Last updated on January 6th, 2024 at 08:33 am

       Just a little tweaking will not do the job

The writer is a very strong supporter of the principle of Managed Care—there must be some entity to oversee health delivery between provider and patient—but the current iteration of Managed Care needs major reform.

The following are just some of the needed changes that managed care must be forced to undergo if we are ever to have improved quality of healthcare at lower cost.  The only entity that has the power to force these changes is the private self-insured employer sponsored employee health plans. However, this entity must first be educated about what current drug and non-drug therapies reflect a reasonable standard of efficacy and safety and what current drug and non-drug therapies do not.  Having reviewed the research literature I suspect that 40% or more of “everyday” delivered healthcare does not meet an adequate efficacy or safety standard and these services should no longer be covered in the health plan.

What principles are common to poor quality of healthcare?

1. Sound research finds that many popular, “everyday” healthcare is based on clinical opinion rather than on the available sound health research. If we followed the latter I suspect we could decrease healthcare costs by 40% or more and at the same time improve its quality.

        2. We have in the U.S. basically a disease approach to healthcare which prefers biophysical solutions when the research finds that                most of our everyday health problems arise not from organic disease but from our behavior or from the patient’s distressing                      personal or current life situation problems. Such poor care is compounded by prescribing inappropriate psychiatric drugs to                          address these non-organic health problems, which exposes these patients to serious adverse side effects including the impairing of                brain functions.

        3. Many health problems are basically self-limiting but it is rare to come away from a physician office visit without a prescription for               a pharmaceutical. All patients need information on how best to treat or manage their own health problems but unfortunately                     giving patients such knowledge is near the bottom of the physician’s priority list.

4. The major killers (Type 2 diabetes, cancer, stroke and heart disease) are largely preventable but the preventable causes (e.g. excess weight, sedentary life style, poor nutrition, stress) are largely ignored by medical care in favor of biophysical therapies.  For example, a type 2 diabetes patient 45 pounds overweight needs education from the physician that life style change will have a greater effect on outcome of the disease than any medication but typically a drug is prescribed as soon as the patient is given the diagnosis.

5. When a patient is given a diagnosis of one of the major killers the diagnosis itself gives the patient a severe dose of anxiety which has serious negative effects on the patient’s emotional wellbeing,  adjustment and health.  Physicians tell us they have drugs to take care of those non-disease health problems but there is simply no evidence to support such a belief.  Those who are diagnosed with these and other diseases with serious emotional and life consequences secondary to the disease should be referred to health experts with substantial training and expertise in normal and abnormal human behavior.

What are some other changes/additions Managed Care should implement?

1. There has to be major changes in the medical software and health database for each patient, the software designed by health experts working with software engineers. There needs to be a system to measure the patient’s improvement in response to the treatment or the worsening of the patient’s health problem(s).  Within this system is the capability of intervening with the provider and or patient when the patient is not improving when the patient has a very treatable health problem.

2. Educating the patient and providers. Giving the patient knowledge of their health problem is critically important to favorable outcomes.  Managed care needs to have a library of best practice articles that can be dispersed to patients with a variety of health problems and what patients can do to improve their health.

Patient access to self-help information to treat some health problems

1. For some health problems patients should be enlisted in “treating” their own health problems. For example a flu in most cases is ordinarily self-limiting but patients require knowledge about the flu and when to use self-help procedures at home or when to call for an office visit to consult their doctor.
2. Almost everyone, including those without a diagnosis of a mental health disorder, will have one or more periods of insomnia in response to normal life stresses/situations. Perhaps 90% of these impaired sleep episodes will fully respond to following a self-directed sleep hygiene approach even if the patient has mild “depressive” symptoms.  Patients who do not respond to a self-directed sleep hygiene program are referred to the behavioral health carve out for diagnosis and therapy by an expert in the health problem.  There is no evidence that benzodiazepine drugs are an effective and safe treatment for insomnia and these drugs cause more health problems than these drugs resolve. Treating even severe cases of insomnia by a trained healthcare professional is adequate and there is no reason insomnia needs to be treated in a Sleep

The above are just a few of the many changes that are required in the managed care system to improve the quality and cost of delivered healthcare.  I will end this discussion with an assessment tool that has the potential for improving the quality and cost of care in many areas of healthcare that are now under the radar.

All patients in the plan with or without health problems should have access to ongoing cognitive screening perhaps 3 times a year. Such a screening program would help in the early identification of both reversible brain impairment (e.g., from many medications) and irreversible or structural damage to the brain. The author would recommend that these computer delivered, brief, online Ci screenings take place prior to and following any major surgery to assess whether or not there are any brain impairing effects from the anesthesia or botched surgery.  In the writer’s experience some patients who undergo major surgery seem to be cognitively impaired following surgery. The patient’s impairment is often misattributed to a psychiatric disorder and the patient is inappropriately treated psychiatrically with drugs when the cause of the impairment is structural brain damage.

Some cancer patients complain of “brain fog” following the initiation of chemotherapy.  To better understand these issues cancer patients should perform cognitive testing prior to and following initiation of a drug to treat the cancer. Most oncologists attribute this seeming impairment to the effects of depression and advise treating the assumed depression with drugs. This last is opinion and not proof. Ongoing cognitive screening of cancer patients treated with drugs would help to identify the source of the “brain fog” and whether or not it arose from depression or to the brain impairing effects of chemotherapy.  If the latter this would spare the cancer patient from being exposed to inappropriate drug treatment.

The above recommended changes to improve the system of Managed Care are only a few of the many needed for Managed Care to have a major role in improving the quality and cost of delivered healthcare to patients.