“Persistent”

Future factors that will contribute to the convoluted mix of problems plaguing the healthcare system include concepts such as medical necessity and medical unbelievability (the latter is a term introduced in 2007 by Medicare). How are these new concepts for cost control measured? How are they defined? Why would a provider ever prescribe a regimen that is not medically necessary? Imagine the confusion of the average consumer reading the explanation of benefits noted above: “Services denied due to lack of medical necessity; however, please note that this does not mean that the services ordered by your provider were not medically necessary.” This statement would appear to be more “lawyer speak” than providing meaningful information to the patient.

That leads us to the concept of consumer-directed health plans. How is a consumer, without the training of a healthcare auditor, reimbursement analyst, healthcare professional, or claims analyst, ever supposed to self-advocate? What are we putting the consumer in control of? Are consumer-directed health plans of accountable care organizations (ACOs) another type of cost shifting? Will these new and emerging delivery models address the real issues?

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