HMOs and managed care companies, in their tireless quest to save medical care from the machinations of scheming physicians and therapists, have created a whole new confusing vocabulary for the health care field. As a service to our readers, TAP has asked us to clarify some of these terms.
Provider, Consumer. Terms used by HMOs and managed care companies to refer to doctors and therapists (“providers”) who “deliver services to” (this used to be known as treating or taking care of) people who used to be known as patients (“consumers”). The purpose of these terms is to obscure the fact that health care takes place between specific individual human beings. The intent is to dehumanize the process and convey the impression that healing can be accomplished by interchangeable widgets on an assembly line. Since providers are all the same, why not use the least trained and least costly ones. Usage: “We've got to get you to a provider, right away.” “I want to be a provider when I grow up.”
Case Manager. Usually at least a high school graduate, whose purpose is to make medical decisions and deny care whenever possible. This task is simplified by avoiding the confusing complications that might occur as a result of a professional education or having examined the patient. The case manager makes decisions by looking at lists on a computer screen. Several policies keep case managers stress-free and happy in their work. Since they never actually see the patient, they are spared any unreasonable distress that might occur as a result of witnessing the patient's pain and suffering. Another advantage to using case managers, as opposed to actual professionals, is that they and their HMO employers are protected from any nagging concern about being sued as a consequence of their decisions (see ERISA, below).
Carve-Out. A term adapted from the ancient practice of human sacrifice, now applied successfully to companies hired by HMOs specifically to “manage” mental health care. As much as health care has deteriorated under the managed care system, at least it has always been an integrated deterioration. In this new wrinkle, mental health is split off from the rest of health care. This allows for the development of a whole host of discriminatory practices. The result? A five-fold decrease in benefits and a correspondingly huge increase in overhead and corporate profit, compared to the rest of medicine. Both the APA and the AMA have declared carve-outs to be inherently discriminatory.
Confidentiality. As defined by the Bennett Bill, now the Medical Records Confidentiality Act of 1995, “confidentiality” is what happens to medical information once the insurance company or databank receives it — all without patient consent, of course. To us, confidentiality means the opposite: the protection of the patient's information within our offices, unless the patient gives written consent for it to be released. However, the Bennett definition is now widely accepted in Washington, and the term is beloved by HMOs, who promote “confidentiality” legislation in order to gain unfettered access to patient information. (This is one of the reasons we have worked hard to get the term “privacy” adopted as the basis for the right of patients to have control of their own psychotherapy and psychoanalytic information.)
Credentialing, Recredentialing. Terms used by HMOs and managed care companies to gain status by creating the impression that they have the power to grant a “credential.” In regular parlance, “credentials” usually refer to degrees or certificates granted by universities or professional training programs, or possibly licensing by state agencies. No insurer or HMO has the ability to grant such a credential. In fact, the process merely involves whether the therapist may participate in the HMO panel, or list of approved providers. A more accurate term therefore might be “empanelment,” “re-empanelment,” or “participation.”
ERISA. Acronym for the Employee Retirement Income Security Act, a federal bill passed in 1974. Originally designed to protect employer-sponsored pension plans by putting them under federal jurisdiction and thus inaccessible to state suits, this act has arcane provisions that have been utilized in a way never intended at the time it was passed. The result has been that employer-sponsored health plans have also been interpreted as inaccessible to state suits. The effect has been to make managed care immune to state malpractice or liability suits brought through state courts, which is generally the only way such suits can be filed. Weakening or repeal of this bill would make HMOs accountable for medical decisions — a policy that would aim a dagger at the heart of the managed care industry. This issue is usually the chief point of conflict between Republicans and Democrats in patients' rights bills.
Medical Necessity. Along with ERISA, the heart and soul (if one can use either of those terms) of managed care. This one is pure genius, because it allows HMOs to advertise that they are giving all the care that is really necessary. You just don't need as much as you thought you did. So what is “medical necessity” anyway? The term actually has no meaning whatsoever! Consider this. The HMO, whose profit margin depends on giving you as little care as possible, gets to tell you how much care they think you need. They get to define medical necessity however they want. And you can't sue them. “Medical necessity” brought you “drive-by” deliveries and mastectomies.