Question

With the advent of managed care, medicine changed radically. If you went to the ER with abdominal pain in the 1970's or mid 1980's, they would run a battery of tests right away to determine the problem. This benefited the patient because a lot was ruled out immediately. It also benefited the hospital because they could generate income from all of the tests which were run.

Fast forward to the late 1980's and early 1990's through today.  Managed care dictates pathways to which physician's must adhere when treating patients. A patient presenting to the ER with abdominal pain now goes through a much different plan of care with a more narrowed and structured set of testing which is performed, often causing longer ER stays and delays while requested testing is approved by insurance carriers.

The pathways were set up to curb over-ordering of services and decreasing costs. One way managed care organizations try to discourage use of ERs (they prefer patients to see their primary care doctor first if at all possible) by having a much higher copay for ER services. The reasoning behind this is primary care doctors are usually much more aware of how an insurance plan work, spend more time with the patient, and thus overall reduce costs by ordering tests which are more likely to identify the problem. ER physicians are under more time constraints and may not always check what insurance the patient has before running test. Thus, except for real emergencies, the patients and the insurance company are paying much less for care by using primary care physician versus the ER.

Do you think patients with managed care insurance are influenced by differences in copay amounts between the PCP and ER? Do you think the average person really understands managed care?

Answer 1

ANS- Yes, patients with managed care insurance are influenced by differences in copay amounts between the PCP and ER because they have to pay higher copay amounts if they use ER services and they have to pay less when they use PCP. This cost influences them to use those services which they are capable of.

An average person will have difficulty in understanding managed care but if someone makes them understand then they will understand it.