HEALTH CARE AS A COMMODITY

The benefits of the new approach are significant. The insurance companies can butt out of the doctor-patient relationship until the allowance runs out?which, if the technology is tuned correctly, shouldn’t happen. That should cut into the massive bureaucracy of reimbursement, copays and network referrals. Employers can offer their workers broader coverage since their employees can apply the medical allowance to whatever care they choose. And the employees can choose what drugs to use and what doctor to go to based on cost and need.

"It’s the radical free marketization of health insurance," says Goltz of Destiny Health.

But that free market aspect of the plan worries many health-care experts.

Even the man credited with conjuring up managed care, Uwe Reinhardt, an economist at Princeton University, is concerned. Reinhardt, along with others like Mathematica’s Chollet, say the new model could end up shifting cost to the sick and the poor by making them pay more for their care. In the United States, about 80 percent of health-care expense is incurred by 15 percent of the population, according to Reinhardt. But that’s not how the cost is currently distributed. There’s always been a cross-subsidy whereby the healthy pay more into a pool of risk to help cover those with more health-care needs.

"Normally we think this is fair. Something that, as a society, we should do," says Dr. Stephanie Woolhandler, a practicing physician who also teaches at Harvard Medical School. "These plans eliminate that."

With the new plans, for instance, healthy people can choose less expensive generic drugs. They can choose to go to community hospitals, rather than the more costly teaching hospitals. The CRM systems will automatically generate a plan with lower cost for someone who is healthy. A chronically ill patient who needs brand-name drugs and requires specialists simply won’t be offered the choice of the less expensive plan. And since research shows that the poor are more likely to be chronically ill, the most expensive customized plans may be offered to those who can least afford them.

The new plans create a two-tiered system in more ways than one. The technologically literate who have access to the Web are more likely to benefit from the CRM offerings than those not so connected.

Already, some doctors have started offering 24-hour "concierge" service whereby a patient can pay for the doctor’s 24-hour availability and other deluxe services. It’s not a stretch to envision IT allowing insurance companies or providers to create Web content for the premium-paying customers only, or set up special e-mail addresses to which a doctor gives priority.