Topic B: Managed Care

Question 1  What does managed care do well?

Answer: Well-run managed care programs can organize routine care and preventive services effectively, if they do not squeeze the providers of that care too hard.

However, much of this work is done by physician extenders, not by physicians themselves. It is more difficult for the patient to develop a relationship with a particular patient in this kind of system, and it is likewise more difficult for the physician to bond to a particular patient.

By limiting expenditures, insurance companies can make care more affordable and available to more people. Unfortunately, in limiting expenditures, managed care must also limit the care itself. Over the past four years, while managed care has proliferated, the number of uninsured individuals in the United States has actually risen rather than fallen. So one of the great promises of managed care goes unfulfilled.

Question 2  What is the best kind of patient for a managed care plan?
Answer: The best patient is a healthy person who does not need much medical attention. As soon as the patient becomes ill, that person is a liability to the plan, rather than an asset. Every test and procedure is a cost to the plan, rather than a source of income. The inclination to go all out for an individual patient is significantly compromised under managed care. However, under the old system, incentives worked in the opposite manner, sometimes driving physicians to do too much.

In managed care, profit does not come from doing more, but from doing the least which can be demonstrated to be cost effective for a population of patients. The rationale for giving extensive care from the standpoint of the health plan is that not to do so would be still more expensive. The decision is not made on the basis of what is best for an individual patient, but on the basis of what is best for the plan or for a large group of patients.

Question 3  Does managed care help people by shortening hospital stays?
Answer: By and large, the answer is yes. Under the old system, neither hospitals nor physicians had incentives to be efficient with the hospitalized patient. Tests and procedures were scheduled at a leisurely pace. Hospital days are extremely expensive, compared to outpatient care. Greater efficiency in providing hospital care has saved a lot of money.

However, the point has been taken to extremes in some cases, pushing people out who are not ready to go home. For example, state legislatures have had to step in to stop, health plans from sending mothers home within hours of having their babies, so-called drive through deliveries, or sending out women the same day they have had mastectomies.

Question 4  What is medicine by algorithm?
Answer: An algorithm is a structured set of procedures with branches at decision points. This approach can be highly effective for a number of common conditions which require careful medical management over a prolonged period of time, such as diabetes or asthma. It makes it less likely that effective care measures will be overlooked and can save money by preventing acute episodes and complications. Algorithm medicine can also be effective for extremely complex acute cases, such as patients in shock in intensive care units, where numerous complex decisions must be made over short periods of time.

However, medicine by algorithm does not work well in puzzling diagnostic cases or in less common or rare disorders. It can also be used to limit care in the later more complex and more expensive stages of advanced disease, providing a cover hard to penetrate by the layman. Medicine by algorithm does not help the physician care for the patient who has no medical ailment but is simply troubled and in need of time and attention.

An algorithm is a structured plan with relatively fixed branching points. Human beings are complex with highly individualized health problems. The managed care arrangement does not respond so well to a non-structured perplexing set of symptoms. There are literally thousands of disorders to which a person can fall victim.

If a problem does not sort out readily into one of the common ailments, managed care can, by its very structure, become a highly restrictive mechanism for diagnosis and care. Tests for rare conditions are expensive and have a low yield. Yet, to the individual and to a family, finding the rare or unusual condition can be a matter of life and death, markedly reduce suffering, and end long and frustrating quests for answers.

Contact DrRobinson@MD-1.com for further information.
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