25 May 2012

Restoring the sanctity of the patient-physician relationship. Part 5

Posted by Jody under: Wellness .

What’s potentially hazardous to our health as healthcare consumers, however, is the underlying set of financial incentives inherent to certain forms of managed care. Serious gaps may exist between the care you need (and which your doctor deems medically advisable) and the care which managed care is willing to pay for. “Medical necessity” is a term that’s open to interpretation, and managed care organizations have been known to use it as a weasel word when they don’t want to pay or when they want to delay claims processing and payment. As an enlightened healthcare consumer, you need to ask yourself this: who should be deciding what is or is not medically necessary for you and your family…your doctor or a managed care clerk somewhere?

In the old fee-for-service system, physicians and hospitals made their money on the basis of the procedure, test, or treatment given — and on the length of “inpatient” hospital stays. The sicker patients were, and the more surgeries and procedures patients needed, generally speaking, the more money the physicians and hospitals made. This was really a “sick care” system, because people profited from other people’s bad health. The system was driven, in many cases, by physicians and hospitals, who were paid for their services by insurance companies or, in the case of Medicare or Medicaid, by the U.S. government.

Today, financial risks have shifted back onto the doctors and hospitals and other healthcare providers. Under global capitation, with doctors getting a set amount of money per patient per month to deliver care, the incentive scheme changes dramatically. Under this scenario, the more care that doctors provide and the sicker patients are, the less money they make. Thus, doctors have a financial incentive to have healthier patients to begin with, and to keep these patients healthy. (The insurance industry long ago turned “cherry picking,” or selecting the healthiest patients with the lowest risks as health plan subscribers, into a near art form.) The danger is that doctors may now limit care in an effort to preserve a bigger piece of the capitation money pie for themselves. Some doctors receive bonuses at the end of the year based on their patients’ utilization of medical services. The less care they provide, the bigger bonuses they get. Now, doesn’t that just fry your goose — the thought that your doctor will get more money at the end of the year because he or she limited care to you and your family? Does that make you trust your doctor more or less?

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