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Chapter 3 Index
A. The Business of Private Practice
--Interviewing for Private Practice
--Negotiating
Contracts for Pediatric Practice |
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Managed Care
| BEFORE MANAGED CARE |
PRESENT DAY SITUATION |
| I. OFFICE PRACTICE |
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1. Private Insurance: more you do, the more you
make; more patients seen, more you make
i.e. Insurance company is at risk, not doctor |
1. Managed care: more you do,
less you make, more patients seen, might make less.
i.e. risk is assumed by primary doctor (see 7) |
| 2. Patient chooses doctor |
2. Plan chooses doctor |
| 3. Satisfaction: satisfied with medical care |
3. Satisfaction: satisfied
with cost, availability, parking, personnel, and with quality of care |
| 4. If not satisfied with doctor, patient switches |
4. Patient limited in choice
of doctor |
| 5. Expect doctor to be ombudsman: social service,
counselor, medical care |
5. Patients no longer have
that expectation |
| 6. If patient wants referral can self-refer to a
specialist or sub-specialist |
6. If patient wants referral
cannot self-refer: must be referred by primary doctor (PCP) |
7. If doctor wants to refer a patient, he can:
a. choose the specialist he refers to
b. does not worry about the cost (i.e. insurance company takes the risk |
7. If doctor wants to refer a
patient, he must:
a. refer to the plan s specialist
b. may have to pay for the specialist out of his own money |
| 8. Primary care doctor is second class citizen
with the lowest reimbursement, longest hours |
8. Primary care doctor
supreme: many subspecialists going out of business, because of not being
referred patients; many retraining |
| 9. Ancillary services: lab, audiology,
counselors, phone nurses - all pluses |
9. Ancillary services are
expensive, cannot be reimbursed, and therefore often stopped. |
| 10. Doctor ultimate
“self-employed” person |
10. Doctor no longer independent |
| INPATIENT THEN |
AFTER MANAGED CARE |
| 1. MD decides if sick enough to admit |
1. Plan decides if admission
is “justified” |
| 2. MD can decide if for social reasons, other
reasons important to admit |
2. Plan refuses these
admissions |
| 3. Length of stay (LOS): more days in the
hospital more get paid: another example of risk by insurance company |
3. LOS “approved” for
diagnosis- no more
e.g. newborns: 24 hours in hospital
e.g. DRGs |
| 4. No utilization review if
document you think admission is necessary |
4. Utilization review: Case management:
a. critical pathways being developed
b. MDs rated on their LOS
c. report cards made public on doctors’ perfor. |
| 5. Private industry not organized |
5. Private industry very
organized:
a. form their own provider networks - hire doctors, have them follow
their recommend.
b. form coalitions in areas such as Augusta
*c. choose the low cost provider - not the best quality, but the lowest
cost- most import. issue |
| 6. Subspecialty referrals
common |
6. Subspecialty referrals less common. |
Future for physicians: more and more clinical pathways defined with
outcome analysis done so that there will be as much intervention in the
office as there has been in the hospital.
Outcomes will be assumed to be good, but cost containment will be primary
- this is the way you will be chosen as the doctor.
Managed Care: Definition: Control of utilization, quality
of care, and costs using a variety of cost containment measures. Recognized
that four stages of evolution of managed care:
| Stages |
Reimbursement to doctor/ month/ patient |
| 1. Unstructured |
$135 |
i.e. reimbursement to doctor less as
managed care becomes more organized. |
| 2. Loose framework |
$128 |
| 3. Consolidation |
$118 |
| 4. Managed competition |
$103 |
Even the earlier stages of organization are associated with decreased
costs: HMOs much better than PPOs and both much better than private
insurance.
Statistics: As private insurance decreases, HMOs increase;
PPOs less. Quite variable depending on where live. e.g. California is stage
4; MCG stage 2.
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