Million-Dollar Claims Challenge Plans’ Ingenuity

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.

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HAP, a subsidiary of Henry Ford Health System, is a nonprofit health plan providing coverage to individuals, companies and organizations. This executive develops strategies to meet membership and revenue targets through products, pricing, market segmentation and advertising.  Aligns business among Business Development, Commercial Sales, Medicare and Public Sector Programs and Product Development. Seeks to enhance and be responsible for business development and expansion through the development of an effective product portfolio, strong interpersonal relationships and service excellence.

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