and Accountable Care Organizations? (American Health Lawyers Association, 2009); MedPac Report to Congress, Improving Incentives in the Medicare Program (June 2009); E. Fisher, et al., Fostering Accountable Health Care, 28(2) Health Aff. w219 (Feb. 2009); Center for Healthcare Quality and Payment Reform; Kelly Devers & Robert Berenson, Can Accountable Care Organizations Improve the Vlaue of Health Care . . . (Urban Institute 2009); Maria Currier & Morris Miller, Medicare Payment Reform, 22(3) Health L. 1 (Feb. 2010); Diane Rittenhouse, et al., Primary Care and Accountable Care: Two Essential Elements of Delivery-System Reform, 361 New Eng. J. Med. 2301 (2009); Jeff Goldsmith, Analyzing Shifts in Economic Risks to Providers in Proposed Payment and Delivery System REforms, 29 Health Aff. 1299 (2010); Symposium, 25(6) J. Gen. Intern. Med. 584 (June 2010); Symposium, 27 Health Aff. 1218 (2008); Symposium, 67(4) Medical Care Res. & Rev. (Aug. 2010).
For legal and practical issues, see Bill
Asyltene, et al., Accountable Care Organizations: Physician/Hospital Integration, 21(6) Health Lawyer 1 (Aug 2009); Douglas
A. Hastings, Constructing Accountable Care Organizations: Some
Practical Observations at the Nexus of Policy, Business, and Law, 19
BNA Health L. Rep. 883 (2010); Robert Leibenluft & Wm. Sage,
Overcoming Barriers to Improved Collaboration and Alignment: Legal and
Regulatory Issues, in Crosson & Tollen, Partners in Health supra (2010); Anne Claiborne et al., Legal
Impediments to Implementing Value-Based Purchasing in Healthcare, 35
Am. J. L. & Med. 442 (2009).
Consumer Driven Health Care:
Treasury Department has a useful website on Health Savings Accounts, at http://www.treas.gov/offices/public-affairs/hsa/.See
also Paul Fronstin and Sara R. Collins, Early Experience
With High-Deductible and Consumer-Driven Health Plans (Commonwealth Fund, Dec.
2005); U.S. GAO, First-Year
Experience with High-Deductible Health Plans and Health Savings Accounts
(Jan. 2006); U.S. GAO, Early Experience with a
Consumer-Directed Health Plan (Nov. 2005).
Regarding consumer-driven health care, see Carl Schneider & Mark Hall, The Patient Life: Can Consumers Direct Health Care? 35 Am. J. L. & Med. 7 (2009); John A. Nyman, Consumer-driven health care: moral hazard, the efficiency of income transfers, and market power, 13 Conn. Ins. L.J. 1-17 (2006-2007); James Robinson & Paul Ginsburg, Consumer-Driven Health Care: Promise and Performance, 28(2) Health Aff. w272 (Jan. 2009); Symposium, Realizing True Consumer-Directed Health Care: What the Policy Community Needs, 66 Med. Care Res. & Rev. 3S (Feb. 2009); Amal Trivedi, Increased Ambulatory Care Copayments and Hospitalizations among the Elderly, 362 New Engl. J. Med. 320 (2010); Thomas Buchmueller, Consumer-Oriented Health Care Reform Strategies: A Review of the Evidence, 87 Milbank Q. ___ (2009).
Medical tourism -- traveling to other countries to obtain cheaper care -- is a new development receiving increased attention. See Nathan Cortez, Recalibrating the Legal Risks of Cross-Border Health Care, 10 Yale J. Health Policy L. & Ethics 1 (Winter 2010); Nathan Cortez, Patients without borders: the emerging global market for patients and the evolution of modern health care, 83 Ind. L.J. 71-132 (2008); Nicolas P. Terry, Under-regulated Health Care Phenonmena in a Flat World: Medical Tourism and Outsourcing, 29 W. New Eng. L. Rev. 421 (2007); Kerrie S. Howze, Medical Tourism: Symptom or Cure?, 41 Ga. L. Rev. 1013 (2007); Thomas R. McLean, The Offshoring of American Medicine, 14 Ann. Health L. 205 (2005); Comment, 28 J. Legal Med. 223 (2007); Comment, 28 J. Leg. Med. 223 (2007); Note, 20 (5) Health Law. 42 (2008); Note, 70 Law & Contemp. Probs. Spring 211 (2007); Note, 18 Kennedy Institute Ethics J. 193 (2008) (bibliography); Symposium, Medical Tourism Meets Health Law: US-EU Dialogue. 26 Wis. Int'l L.J. 591-964 (2008).
The following are some of the better selections of managed care humor and parodies that have come to our attention:
Welcome to Managed Friendship, a whole new way of thinking about friends and relationships. The Managed Friendship Plan (MFP) combines all the advantages of a traditional friendship network with important cost-saving features.
How Does It
Under the Plan, you choose your friends from a network of pre-screened accredited Friendship Providers (FPs). All your friendship needs are met by members of your Managed Friendship Staff.
Wrong with my Current Friends?
If you're like most people, you are receiving friendship services from a network of providers haphazardly patched together from your old neighborhoods, jobs, and schools. The result is often costly duplication, inefficiency, and conflict. Many of your current friends may not meet national standards, responding to your needs with inappropriate, outmoded, or even experimental acts of friendship. Under Managed Friendship, your friendship needs are coordinated by your designated Best Friend (BF), who will ensure the quality and goodness of fit of all your friendly relationships.
How Do I
Know That the Plan's Panel of Friends Is Not Made Up of a Bunch of Losers Who
Can't Make Friends on Their Own?
Many of today's most dedicated and highly trained Friendship Providers are as concerned as we are about delivering Quality Friendship in a cost-effective manner. They have joined our network because they want to focus on acting like a friend rather than doing the paperwork and paying the high bad-friendship premiums that have caused the cost of traditional friendship to skyrocket. Our Friendship Providers have met our rigorous standards of companionship and loyalty.
What If I
Need a Special Friend, Say, for Poker or Fishing or Shopping?
Special Friends are responsible for most of the unnecessary and expensive activities that burden already costly relationships. Under the Managed Friendship Plan, your Best Friend is qualified to pre-approve your referral to a Special Friend within the Managed Friendship Network should your needs fall outside of the scope of his/her friendship.
Want to See Friends Outside the Managed Friendship Network?
You may make friends outside of the Managed Friendship Network only in the event of a Friendship Emergency.
What is a
The Managed Friendship Plan covers your friendship needs 24 hours a day, 365 days a year, even if you need a friend out of town, after regular business hours, or when your Best Friend is with someone else. You might be on a business trip, for instance, and suddenly find that you feel lonely. In such cases, you may make a New Friend, and all approved friendly activities will be covered under the Plan, provided you notify the Managed Friendship Office (or 24-hour Friendship Hotline) within two business days.
What Friendly Activities Are Covered Under
- Agreeing with you
- Appearing sympathetic
- Chewing the fat
- Dropping by
- Feeling your pain
- Hanging out
- Holding your hand (up to 5 minutes per activity)*
- Kidding around
- Listening to you whine
- Passing the time
- Patting your back
- Sharing a meal
- Shooting the breeze
- Slinging the bull
*up to 15 minutes under the Premium Gold Friendship Plan
Friendly Activities Are Not Covered Under the Plan?
- Bar hopping
- Bending over backwards
- Drinking to excess
- Giving a hoot
- Going the extra mile
- Lending money
- Real empathy
- Sexual favors
- Truly caring
- Using illicit drugs
A managed care company president was given a ticket for a performance of Schubert's Unfinished Symphony. Since she was unable to go, she gave the ticket to one of her managed care reviewers. The next morning she asked him how he had enjoyed it. Instead of a few observations about the symphony in general, she was handed a formal memorandum which read as follows:
Q: What does HMO stand for?
A: This is actually a variation of the phrase, "Hey, Moe!" Its roots go back to the concept pioneered by Dr. Moe Howard, who discovered that a patient could be made to forget about the pain in his foot if he was poked hard enough in the eyes. Modern practice replaces the finger poke with hi-tech equivalents such as voice mail and referral slips, but the result remains the same.
Q: Do all diagnostic procedures require pre-certification?
A: No. Only those you need.
Q: I just joined a new HMO. How difficult will it be to choose the
doctor I want?
A: Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors who were participating in the plan at the time the information was gathered. These doctors will fall into two basic categories: those who are no longer accepting new patients and those who will see you but are no longer part of the plan. But don't worry--the remaining doctor who is still in the plan and accepting new patients has an office just half a day's drive away.
Q: Can I get coverage for my pre-existing conditions?
A: Certainly. As long as they don't require any treatment.
Q: What happens if I want to try alternative forms of medicine?
A: You'll need to find alternative forms of payment.
Q: I think I need to see a specialist, but my doctor insists he can
handle my problem. Can a general practitioner really perform a heart transplant
right in his office?
A: Hard to say, but considering that all you're risking is the $10 co-payment, there's no harm in giving him a shot.
Q: My pharmacy only covers generic drugs, but I need the name brand. I
tried the generic medication and it gave me a stomach ache. What should I do?
A: Poke yourself in the eye.
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