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January 19, 2013


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The author is clearly from the academic tradition that cannot distinguish health care from healthcare insurance.

Although the author is the only person I have ever heard use the term "Medicare Managed Care," the author does not seem to be using the word "managed" in the sense Medicare might use it if it ever uses it (see next paragraph). The point of most Part C plans is that a primary doctor "manages" your health care needs. The word "managed" is not used anywhere that Medicare might use it if it ever uses it (again see next paragraph) in the sense of rationing by an insurance company.

Furthermore -- and I repeat this term "Medicare Managed Care" appears to be a figment of the blog author's imagination -- I don't even see the word "managed" without the other two words used at all in the primary Medicare documentation on this subject although it might be in the fine print of pages 74-75 of "Medicare and You, 2013" somewhere. But managed care for non-seniors in the sense I am using the word "managed" is the linchpin of the 2010 Patient Protection and Affordable Care Act. Everyone better learn to love it.

Specific to Alice, we have to assume what the author of this post means is that sometime between October 15, 2012 and December 7, 2012 Alice chose to join an HMO-type (networked, coordinated, accountable care using so-called global or capitated payments) Part C Medicare health plan effective January 1, 2013 as opposed to
-- choosing a Part C Medicare PPO or FFS or HMOPOS or SNP or Medicare Cost or HSA health plan, none of which have the same extent of physician "management" or networking requirements as an HMO-type Part C Medicare health plan
-- staying with whatever Alice's 2012 status quo Part A/B situation was, which may or may not have involved a former employer's retiree plan and/or a Medigap plan and/or a Part D plan (but apparently did not include a Medicare Savings Plan or LIS)

And we cannot even begin to guess why Alice did this but any scenario I can think of is not instructive one way or the other of "managed care," under Medicare, Obamacare or any other health care insurance policy. And, if Alice was with it (as the author strongly implies), it definitely does not support the author's attack on Part C insurance companies (what is that whole "they don't think she is a subscriber" thing about?).

It appears that the whole whine by this author revolves around the fact that the surgeon that operated on Alice in December is not in the network of the HMO Alice joined in January. This is the least of Alice's issues:
-- Specifically, the rehab benefits under Original Medicare and Part C are exactly the same by law. (But Alice might have had a Medigap policy in 2012 that provided better rehab coverage than Part C and Original Medicare provide but we do not know that from the background provided by the author because the author's apparent intention is simply to deride Medicare Part C, not to help Alice.)
-- The regular post-op visit to the surgeon might actually be included in the fee charged in December.
-- If more extensive follow-up and further surgical intervention is needed than Alice has to go to someone in the network. Presumably if Alice is robust and lively, she knew this when she chose an HMO (given the description in the blog, it's not like she had a favorite orthopedic guy or gal and then -- my god -- found out he or she didn't take the Part C plan). Hopefully Alice chose a network that included her regular doctors
-- How much money did Alice really save? Depends on where she lives; the author does not tell us.
-- Depending on where she lives, Alice might not be able to get back into a Medigap policy without some waiting period if she uses the Part C disenrollment option between now and February 14

Medicare Managed Care Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c01.pdf

Thank you. Looking at this document (that no Medicare beneficiary like me or Alice would ever see), it appears that -- as I said -- when the Medicare bureaucracy uses the term "managed," it means "coordinated" (by a primary care physician), not rationed. In fact, it appears that in January 2011, the Medicare bureaucracy specifically changed the word "managed" to "coordinated" in the text but apparently did not want to change the name of the document itself. And more important, as I said, in the documentation we seniors receive the word "managed" with or without "care" does not seem to ever appear.

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