The Abyss of Managed Care

Abstract

Modern American health care affords every hospital patient the inalienable right to emergency treatment, although this same system has yet to create any parallel infrastructure beyond the clinical delivery of such care. While today’s emergency department physicians across the nation have access to cutting-edge, integrated technology-based tools designed to improve patient outcomes by combining advances in medicine with evidence-based clinical guidelines, the science of overseeing managed care patients often appears to be light years removed from the era in which it was born. As a result, American health care has become a system of fundamental brilliance that finds itself limited by gross inefficiencies, a combination that has led to a symbolic, if not actual, nationwide revolution.

At their core, the 2010 Patient Protection and Affordable Care Act and the amendments set forth in the 2010 Health Care and Education Reconciliation Act address the concept of patient access, one of health care’s greatest challenges in recent years. Notwithstanding the 961 regulatory pages known as the Affordable Care Act, or “Obamacare,” the relationship between the patient and the entity responsible for covering the cost of care has received surprisingly less attention in comparison.

In California, the recent decision in Children’s Hospital Central California v. Blue Cross of California has been seen by many as the culmination, and by some as the resolution, of conflict between providers and payers within the managed care system. This article focuses on events preceding the Children’s Hospital Central California decision, how the managed care system of private payers has evolved over the past 40 years, and the challenges faced by payers and providers simply trying to coexist.