The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

by Marc S. Ryan
The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

by Marc S. Ryan


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The Healthcare Labyrinth is not just a comprehensive guide to navigating health plans—it offers a blueprint for fixing our broken healthcare system.

The American health insurance system is anything but simple to maneuver. Health plan enrollees become entangled in an intricate and opaque maze of confusion, often resulting in frustration, regret, and deep debt.

In The Healthcare Labyrinth, health plan and healthcare technology veteran Marc S. Ryan seeks to demystify the U.S. healthcare system, helping Americans become wiser consumers and allowing them to navigate the maze with more confidence and certainty.

Marc walks through how the current system operates, tracing the dysfunction, high costs, and lack of quality to three major issues:

—a lack of affordable universal access;

—little focus on wellness, prevention, and care management; and

—outrageous pricing, especially compared to other developed nations.

Using his decades of experience, Marc outlines a bipartisan blueprint to transform America's unique system without upending the employer-based system. He relies on leading academic, research, and mainstream media sources from across the political spectrum to examine the U.S. healthcare system and compare it to those of other developed nations.

Product Details

ISBN-13: 9781645439936
Publisher: RealClear Publishing
Publication date: 05/03/2022
Pages: 528
Sales rank: 991,376
Product dimensions: 6.00(w) x 9.00(h) x (d)

About the Author

Marc S. Ryan is President of MHK, a fast-growing healthcare software technology firm. Marc was one of MHK's first executives after its founding in 2010 and previously served as Chief Strategy and Compliance Officer and Chief Operating Officer.

MHK's CareProminence platform focuses on improving the compliance, efficiency, and quality of various clinical and administrative functions for health plans and pharmacy benefits managers. MHK's MarketProminence platform focuses on enrollment and financial reconciliation products for Medicare.

From 1998 to 2005, Marc was Connecticut's State Budget Director and Secretary of the Office of Policy and Management, where he oversaw all aspects of state budgeting, policy formulation, and day-to-day management of state government. After leaving state service, Marc began his healthcare career. He has served in numerous executive-level policy, regulatory, compliance, business development, and operations roles at health plans. He has launched Medicare, Medicaid, commercial, and Exchange Marketplace plans.

In 2004, Marc was appointed by the HHS Secretary to serve on the federal State Pharmaceutical Assistance Transition Commission, which worked to integrate state senior drug assistance programs with the new Medicare Part D program. From 2005 to 2008, Marc also served on the Florida Agency for Health Care Administration's Medicaid Reform Technical Advisory Panel.

Table of Contents

Part 1 Why This Book?

Chapter 1 My Journey through the Labyrinth 3

Chapter 2 Uncle Otto: "All Hail Bismarckian Socialism" 9

Chapter 3 Origins and Brief History of U.S. Healthcare 15

Part 2 Fundamentals of U.S. Health Insurance

Chapter 4 Lines of Business 27

Chapter 5 Terminology, Part 1 (Key Plan Definitions) 33

Chapter 6 Terminology, Part 2 (Payment Issues) 49

Chapter 7 Terminology, Part 3 (Balance and Surprise Billing) 55

Chapter 8 Terminology, Part 4 (Clinical Practices) 67

Chapter 9 Fee-for-Service (FFS) versus Managed Care 75

Chapter 10 Types of Plans/Products/Coverage 89

Chapter 11 Players in the U.S. Health Insurance System, Part 1 95

Chapter 12 Players in the U.S. Health Insurance System, Part 2 107

Part 3 Where We Are Today

Chapter 13 Healthcare Statistics 121

Chapter 14 Pieces of the Healthcare Pie 129

Chapter 15 How a Health Plan Operates 141

Chapter 16 Why Do I Need Health Insurance? 157

Chapter 17 Commercial Line of Business 163

Chapter 18 What Are Dual Eligibles? 173

Chapter 19 The Medicare Line of Business 179

Chapter 20 Medicare Advantage Explained 197

Chapter 21 Why Medicare Advantage Is Good 219

Chapter 22 Special Needs Plans 231

Chapter 23 The Medicare Part D Drug Benefit 239

Chapter 24 The Medicaid Line of Business 255

Chapter 25 Why Medicaid Is Good 267

Chapter 26 The State Children's Health Insurance Program 279

Chapter 27 Obamacare Marketplaces/Exchanges 285

Part 4 The Future of U.S. Healthcare

Chapter 28 Our Dysfunctional Healthcare System 303

Chapter 29 Progress Toward a New Paradigm 327

Chapter 30 Various Healthcare Models 357

Chapter 31 What's Wrong with Medicare for All 365

Chapter 32 The Right Healthcare Reform Solution 377

Chapter 33 The Healthcare Consolidation Craze 407

Chapter 34 The Big Drug Debate 417

Chapter 35 The Aging of America Time Bomb 445

Afterword: What the CDVID-19 Crisis Has Taught Us 459

Acknowledgments 463

Citations 467

Acronym and Style Guide 511

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