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Managed Care

Some of the most common questions surrounding private medical insurance concern the idea of managed care; what does it mean, how long has it been around and what considerations are there for anyone taking out cover?

What exactly is it?

Managed care is, in short, the process of taking choice away from the patient and putting it in the hands of their insurer. Under traditional, non-managed care, a patient who has fallen ill would visit their GP, who would then recommend a surgeon or consultant. The patient would then visit this consultant and get the treatment they need, with the insurer stepping in to pay for it.

This all sounds easy and straightforward, of course, leaving the patient to concentrate solely on their recovery. However, in the real world this doesn’t quite work out to always be so simple.

For example, the health insurance market has changed dramatically over recent decades, with greater competition driving prices down. This is great news for consumers but leaves insurers struggling to make money. As such, these insurers have shifted focus from making their money from premiums to saving costs elsewhere.

With managed care, certain insurers have a panel of consultants, anaesthetists and preferred hospitals, with whom they’ve set up contracts to stipulate how much they’re willing to pay for certain procedures. If the costs are not agreed, the health professionals will not be included on the panel and will therefore not be provided with work, paid by these insurers.

It means that certain insurers have some health practitioners locked in, making them choose between very low costs or turning people away. This approach then has a knock-on effect on patients, by severely limiting the choice on who they can see.

Managed care is heralded by the companies that use it as a way for patients to receive care without having to worry about organising anything themselves. However, managed care really means it’s not the GP that recommends where a patient goes, but their insurer. In many instances, this means the patient sees a different consultant or physician to the one their GP would have chosen for them, or one that’s situated many miles from home.

The patient’s GP would have referred them to their preferred consultant or physician, had they been in overall control of the referral process. The individual may have wanted to use a particular hospital, or see a specialist recommended by their best friend. However, they actually see the consultant their insurer wants them to see, a consultant who may not have admitting rights to the hospital facility they wish to attend meaning they, the patient, end up elsewhere.

It could also mean certain insurers only allow patients to see less experienced surgeons, as these are the ones more likely to accept their lower fees.

Where did it come from?

Managed care emerged out of America many decades ago – seeing huge growth as a result of the Health Maintenance Organization Act of 1973. British companies, spurred into action by increased competition and the need to offer more competitive pricing, quickly took interest. Many have now been providing it for decades, as some of the earliest adopters toyed with the idea from the very beginning.

What makes General & Medical different?

As mentioned previously, we don’t subscribe to the managed care system, instead taking the traditional approach. This means we give patients GP's the choice to choose their specialists. That decision is taken entirely by the patient and their GP, with no financially-motivated persuasion from us. Provided the consultant or hospital in question is covered in an individual’s premium, they are entitled to choose them.

As such, patients can see whomever they like, in the most convenient location, at a time that suits them. Managed care can sometimes leave patients travelling far out of their way to reach a nominated consultant – that simply doesn’t happen at General & Medical.

Our system is not a restrictive one, and doesn’t require the patient to put in legwork. They simply have to agree with their GP which consultant to see, then leave us to pick up the bill.

What does the industry think about managed care?

Given the financial implications listed above (of excluding certain practitioners who don’t accept lower costs or giving them difficult financial decisions to make), it’s understandable that health professionals aren’t enamoured with the managed care system.

We know this for a fact as General & Medical has an advisory panel made up of qualified surgeons, GPs, anaesthetists, consultants and more. In our regular meetings they tell us that they do not like managed care at all, because it doesn’t give patients any choice. Instead, the only people with real decisions to make are the insurers.

In fact, one instance involving a consultant on our panel showed just what the real-world implications of managed care are. Our panel member had a patient who was told by her insurer that she could only see a certain consultant. This, our consultant believes, was because the insurer had a cheaper rate with the less-experienced consultants, so elected to send as many patients there as possible, to save money.

Industry professionals see the situation as we do: our traditional approach allows patients to choose where they go based on what their own GP says. We don’t force them to go with certain practitioners because it means a better deal for us. We’re more concerned about the patient.

This should clear up not only what managed care is but the real world implications of it for patients and policy holders. Get in touch if you want to find out more or have any other questions.

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