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Robert B. Sklaroff, M.D.
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Managed Health Care ["MHC"]: College of Nursing and Health Professions, Drexel University October 14, 2006 ["Saturday Scholars" – Room 4217] Stephen F. Gambescia, Ph.D., M.Ed., M.B.A., CHES Robert B. Sklaroff, M.D., F.A.C.P. ["Anti-Tobacco Activist"] Quality/Access/Cost of Care as related to the Services/Providers Background: MHC Organization, Delivery, Medical Management Discussion Points: Specialist, The Blues, Organized Medicine Enduring Myths: Insurer=Deliverer, Time=$$$, Gag-Rules Parameters: Ideal>Reality, Demand>Supply, Longitude>Latitude Terms: Primary Care Physician, Consultant, Principal Care Delivery Pitfalls: Single-Payor, Professional Liability, Indemnity=Dinosaur
Discovering a Philosophy of Health Education Society for Public Health Education – Annual Meeting 11/2/2006 Presidential Address [pre-print] – Updating Hippocrates 1. How do I know what I know? (epistemology, absent dogma) 2. What should I do; how should I behave? (ethical and moral discourse, viewed as a community of practitioners) 3. How do I interact with others; and what is my relationship to them? (governance and justice, eschewing paternalism) "Health Education is the most essential service of a Public Health Department in a democratic society." "Macro"-application: American Council of Science and Health "Micro"-application: The Patient-Physician Relationship
Managed Health Care ["MHC"]: College of Nursing and Health Professions, Drexel University October 14, 2006 ["Saturday Scholars" – Room 4217] Stephen F. Gambescia, Ph.D., M.Ed., M.B.A., CHES Robert B. Sklaroff, M.D., F.A.C.P. ["Anti-Tobacco Activist"] Quality/Access/Cost of Care as related to the Services/Providers Background: MHC Organization, Delivery, Medical Management Discussion Points: Specialist, The Blues, Organized Medicine Enduring Myths: Insurer=Deliverer, Time=$$$, Gag-Rules Parameters: Ideal>Reality, Demand>Supply, Longitude>Latitude Terms: Primary Care Physician, Consultant, Principal Care Delivery Pitfalls: Single-Payor, Professional Liability, Indemnity=Dinosaur
The Specialist C.V. – Medico-Legal, Disability, Handouts Pre-Approvals for Imaging Studies and Selected-Rx Serial CT’s (Breast Cancer) and Gleevec (CML) Clinical Pathways (Inpatient) and Bundling (Outpatient) Issues: Biased Quantitation (re: Professional Liability Insurance) Divide and Conquer (Primary vs. Specialty Care Designation) [De-]Credentialing (stills complaints, unnoticed by patients) Types of Reimbursement Arrangements (for identical service) Organizational Models for Capitating Specialty Services ( ) Common Problems with Specialty Capitation (SUB-Divide…) Other Forms of Specialty Physician Reimbursement (Episode) Risk and Reward ("Scoping for $$$")
Managed Health Care ["MHC"]: College of Nursing and Health Professions, Drexel University October 14, 2006 ["Saturday Scholars" – Room 4217] Stephen F. Gambescia, Ph.D., M.Ed., M.B.A., CHES Robert B. Sklaroff, M.D., F.A.C.P. ["Anti-Tobacco Activist"] Quality/Access/Cost of Care as related to the Services/Providers Background: MHC Organization, Delivery, Medical Management Discussion Points: Specialist, The Blues, Organized Medicine Enduring Myths: Insurer=Deliverer, Time=$$$, Gag-Rules Parameters: Ideal>Reality, Demand>Supply, Longitude>Latitude Terms: Primary Care Physician, Consultant, Principal Care Delivery Pitfalls: Single-Payor, Professional Liability, Indemnity=Dinosaur
The Control over the Health Care Delivery System in the Commonwealth of Pennsylvania Watergate : "Follow the Money!"Silent Hand: The Blues (W-/SE-BC have 85%/65%) Structure: Not-for-Profit Shell encompasses For-Profits Goal: One Statewide Entity (sandwiching C-/NE-BC) Antitrust Analysis (HHI): Geographic/Service Parameters Geography: Statewide vs. Regional (vs. sub-regional) Service: Insurance vs. All-Products (vs. sub-types) CHALLENGER empowered to DEFINE the defect! The Blues – I - Context C.V. – Pennsylvania Society of Internal Medicine (Prez) Insurance Regulation - State - McCarron-Ferguson Act (1945) {antitrust import} - Federal - ERISA (1974) Employee Retirement Income and Security Act - Protects interests of employee benefit plan participants - Protects beneficiaries of financial and other information - Establishes standards of conduct & responsibility - Excludes government and church plans The Blues – II - Events C.V. – Pennsylvania Society of Internal Medicine (Prez) PA Blue Crosses (1937) including "Western PA" PA Blue Shield (1939) statewide Consolidation (12/6/1996) creating "Highmark" Decision Challenged (12/5/1996) by PCMS/PSIM Adjudicatory Adverse-Party Hearings (12/19-20/2002) Commonwealth Court (with Capital Blue Cross case) Time-Frame: end of 2007 (after PA-Supremes rule) Goal: permanently ensure TRUE competition
Managed Health Care ["MHC"]: College of Nursing and Health Professions, Drexel University October 14, 2006 ["Saturday Scholars" – Room 4217] Stephen F. Gambescia, Ph.D., M.Ed., M.B.A., CHES Robert B. Sklaroff, M.D., F.A.C.P. ["Anti-Tobacco Activist"] Quality/Access/Cost of Care as related to the Services/Providers Background: MHC Organization, Delivery, Medical Management Discussion Points: Specialist, The Blues, Organized Medicine Enduring Myths: Insurer=Deliverer, Time=$$$, Gag-Rules Parameters: Ideal>Reality, Demand>Supply, Longitude>Latitude Terms: Primary Care Physician, Consultant, Principal Care Delivery Pitfalls: Single-Payor, Professional Liability, Indemnity=Dinosaur
[Dis-]Organized Medicine C.V. – AMA/PMS/PCMS plus sub-entities thereof Proactive: Medical/Health Savings Accounts Reactive: Administrative Analysis of Statutory/Procedural Actions Act 68 Critique: Overall intent was to enhance user-friendliness Policy Compendium: http://www. AMA-Assn.org Policy Implementation: Means Testing vs. Income Relatedness Tort Reform: Failures/Successes Strategies/Colleagues Blues Litigation: Stephen Foreman, Ph.D. & Dennis Shea, Ph.D. Membership/Dues/Interactions/Services: Egoism/Manipulativeness Solution: Collaboration to achieve Efficiency-of-Scale Physician-Members choose Employers over Medical Societies Ergo: Physician-Income Decrements (from MHC) enervate Societies
Overview Conclusions THIS PRESENTATION IS SUBJECT TO CRITIQUE, INPUT, FEEDBACK, ANALYSIS…BOTH PHILOSOPHICALLY AND WHEN VIEWED ON A PRACTICAL LEVEL. THERE ARE NO SIMPLE-ANSWERS, AND THE BIASES OF EACH OF THE "PLAYERS" MUST CONSTANTLY BE WEIGHED WHEN ASSESSING "SUGGESTIONS." ULTIMATELY, THE PATIENT-FOCUS MUST BE PRESERVED; INDEED, IT MUST BE ENHANCED MAXIMALLY!!! |
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To contact me--Robert B. Sklaroff, M.D.--just send an e-mail (rsklaroff@comcast.net).
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