Chapter 1.C.3--Managed Care and Consumer-Driven Health Care

The Community Tracking Study issues very useful reports about current marekt developments, at  See also John K. Iglehart, Changing Health Insurance Trends, 347 New Eng. J. Med. 956 (347); Allan Baumgarten, Trend Note: HMO Enrollment Continues to Decrease in 2001-2002 (April 16, 2003) (showing HMO enrollment drops of 10-20% over 2 years in several large states); James C. Robinson, Jill M. Yegian, et al., Forum On Tiered Hospital Networks, Health Affairs Web Exclusive (March 19, 2003).

Discussing the meaning and types of managed care, see Jacob S. Hacker & Theodore R. Marmor, How Not to Think About "Managed Care,"  32 U. Mich. J.L. Ref. 661 (1999).

On consumer-driven health care, see generally Regina Herzlinger, ed., Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers (2004); Wendy K. Mariner, Can Consumer-Choice Plans Satisfy Patients?  Problems with Theory and Practice in Health Insurance Contracts, 69 Brooklyn Law Rev. 485, 488-490 (2004); James C. Robinson, Reinvention of Health Insurance in the Consumer Era, 291 JAMA 1880 (2004); Joseph P. Newhouse, Consumer-Directed Health Plans And The RAND Health Insurance Experiment, 23(6) Health Affairs 107 (Dec. 2004); Symposium, Consumer-Driven Health Care: Beyond Rhetoric with Research and Experience, 39 Health Services Research 1049 (2004); Beth Fuchs & Julia A. James, Health Savings Accounts: The Fundamentals (National Health Policy Forum, April 2005);  John V. Jacobi, Consumer-Driven Health Care and the Chronically Ill, 38 U. Michigan J. Law Reform 531 (2005);  J.M. Razor, Health savings accounts: increasing health care access in America? 17 Loy. Consumer L. Rev. 419-449 (2005); Richard L. Kaplan, Who's afraid of personal responsibility? Health savings accounts and the future of American health care. 36 McGeorge L. Rev. 535-568 (2005); Timothy Stoltzfus Jost, Consumer-driven health care in South Africa: lessons from comparative health policy studies. 1 J. Health & Biomed. L. 83-109 (2005); Edward J. Larson & Marc Dettmann, The Impact of HSAs on Health Care Reform: Preliminary Results after One Year, 40 Wake Forest L. Rev. 1087 (2005); Timothy S. Jost and Mark A. Hall, The role of state regulation in consumer driven health care, 31 Am. J.L. & Med. 395-418 (2005); Amy B. Monahan, The promise and peril of ownership society health care policy, 80 Tul. L. Rev. 777-848 (2006); Mark A. Hall and Clark C. Havighurst, Reviving Managed Care with Health Savings Accounts, 24(6) Health Affairs 1490-1500 (Nov/Dec 2005);Douglass Farnsworth, Moral Hazard in Health Insurance: Are Consumer-Directed Plans the Answer?, 15 Ann. Health L. 251 (2006).

Consumer-driven ideas being applied even to Medicaid.  Jeb Bush, Market principles: the right prescription for Medicaid, 17 Stan. L. & Pol'y Rev. 33-55 (2006).
Questioning the premise that moral hazard is a problem under health insurance, see Malcom Gladwell, The Moral-Hazard Myth, The New Yorker, Sept. 8, 2005.

The Treasury Department has a useful website on Health Savings Accounts, at
See also  John C. Goodman and Devon M. Herrick, Health Savings Accounts: Answering the Critics (March 21, 2006).;  Paul Fronstin and Sara R. Collins, Early Experience With High-Deductible and Consumer-Driven Health Plans (Commonwealth Fund, Dec. 2005);  U.S. GAO, First-Year Experience with High-Deductible Health Plans and Health Savings Accounts  (Jan. 2006);   U.S. GAO, Early Experience with a Consumer-Directed Health Plan  (Nov. 2005).

The following are some of the better selections of managed care humor and parodies that have come to our attention:


Welcome to Managed Friendship, a whole new way of thinking about friends and relationships. The Managed Friendship Plan (MFP) combines all the advantages of a traditional friendship network with important cost-saving features.

How Does It Work?
Under the Plan, you choose your friends from a network of pre-screened accredited Friendship Providers (FPs). All your friendship needs are met by members of your Managed Friendship Staff.

What's Wrong with my Current Friends?
If you're like most people, you are receiving friendship services from a network of providers haphazardly patched together from your old neighborhoods, jobs, and schools. The result is often costly duplication, inefficiency, and conflict. Many of your current friends may not meet national standards, responding to your needs with inappropriate, outmoded, or even experimental acts of friendship. Under Managed Friendship, your friendship needs are coordinated by your designated Best Friend (BF), who will ensure the quality and goodness of fit of all your friendly relationships.

How Do I Know That the Plan's Panel of Friends Is Not Made Up of a Bunch of Losers Who Can't Make Friends on Their Own?
Many of today's most dedicated and highly trained Friendship Providers are as concerned as we are about delivering Quality Friendship in a cost-effective manner. They have joined our network because they want to focus on acting like a friend rather than doing the paperwork and paying the high bad-friendship premiums that have caused the cost of traditional friendship to skyrocket. Our Friendship Providers have met our rigorous standards of companionship and loyalty.

What If I Need a Special Friend, Say, for Poker or Fishing or Shopping?
Special Friends are responsible for most of the unnecessary and expensive activities that burden already costly relationships. Under the Managed Friendship Plan, your Best Friend is qualified to pre-approve your referral to a Special Friend within the Managed Friendship Network should your needs fall outside of the scope of his/her friendship.

Suppose I Want to See Friends Outside the Managed Friendship Network?
You may make friends outside of the Managed Friendship Network only in the event of a Friendship Emergency.

What is a Friendship Emergency?
The Managed Friendship Plan covers your friendship needs 24 hours a day, 365 days a year, even if you need a friend out of town, after regular business hours, or when your Best Friend is with someone else. You might be on a business trip, for instance, and suddenly find that you feel lonely. In such cases, you may make a New Friend, and all approved friendly activities will be covered under the Plan, provided you notify the Managed Friendship Office (or 24-hour Friendship Hotline) within two business days. What Friendly Activities Are Covered Under the Plan?
- Agreeing with you
- Appearing sympathetic
- Chewing the fat
- Dropping by
- Feeling your pain
- Gossiping
- Hanging out
- Holding your hand (up to 5 minutes per activity)*
- Joshing
- Kidding around
- Listening to you whine
- Partying
- Passing the time
- Patting your back
- Ribbing
- Sharing a meal
- Shooting the breeze
- Slinging the bull
- Teasing
*up to 15 minutes under the Premium Gold Friendship Plan

What Friendly Activities Are Not Covered Under the Plan?
- Bar hopping
- Bending over backwards
- Drinking to excess
- Giving a hoot
- Going the extra mile
- Lending money
- Real empathy
- Sexual favors
- Truly caring
- Using illicit drugs


A managed care company president was given a ticket for a performance of Schubert's Unfinished Symphony. Since she was unable to go, she gave the ticket to one of her managed care reviewers. The next morning she asked him how he had enjoyed it. Instead of a few observations about the symphony in general, she was handed a formal memorandum which read as follows:

  1. For a considerable period, the oboe players had nothing to do. Their number should be reduced, and their work spread over the whole orchestra, avoiding peaks of inactivity.
  2. All 12 violins were playing identical notes. This seems an unneeded duplication, and the staff of this section should be cut. If a volume of sound is really required, this could be accomplished with the use of an amplifier.
  3. Much effort was involved in playing the 16th notes. This appears to be an excessive refinement, and it is recommended that all notes be rounded up to the nearest 8th note. If this were done, it would be possible to use para-professionals instead of experienced musicians.
  4. No useful purpose is served by repeating with horns the passage that has already been handled by the strings. If all such redundant passages were eliminated then the concert could be reduced from two hours to twenty minutes.
  5. The symphony had two movements. If Mr. Schubert didn't achieve his musical goals by the end of the first movement, then he should have stopped there. The second movement is unnecessary and should be cut. In light of the above, one can only conclude that had Mr. Schubert given attention to these matters, he probably would have had time to finish the symphony.

Q: What does HMO stand for?
A: This is actually a variation of the phrase, "Hey, Moe!" Its roots go back to the concept pioneered by Dr. Moe Howard, who discovered that a patient could be made to forget about the pain in his foot if he was poked hard enough in the eyes. Modern practice replaces the finger poke with hi-tech equivalents such as voice mail and referral slips, but the result remains the same.

Q: Do all diagnostic procedures require pre-certification?
A: No. Only those you need.

 Q: I just joined a new HMO. How difficult will it be to choose the doctor I want?
A: Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors who were participating in the plan at the time the information was gathered. These doctors will fall into two basic categories: those who are no longer accepting new patients and those who will see you but are no longer part of the plan. But don't worry--the remaining doctor who is still in the plan and accepting new patients has an office just half a day's drive away.

 Q: Can I get coverage for my pre-existing conditions?
A: Certainly. As long as they don't require any treatment.

 Q: What happens if I want to try alternative forms of medicine?
A: You'll need to find alternative forms of payment.

 Q: I think I need to see a specialist, but my doctor insists he can handle my problem. Can a general practitioner really perform a heart transplant right in his office?
A: Hard to say, but considering that all you're risking is the $10 co-payment, there's no harm in giving him a shot.

 Q: My pharmacy only covers generic drugs, but I need the name brand. I tried the generic medication and it gave me a stomach ache. What should I do?
A: Poke yourself in the eye.

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