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Unmanageable CareAn Ethnography of Health Care Privatization in Puerto Rico$
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Jessica M. Mulligan

Print publication date: 2014

Print ISBN-13: 9780814724910

Published to NYU Press Scholarship Online: March 2016

DOI: 10.18574/nyu/9780814724910.001.0001

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Regulating a Runaway Train

Regulating a Runaway Train

Everyone Is Replaceable

(p.61) 2 Regulating a Runaway Train
Unmanageable Care

Jessica M. Mulligan

NYU Press

This chapter discusses the everyday nature of health regulation through audit, performance management, and corrective action in Puerto Rico. It sheds light on the unstable side of private enterprise by retelling the stories of former employees of Acme—one of the leading Medicare managed care corporations in the nation. The corporation is known for its “runaway train” principle when handling employees, a metaphor that explains the volatility created by the rapid growth of the Medicare Advantage market brought by privatization. Acme told employees not to expect stability and security and that everyone is replaceable. The image of the runaway train captures the momentum and sheer force of Acme's growth and constant transformation. The chapter uses Acme's principle to explain how the MMA had a major impact on the entire health care system in Puerto Rico by creating a lucrative market in Medicare plans.

Keywords:   audit, performance management, corrective action, Puerto Rico, private enterprise, Acme, health regulation, runaway train, Medicare, health care system

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