I was in a chiropractors office recently and a patient was discussing her health insurance. The receptionist was concerned because the woman’s plan required pre-certification and limited the number of visits each year. In other words, the care was managed. To some Americans this is an intrusion between doctor and patient, to others it is managing potential abuse.
I took the opportunity to ask the receptionist how it was dealing with Medicare. Oh, she said they are not a problem, they just pay what we submit. Yipee!
That sounds a lot like the expectations many people have for government run health care. The “just pay what is submitted” process is, in fact, what Medicare does in most cases. That is a criticism of Medicare in a report from the Congressional Budget Office. Nevertheless, that is what many people expect from getting the insurance companies out of the business of providing health insurance. Medicare does not have any pre-set limits for chiropractic care, but it does not cover maintenance care and neither does most private insurance which, of course is the reason there is oversight and limits.
Historically, chiropractic care has been an area where abuse has occurred with some people getting feel good treatment that was willingly provided by less than fully credible practitioners. Hence the reasons for limits and close review of services. I once had a case of a family of five where each member of the family was going to the chiropractor three times a week, not a bad way to get a massage. Mental health benefits are another area where there were limits on care and strong oversight simply because it was an area of potential abuse by both patient and provider. Those limits have largely been legislated away ignoring the logic that put them in place.
The point of all this is simply that the easy to swallow perception fostered recently by politicians that the controls, oversight and management of claims by insurance companies is done solely to add to profits is bogus. There are good reasons for these efforts and one of them is to help control premiums thereby making the insurance more affordable for all participants not just the ones who happen to be using the coverage at the moment.
Those folks who believe that we can have an affordable (or high quality) health care system that is totally unrestricted where “no one comes between you and your doctor” are living in a dream world. Patients who want this are risking their health unless they believe of course, that they too are going to the BEST doctor there is as recommended by Aunt Sadie.
And no, for the record, I have no affiliation with any insurance company and never have.
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If health management by the insurance companies is for the purpose of controlling costs, then it has failed. If it were succeeding we would expect to see insurance premiums and patient copayments decreasing? Have you seen any market data that provides any evidence of successfully managed care resulting in the outcome you suggest?
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No it has not been successful in the pure sense because no matter what, the core costs keep going up. The real question is how much worse would it be if there were zero attempt at management. Medicare is a good example of no management.
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Excellent post. Dick, I believe that all this is likely leading us to a three-tier reimbursement system.
1) Preventive care – that has a guideline and a schedule (though the guideline implementation might become problematic i.e., mammography screening);
2) The old system of a schedule of benefits — bundled payments based on episodes of care, and other one off type of services;
3) Catastrophic care
Further, I think that we are beginning down a journey of disaggregating health plans.
1) If the exchanges evolve as I expect them to, they will become the network contracting arm (rates will be negotiated much as government purchasing contracts)
2) There will be a schedule of payments as described above to plan participants — the balance is out of pocket expense. This will in effect eliminate much of the complexity of claims adjudication.
3) Outsource the customer serive function to third parties such as ACS (which in the spirit of full disclosure, Xerox is currently in the process of purchasing).
4) Payments to participants and providers will be outsources to companies such as Paychex, or ADP that do millions of payments to small and medium sized companies and to their employees as a core competency at an administratively efficient rate.
5) Risk – that will be taken by all plan sponsors since we would now be in a scheduled payment world for everything below catastrophic, for which companies would reinsure.
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