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.
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About the Author
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
Acronym and Style Guide 511