Dear Penners: An economist friend who doesn't usually subscribe to PEN-L received the post from SID and sent this comment. [aside to Harry Cleaver: Bill wants you to contact him!] Bill Moore wrote: > From: Bill Moore <[EMAIL PROTECTED]> > > Why am I not surprised? A good friend of mine (a CPA, mind you) became a > mid-level financial manager for Central Texas Health Plan (a local HMO in > Austin, now defunct) and did a good job in developing a cost allocation > plan which resolved some of the capitation issues between GP's and > specialists. As a result, he was hired away by Traveler's HMO and > transferred to Sacramento to work on "the same problem in CA." Six > months later, in a phone conversation, he tells me that instead of > looking at flexible formulas (I think that was the terminology for the > methodology he pioneered), he was being asked to consider *individual* > cases and determine whether some "specialist" charges should be disallowed > completely, irrespective of referrals by the PCP's. When he protested > that that was a *medical* decision and that he was unqualified to make > any such judgments, he was told that the Medical Director "knew the costs > and the benefits to the HMO" and would support his decisions 100%. > > He struggled internally for several months without making any decisions, > putting his supervisors off with "need to study this more and develop an > overall policy" and finally requested (and received) a transfer to > Atlanta so he wouldn't have to deal with the mess. As I understand it, > the folks in Sacramento then took the tack of issuing a blanket rejection > of *all* the claims which had been pending based on a *business* decision > that very few of the rejectees would appeal the decision and that the > ones who did could be staved off indefinitely via appeals, litigation, etc. > > Unfortunately, I've completely lost touch with Jim, so I'm reciting from > memory and have no way to verify all the facts; but it is a horrifying > prospect to contemplate that medical decisions between doctors and > patients (difficult enough in the HMO environment) are subject to second > guessing by financial and accounting folks... > > Bill > -- Mike Meeropol Economics Department Cultures Past and Present Program Western New England College Springfield, Massachusetts "Don't blame us, we voted for George McGovern!" Unrepentent Leftist!! [EMAIL PROTECTED] [if at bitnet node: in%"[EMAIL PROTECTED]" but that's fading fast!]
