Managed Care

 

Million-Dollar Claims Challenge Plans’ Ingenuity

MANAGED CARE March 2009. © MediMedia USA
Editor's Memo

Million-Dollar Claims Challenge Plans’ Ingenuity

John Marcille
MANAGED CARE March 2009. ©MediMedia USA

John Marcille

Each month our Plan Watch column looks at some of the interesting things individual insurers are doing. This month we practically present an entire edition of Plan Watches.

One of our stories looks at how Harvard Pilgrim Health Care delivers such amazing HEDIS scores for cardiovascular care. Geisinger Health Plan comes front and center as we look at how it dismisses the old notion of trying to control physicians with another approach that’s much less fractious and, it seems, much more effective. Further on, Cigna unveils some of the findings from a study of 440,000 members that indicate that consumer-directed health plans foster better preventive medicine and save money to boot.

I am not forgetting other health plans that are also praised for their efforts in this issue, but are sort of in the background. For instance, there is a very complimentary mention of Aetna in the Harvard Pilgrim story. Let us also not forget the official Plan Watch in which Kaiser Permanente offers advice on how to keep physicians content.

These are all great examples of how resourceful health plans can be, but they are not why you started reading this issue. No, it was probably because you got a gander at our cover about million-dollar claims. That story by Contributing Editor Maureen Glabman highlights how plans with traditional levels of reinsurance can get into trouble, and describes other ways in which the megaclaim threat can be dealt with.

The story of managed care is in many respects a story of how health insurers and integrated systems discover inadequacies in the system and create socially acceptable and effective ways of fixing them. It’s true that managed care has had limited success in controlling costs, and megaclaims are an extreme example, but I shudder to think where we would be, cost- and outcomes-wise, if we still had an uncontrolled indemnity system.

Meetings

2014 Annual HEDIS® and Star Ratings Symposium Nashville, TN November 3–4, 2014
PCMH & Shared Savings ACO Leadership Summit Nashville, TN November 3–4, 2014
Medicare Risk Adjustment, Revenue Management, & Star Ratings Fort Lauderdale, FL November 12–14, 2014
World Orphan Drug Congress Europe 2014 Brussels, Belgium November 12–14, 2014
Healthcare Chief Medical Officer Forum Alexandria, VA November 13–14, 2014
Home Care Leadership Summit Atlanta, GA November 17–18, 2014
6th Semi-Annual Diagnostic Coverage and Reimbursement Conference Boston December 4–5, 2014
Customer Analytics & Engagement in Health Insurance Chicago December 4–5, 2014
Pharmaceutical and Biotech Clinical Quality Assurance Conference Alexandria, VA December 4–5, 2014
9th Semi-Annual Medical Device Coverage and Reimbursement Conference San Diego December 5, 2014
8th Annual Medical Device Clinical Trials Conference Chicago December 8–9, 2014
HealthIMPACT Southeast Tampa, FL January 23, 2015