In a message dated 97-08-18 14:40:50 EDT, (D ROSEN) writes:
> What exactly IS managed care?
>
I just thought everyone knew! I guess those of us in the medical profession
forget that the whole world doesn't think about insurance companies all day
long.
Here goes:
Managed care is the current term for insurance companies that try to run our
practices. Theoretically, I suppose, it refers to the process by which
insurers try to save money while still ensuring adequate medical care for
their clients. This is done by monitoring the care patients receive by
reviewing charts periodically, keeping track of procedures done for each
patient and by each doctor, and by keeping track of referrals to specialists,
or requiring insurance company approval of such referrals. Many companies,
especially most HMOs (Health Maintenance Organizations) require each patient
to have a PCP (Primary Care Physician) who is in charge of their care. All
referrals for specialists, hospitalizations, labs tests, xrays must originate
with the PCP. This is generally referred to as a Gatekeeper. The PCP often
has financial incentives to keep the referrals to a minimum. We've tried to
stay away from those plans, but it's getting very hard to do this. The
insurance company sets up a fund from patient premiums, or from money
withheld from the physicians payments to pay for all these extras. If there
is money left over at the end of a quarter or year, it's given back to the
physician. The companies each have their own list of approved providers--you
have to sign a contract with them in order to see their patients. The
contract specifies all the above details, as well as how much we get paid.
We are not allowed to bill the patients for anything other than whatever
deductible and copayments are specified in their contract with the insurer.
There are vast differences among the insurance companies ("managed care
organizations"--MCOs) as to how they implement managed care. Some are more
liberal than others, and some are very restrictive. The ones that charge the
lowest premiums are usually the most restrictive, and hardest to deal with,
but end up with the most patients, because the patients have no idea how
managed care works. This forces us, as providers, to deal with these
insurers, since they have the patients.
I could go on all day, but I think that's enough for now.
Moshe Adler, MD