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Home > Resources > eNews > July 1999 |
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The Managed Care Insider eNews Volume One Number 1 July 1999 PART ONE of TWO Welcome to the first edition of The Managed Care Insider eNews. You are receiving this because you have subscribed; the eNews is never sent unsolicited. Subscribe/unsubscribe information can be found at the end of this eNews. The Managed Care Insider eNews is published, copyrighted, and owned by the Scheur Management Group, Inc. (SMG), http://www.scheur.com and is distributed monthly, free to subscribers. If you wish to forward this edition, you may do so only if the edition is forwarded in its entirety. No reproduction of any part of this publication is permitted without the express permission of the publishers. Introduction to The Managed Care Insider eNews by Barry S. Scheur, President, Scheur Management Group. It is with great pleasure that I welcome you to the first edition of the Managed Care Insider eNews. So why another publication about managed care? Aren't there enough of them already? What's missing is what forms the mission of this publication: realistic, no-holds-barred insights and analysis, whose purpose is to be practical, provocative, and operationally useful. Controversy and dialogue with readers are my intent; your comments are welcome and, if applicable, will be printed here. The eNews information is based upon several hundred years of collective knowledge and wisdom of consultants and executives who have successfully built, grown, and restructured health care companies, for optimum profitability and success. While the first issue tackles the keys to successful medical management, future editions will deal with branding strategies for your services and products; operational nuts and bolts of building and retaining managed care enrollment; avoiding mistakes resulting in poor financial performance of hospital integrated delivery systems; making the best use of management consultants, including practical methods for holding them accountable; compliance issues; Internet and managed care; global trends in health care; and more. We invite you to learn more about us at our web site, http://www.scheur.com ---------------------------------------------------------------- Insider Vision: The New Medical Management, Revolutionizing the Paradigm To most people, medical management means either a process for reducing health care expenditures within a managed care organization (MCO) or, from the consumer's perspective, the threat that appropriate medical care may be denied to them when they need it. While much public attention has been paid to outcomes management, clinical quality improvement, and providing the most cost-effective care in an optimal setting, the true purpose of and need for medical management have eluded the health care industry. As we look toward the millennium, it's time to ask a simple question: What do we really mean by medical management, and by what criteria do we judge its success? The concept of medical management grew historically from the principle that health maintenance organizations (HMOs) would integrate the financing and delivery of health care services, with the intention of coordinating care through the efforts of primary care or personal physicians. This "coordinated care" approach was embodied in the concept of "health maintenance" in the 1970s and 1980s: that prevention, early intervention and coordination of care would result in better care and outcomes for the patient. While not designed to be the main product, cost control was an element of this process. As the competitive market and financial pressures began to overtake the managed care industry, care management became more synonymous with cost management. Managing care began to focus on provider contracting and financial risk shifting mechanisms, whose goals were to reduce the cost of delivering care or transfer the financial risks and incentives for providing care, with the clinical well-being of the patient relegated to a distant third place. While some managed care companies will bristle when confronted with the notion that their primary interest is in managing cost and not the health status of patients, consider the following evidence. The managed care backlash "Managed care" has become a lightning rod for consumer dissatisfaction, stemming from the unhappiness of both the provider community (i.e., physicians and hospital executives) when facing impossible demands and threats from managed care companies, and the public whose "freedom of choice" is curtailed. While HMOs and managed care organizations have been responsible for reducing the runaway spiral of health insurance premium costs, most people are less interested in this achievement than worried they will not get necessary and appropriate care when they are seriously ill. Lawsuits for denial of care and failure to authorize the use of out-of-network physicians, and complaints that providers bill patients because they haven't been paid by insurance companies are on the rampant increase. The bureaucracy, paperwork and inability to get straight answers from MCOs have caused both physicians and consumers great anxiety. Managed care executives, who have been ripe targets for abuse regarding their high salaries, feel unfairly put upon. But those same executives probably would rank along with used car salesmen, lawyers, and politicians when it comes to assessing their credibility and integrity in the public's mind. This is a sorry state of affairs, and no amount of accreditation review, standard setting, or lofty pronouncements and research studies about how managed care companies are working to improve quality will change these perceptions. Physician and hospital dissatisfaction The failure of the 1994 Federal Health Care Reform effort can be attributed in part to the fact that consumers perceived that the proposed reforms targeted physicians. Although physicians have had their own share of public relations problems with Medicare fraud, overcharging, up coding, high incomes, and lack of sensitivity to patients, there is a great deal of truth in the fact that consumers still believe that the physicians and hospitals are most qualified to balance the competing forces of reducing cost and maintaining quality. The health care reformers' attack on physicians was a poor strategy in the face of increasing profits in the managed care sector, particularly in the case of for-profit publicly traded companies. Physicians are burdened with paperwork and authorizations for care, and practicing within financial formulas and guidelines in which they were never trained. It is not that managed care organizations are evil; in fact, the vast majority of their personnel try to do an honest job. But in the eyes of the public, the politicians and the media, the entire system looks broken when viewed from the simple perspective of providing care to those who need it. The "myth" of quality For almost a decade, there has been significant impetus to monitor and improve the quality of health care delivered through the increasingly complex maze of our health care system. But it is becoming quite evident that quality is only of importance when the price is acceptable. Neither consumers, employers, nor government purchasers want to pay more for health care services than they have to; hence, price still takes front and center stage in purchasing decisions. While it is true that encounter data and outcomes measures are becoming more important factors in the rating of managed care organizations, much of the measurement is still paper driven rather than measured at the level of customer satisfaction. The delay in getting an appointment is unacceptable, waiting times in physicians' offices are interminable, and answers to questions about claims can be lost in an endless maze of double speak and denial of responsibility. We may be measuring clinical quality with respect to the medical treatment and perhaps the patient's overall medical outcome, but not with respect to the patient's well-being or perception thereof. Limited medical influence on financial decision making It is true that all managed care organizations have a medical director, although the range of responsibilities encompassed by that job title too often does not include financial authority and autonomy equal to that of the chief financial officer or chief executive. A medical director's role is unfortunately too often confined to relationship juggling with physician organizations and individual doctors, with responsibility for the improvement of care, quality and patient satisfaction divorced from financial decision making. From one who has practiced in the industry for over twenty years, I am sorry to say that most medical directors are not treated as senior members of the management team, and their views on the financial boundaries beyond which clinical decisions cannot be taken are not given much credence. Disease management is primarily an excuse, not a solution In the last several years, disease management, focusing significant effort on protocols and interventions for a specific and usually high-cost disease such as congestive heart failure, cancer, diabetes, and asthma, has been trumpeted with great fanfare. Some advances have been made through this intensive effort, but the real issues of the patient's overall health, social, psychological, and support needs have for the most part been left untended. Disease management is what its name implies, providing an emphasis on the disease as an event isolated in time or longitudinally by specific body system, rather than on the much larger question of how we can best address the needs of a patient from a dynamic, ever-changing holistic perspective. The great increase in the demand for complementary medicine (acupuncture, herbal remedies, or other alternative forms of treatment) also reflects many patients' continued search for something better to meet their own health care needs. So what is the answer? There isn't a simple one. Most physicians aren't Marcus Welbys or gods. There is significant waste, mismanagement, duplication, and unnecessary care provided by our system. Until we really look at medical management as a process involving the person's integrated social, community, economic, financial and medical needs, we really aren't getting any closer to solving the riddle of providing managed care effectively; that is, providing and managing comprehensive care. We're just running ever faster and ever farther in pursuit of a problem we really don't understand and can't quite figure out how to solve. ---------------------------------------------------------------- Quotable Quotes: "We've met the enemy and it is us." (Pogo) "The difference between 'involvement' and 'commitment' is like an eggs-and-ham breakfast: the chicken was 'involved' - the pig was 'committed.'" (Unknown) ---------------------------------------------------------------- End of PART ONE of TWO, The Managed Care Insider eNews, Volume One, Number 1 Scheur Management Group is a nationally recognized change agent for the health care industry. We provide hands-on operations management and consulting services that improve your business and promote best practices in managed care. We deliver market-driven, customized solutions to clients in all segments of the health care industry. Contributors to this edition are Barry Scheur and Robin McElfatrick. Editor is Ruth M. Aaron. Research by Judith Jaffe. Production Coordinator is The Gracefield Group at http://www.gracefield.com/gg/index.html TO SUBSCRIBE: send email to insider@scheur.com with the word SUBSCRIBE in the subject and name, email, company, title, and country in the message. TO UNSUBSCRIBE: send email message to insider@scheur.com with the word UNSUBSCRIBE in the subject. Or visit our web site at www.scheur.com and go to our subscribe page. You can subscribe/unsubscribe directly from there. Get up-to-the-minute health care news online at www.scheur.com Go to July 1999 Part 2 |
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