Fiduciary duty of health insurance corporations

[pickledpepperRN]

Is a corporations fiduciary duty to make a profit more important that a duty to provide the goods and/or services customers pay for? What if those "customers" are sick patients?

...A corporations prime responsibility is to shareholders. Managers have a fiduciary duty to maximise profits for shareholders and economic theorists advise that they have no responsibility to society....

...Corporate managers have maintained that the medical paradigm is obsolete and that health care is no different from any other commodity to be bought and sold. It is a service to be marketed. Rational argument did not prevail against the public relations machine and economic success. Corporate medicine's ideas have come to dominate thinking in the US health scene. These ideas accurately reflect an economic rationalist ideology which sees all human endeavour through marketplace eyes....http://www.uow.edu.au/arts/sts/bmartin/dissent/documents/health/columb_usa.html

One case in which the primary physician would not refer a man to a cardiologist. The man died of heart failure: http://biotech.law.lsu.edu/cases/hmo/shea_v_esensten.htm

A little law: http://law.enotes.com/everyday-law-encyclopedia/corporations

[wincha]

Insurance companies are now looking at wellness care, disease management to keep their members with chronic health conditions healthy. They also are steering their members to doctors who follow evidence based guidelines and facilities that also follow these guidelines. Yes insurance companies are a business and must show a ROI(return of investment) to show that these programs are saving money for their company and at the same time are keeping their members healthy

[wincha]

One case in which the primary physician would not refer a man to a cardiologist. The man died of heart failure: http://biotech.law.lsu.edu/cases/hmo...v_esensten.htm

As a RN working in disease management my goal would be to get that member to another pcp, a specialist and if his company pays for the benefit of DM would be to get that member into a DM program for CHF to help extend his life. Or to a case manager.

[pickledpepperRN]

Insurance companies are now looking at wellness care, disease management to keep their members with chronic health conditions healthy. They also are steering their members to doctors who follow evidence based guidelines and facilities that also follow these guidelines. Yes insurance companies are a business and must show a ROI(return of investment) to show that these programs are saving money for their company and at the same time are keeping their members healthy

I know that was the promise of managed care.

I think many people don't know how to access the care they need.

A college professor friend was diagnosed with type II diabetes. She cried when she showed me the pamphlet her primary doctor gave her with a prescription.

When I told her to askfor a case manager it turned out her HMO has a program with a dietitian and nurse educator teaching group classes for diabetic patients. All she had to do was ask.

I did hear a Health Net spoksperson admit that preventative care often keeps them healthy for the competition as soon as they change jobs.

Probably the man could have been referred to a cardiologist if he had asked.

[wincha]

This is what I do. Teaching about their condition, making sure their doctor is following evidence based medicine... finding another doctor if he/she is not following evidence based medicine. Finding specialists. Making sure the member knows about all of their health resources that their plan covers(this is what their employer has chosen to cover and isn't what the insurance company has decided). Help them find their medicines at the lowest tier..helps them be more complaint with their medicines and save money. Educate... work on getting their labs WNL through medicines, weight loss, excercise. Preventing complications. I am very successful and appreciated in what I do. I also access for readiness for change and if they are not ready I give the info and hope they contact me later. I work for a large insurance company. Many insurance companies are providing disease management even medicare and medicaid.

[pickledpepperRN]

This is what I do. Teaching about their condition, making sure their doctor is following evidence based medicine... finding another doctor if he/she is not following evidence based medicine. Finding specialists. Making sure the member knows about all of their health resources that their plan covers(this is what their employer has chosen to cover and isn't what the insurance company has decided). Help them find their medicines at the lowest tier..helps them be more complaint with their medicines and save money. Educate... work on getting their labs WNL through medicines, weight loss, excercise. Preventing complications. I am very successful and appreciated in what I do. I also access for readiness for change and if they are not ready I give the info and hope they contact me later. I work for a large insurance company. Many insurance companies are providing disease management even medicare and medicaid.

I am glad you are doing this.

Do you do case finding too?

Like if there is a nrely diagnosed person are you told?

[wincha]

My department receives this information in different ways. We get cases that trigger the medical condition ie A1C, lipid panel, hospitalization, claims. We reach out to our members who have this benefit with outbound calls and mailers. We also call them after they are discharged from the hospital.

[pickledpepperRN]

That is great.

Maybe my friend would have been "found" but i think her doctor should have told her.