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Managed Care ... Who is the Patsy?

To quote the billionaire Warren Buffett, "When you go into a poker game, look around, and you will always see one patsy. If you can't tell who the patsy is, that's 'cause it's you."

Who is the patsy in managed care? Huge profits are made in managed care. Where does it come from? Someone pays. It is not the insurance industry, which has great expertise in the politics of power. It is not the health care providers who now play the managed care game every day with great sophistication. Who is left? You - the consumer. What's your strategy? If you have a managed care policy, think of it as a cardboard lifeboat. When you truly need it, you can't count on it.

One of my patients described how he went bankrupt after he incurred a $35,000 out-of-pocket expense for intensive care treatment of his newborn child. He trusted people, believed in a work ethic, saw the managed care ads on TV, and thought he was secure. The policy served to cover small expenses adequately. Unfortunately for him, when he incurred a major expense, he suddenly realized loopholes existed which were totally legal.

What can you do to protect yourself from abusive managed care?

Option #1: Take control of your own life. Buy a Medical Savings Account plan. This is designed like an IRA, and gives you total control of your health care expenditures. Eliminate the 30% of your premium dollars that go towards insurance company overhead, profit and advertising. Negotiate with every health care provider to receive the same rate which they offer to managed care companies.

Option #2: Only buy a good quality indemnity insurance plan and read the fine print very carefully. Consult with someone who understands insurance loopholes. The larger the deductibles the better. Only insure for the loss you truly cannot absorb.

Option #3: Self-insurance. Since much of insurance today is poor quality, bank the money you would otherwise spend on insurance, and be prepared to pay all expenditures out-of-pocket. True, it is risky - but it may be less risky than insurance which does not truly insure. Corporations have shown an increasing trend towards self-insurance for years.

Option #4: Accept your employers low quality HMO or Managed Care plan, but be prepared to fight. To do this, you must:

Buy one share of stock in your employer's company, the insurance company, and the managed care company(s). As an owner, you are now entitled to the detailed internal records you will need to help protect your interests. If the company fails to produce these records, file a formal complaint with the Security and Exchange Commission. You have more clout as an owner than you have as a consumer.

Demand a detailed copy of your policy containing all exclusions, limitations, requests, co-payments, deductibles, maximums, etc. Study it carefully.

Demand a copy of the criteria used in assessing all claims.

Demand the names, credentials, and the administrative structure of all individuals who manage your claims. Be sure the reviewers have adequate credentials. No one who reviews your claim can be anonymous.

Demand an absolute guarantee that any information submitted in your claim will be kept totally confidential, and not entered into any computerized data bank that others can access.

Be prepared to run an obstacle course to receive health care.

Keep money aside in a special account to pay for services which will not be covered by the plan.

Trust no one. Remember, you are dealing with a system controlled by business ethics, not medical ethics.

Plan your strategy in advance. When you are sick, you will be distracted by other issues.

Understand the relationships that exist or do not exist between providers and insurance companies. Realize health care providers are a highly capable group of individuals. Managed care is neither the first nor the last insurance company power play. Many providers have significantly increased their income with the onset of managed care - frequently at the expense of access and quality of care. Powerful medical groups are being formed, and some of these groups are much stronger than managed care companies. You can look up health care providers in three general groups:

  1. Those who maintain quality of care and do not collude or profit from managed care.
  2. Those who collude and profit from managed care at the expense of quality of care.
  3. Those who recognize their fees were too high and accept a lower fee while maintaining the same quality of care (not many providers will be in this category.)

Educate yourself about reimbursement structures that will prevent your doctor from exercising his full medical judgment to provide good quality health care. Red flags are gag clauses, closed formularies, pharmaceutical benefit management, mail order pharmacies, financial incentives for providing lesser care or financial non-incentives for providing quality care.

Be prepared to file suit against your employer and the benefits manager if you are forced to accept a health care plan which has damaged your health care. The combined efforts of an ethical provider and yourself have more influence over managed care than either of you alone.

Always remember that managed care and HMO's are ruthless, carefully planned financial structures to maximize profit. They have no eye-to-eye, face-to-face relationship with you. Managed care manages money, not care. And remember that health maintenance organizations (HMO's) do not maintain health. Although stating that they trim the fat from health care, they often create fat for themselves at the expense of already lean components of our health care.

In short, to stay healthy, you need to be either wealthy or wise.

1 Buffet, Warren; "The Making of an American Capitalist" by Roger Lowenstein; Random House.


This article above is written by an aggressive academically-oriented psychiatrist in New Jersey named Robert C. Bransfield, M.D. working in Red Bank, New Jersey and phone number is (732) 741 3263.

Reposted with permission and thanks.

Dr. J



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