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PubMed1994

Itching for a fight?

The Health Insurance Association of America complains that the White House has made it a scapegoat in the health reform debate. But the trade group's brawl with the Administration has also been a rallying point for a badly divided industry.

Health Care Reform↗
PubMed1994

Information technology enters the doctor's office: Part II--Six lessons about intended ... and unintended ... results.

Part I of this article ("Six Design and Implementation Lessons," Physician Executive, Sept.-Oct. 1993, pp. 46-50) described an ambulatory utilization review (AUR) program designed and implemented by Metropolitan Life Insurance Company and reviewed some of the lessons learned over the past five years. Those lessons pertained to the tasks of inventing a new information technology to measure and evaluate ambulatory care and some of the practical implementation issues associated with review of 30,000 small dollar value claims per day in 19 claim offices nationwide. This article turns to the basic purpose of AUR--to review the medical necessity and appropriateness of ambulatory utilization. One lesson learned about AUR in this context is that AUR works: savings from the program outweigh costs by almost 5:1. The more important lessons, however, stem from understanding how the savings are achieved, and what some of the other unintended benefits of the program are.

Ambulatory Care↗
PubMed1994

Group insurance.

Health insurers that traditionally have been dominant in the indemnity business are bypassing partnerships with hospitals and physicians and are building their own medical groups. The new relationships bring benefits for all parties.

Ambulatory Care Facilities↗
PubMed1994

Who is responsible?

Increasingly, life-and-death medical decisions are being made by executives and other nonphysicians whose primary responsibility in their institution is for the bottom line. Mr. Hage reminds us that along with that decision-making power comes responsibility for the lives of those affected.

Administrative Personnel↗
PubMed1994

Constitutional rights versus malpractice insurance settlements.

The increasing costs and complexity of malpractice litigation have created an statutory right that allows malpractice insurance companies to settle malpractice claims regardless of the desires of the defendant physician. In the past, the consequences of settling a malpractice claim out of court were not as important as they are today. The Health Care Quality Improvement Act of 1986 mandates that any settlement in behalf of a physician be documented in the National Practitioner Data Bank (NPDB), which must be consulted every time the physician is credentialed. This NPDB requirement denies due process to health care providers and thus becomes a violation of the federal and many state constitutions. Physician executives and medical leaders must bring these issues to the table and negotiate solutions before damage to practicing physicians and the U.S. health care delivery system caused by this legal paradox become too severe.

Civil Rights↗
PubMed1994

Smaller clearinghouses face an uphill climb.

With industry consolidation in full swing and competition intensifying, smaller claims clearinghouses are weighing survival strategies. Market pressures are forcing more clearinghouses to offer a broader range of services designed with managed care in mind.

Computer Communication Networks↗