MANAGED CARE Over the last 20 years, medical care has spiraled upwards in cost. The United States has the most expensive medical care in the world. Oddly enough though,  the life expectancy in the US is not the longest. Many of the great killers of the last generation no longer result in deaths. Modern medical technology is doing a great job of keeping people alive. But that care is coming at a great cost to that. No long ago, I was in a meeting with one of the local Minneapolis HMO's. The company had been doing a lot of research regarding how to curb increasing costs. They came up with several astounding facts. If people weren't going to the doctor, the bills wouldn't be so high. The second thing they found out is few people take personal responsibility for their own health. You know, if I'd known I was going to live this long I would have taken better care of myself. Lifestyle, diet and personal history all have an impact on your health. We all know things we should be doing to improve our health and yet few of us actually do those things. An example they researched is adult on set diabetes. According to their research, diabetes is a 100% preventable disease. And yet it is a common medical problem. Worse, many people that develop diabetes take care of themselves as prescribed to for a couple of years, then the next time you hear from them is when they end up in a hospital in a diabetic coma. Why? What could have been a preventable medical condition becomes a long series of large medical bills. And the patient can have tremendous life threatening problems. What this company instituted is a voluntary case worker to assist in the care of target health problems such as diabetes, premature births and heart disease. If you fit the profile of potentially having or already have one of these conditions, you can ask to participate in the program. The company, through the magic of computers, monitors the care you are receiving. A case worker is assigned to you. Has it had an impact? Yes, the company has cut their claims in each targeted area by a large factor. Someone else, the company, is taking some of the responsibility for each person's health. So what is managed care?  The idea of an HMO is as pure of a definition of managed care as there is. The care received by the patient is "managed". Its managed on several different levels. Prior to managed care, the cost of the care received was left to the providers. The insurance companies merely processed the bills, deciding if the charges were appropriate. If not they paid what they felt was usual and customary, resulting in a "balance bill" being sent to the patient. With managed care, the providers negotiate directly with the provider prior to the care being given to establish a fixed price for each type of procedure or car given. Providers negotiate with groups of providers of care inviting them to join the insurance companies "network". This network is where the employees have to go to receive care without penalties. The idea of fixing prices on care was impacted tremendously by the Federal Government some years ago with implementation of "DRG's, Diagnostic Related Groups. Basically it is a "shop" manual regionally adjusted that specifies what the costs of different types of care that will be paid by Medicare and Medicaid. This concept swept across the US and is in wide spread use by private providers. Another factor that figures into HMO managed care is the idea of having a "primary care" physician. Historically we have become use to looking in a phone book and calling a specialist. If the HMO requires a "primary care" physician, you must consult with that MD first to obtain a referral to a network specialist. Why require this process? It reduces costs. Specialists are much more expensive than general practioners. "Gatekeeper" is a better term to refer to a "primary care" MD. It is cheaper to have a general practioner take a look at you than a specialist. If you need to see a specialist, you need a referral by your "gatekeeper" other wise you will be penalized by the medical plan. (In Minneapolis, not all HMO plans require "gatekeepers". The particular clinic makes that decision. For example, some clinics allow clients to choose any doctor in that clinic system without a referral.) The trend is to give clients more choice or options in care plans and care providers. PPO's are the private insurance companies response to HMO's. PPO stands for Preferred Provider Organization. Insurance established a network of medical care providers who have agreed to a prior determined table of medical care costs. Most PPO's are more open access than HMO's allowing choice among the network providers.   Why managed care? To save on claim costs, its as simple as that.. We can't control the level of care, or the amount of care or when someone needs care. We can impact the cost of the care by pre-negotiating the cost of that care.