John A. Marcille
The time lag between when an employee makes a coverage choice and when the plan receives notification from the employer's personnel office can result in expense and problems for patients, physicians and the plan.
Now that quality is an industry obsession, it makes sense to find ways of paying your 'best' doctors more. But does 'best' just mean immunizations and a patient-friendly office?
Not too long ago, disease management was viewed with widespread suspicion. But the evidence mounts that well-designed programs make medical sense and can help patients as well as the bottom line.
Health plans and physicians have every right to hold down the cost of pharmaceuticals, as long as patients aren't harmed. But not everyone agrees on what actions are acceptable.
Accounting for 12 percent of federal spending this year and projected to consume 15 percent of the budget in 2002 if not reined in, Medicare in 1997 is on the road to profound change.
While development of depression management programs has lagged behind other chronic conditions, emphasis is now being placed on early diagnosis and treatment coordinated by primary care physicians.
You might not expect to hear the term "smoosh" from the lips of one of health care's most erudite observers. But he would argue that the rest of the industry's vocabulary should be as clear.
When Harris Health System began posting losses, it became apparent that a new compensation system, with incentives to providers to control costs, was in order. Risk sharing was the answer.
On the theory that capitating primary care can lead to unnecessary referrals, a group of California physicians has decided to pay fees to primary care and to capitate specialists. It seems to work.
How do you devise a capitation plan that works? With understanding, hard work and gumption, says the chief financial officer of Sharp Rees-Stealy Medical Group in San Diego.
Some academic researchers warn that managed care's emphasis on low-cost care means that plans won't support expensive research at academic medical centers. Industry representatives say research is not being ignored.
Physicians and hospitals have always been subject to liability claims, but now health plans are becoming vulnerable too. Adverse events cannot be eliminated, but there are many ways to reduce liability exposure.
John La Puma, M.D.
Neil Caesar, J.D.
Managed Care Outlook