Managed Care

[Wheels2000]

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Greetings, all!

Folks, let's talk managed health care. This is a topic that many people would rather avoid, but it's something we're all going to have to deal with. I bring it up now because a Biochem professor who wrote one of my recommendations, and who serves on the admit committee of the local medical school, told me that it would be VERY much to my advantage to know quite a bit about this topic in an interview situation. His exact words were that interviewers like to see prospective students informed on this aspect of what they're getting themselves into.

SO, having said that, I'm looking for newspaper articles, news reports, books, and what not and I'd like to hear what my fellow applicants and hopefully future colleagues from this board think about this subject. I admit, I know very little. I'd love to hear your opinions, and/or any good information sources you know of.

Thanks in advance.

--Wheels

 

[cholecalciferol]

In one sentence: HMOs are the price the current generation of doctors are paying for the freewheeling ways of doctors of the previous generation

But worry not, like most things in life, the pendulum swing both ways and the next generation of doctors will wondering why the previous generation ever put up with managed care.

 

[AZMom]

Managed care means that even though certain treatments are medically necessary, a patient's insurance company will not pay for them unless you jump through lots of hoops. It used to be that a pencil pusher made these decisions, and that really irritated lots of practitioners so they changed the decision makers to RNs. For really expensive procedures, they have a Medical Director who is usually a non-practicing physician who play solitaire and surfs the internet all day. It's a great job if you want to get into medicine just for money.

Some insurance companies are now taking out the hoops, finding out that managing care is more expensive than actually paying for claims.

Two terms to know: HMO (Health Maintenance Organization)- payment to physicians is usually made on a capitated basis (the doc receives a pool of money for all of the insureds of a particular plan who sign up for that doc). The physician receives the same pool of money regardless of the number of patients seen. For the patients seen, you usually can collect an additional copayment ($5, $10, $15). In this case, the physician shares some of the risk of the insurance carrier. Sometimes (and beware when you sign up to be a provider), they also assign you to a specialty risk pool (you share in the cost of referring to a specialist - making you less likely to refer out or having it cost you money personally) and/or a hospital risk pool (you share in the cost of admitting a patient to the hospital - again, making you less likely to provide this service to patients or again incur costs personally *or to your group, since most new docs practice in a medical group*)

PPO (Preferred Provider Organization): Physicians get paid fee for service. That means if you see a patient, you get paid. If you don't see any patients, you don't get paid. What you get paid is a predetermined rate of pay, at a discount of what is generally accepted as "usual and customary".

Another term:
POS (Point of Service) - A HMO/PPO hybrid.

That's the nickel tour of managed care.