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Home > Resources > eNews > Apr 2000 |
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The Managed Care Insider eNews Volume Two Number 4 April 2000 PART ONE of TWO Welcome to 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. ---------------------------------------------------------------- This edition of the Insider eNews continues the dialogue, and the controversy, about medical management and managed care as an effective, efficient and humane health benefit plan. Information resources follow each article. As always, we invite your questions, comments and suggestions to insider@scheur.com ---------------------------------------------------------------- THE ULTIMATE HEALTH CARE DILEMMA: THE RIDDLE OF MANAGING MEDICAL CARE SUCCESSFULLY By Barry S. Scheur, President, Scheur Management Group; Chairman, Venture Health Partnership Group Success means many different things to people: to some it's personal happiness; to others it's fulfillment; to others it's financial achievement. But nowhere is the definition of success more challenging than when it comes to the Solomon-like riddle of how to manage medical care effectively to enable a battered managed care industry to regain its respectability. Most critics of the HMO and managed care industry cite the fallacy of insurers' philosophy that they are trying to manage care. The repeated complaint is that as an industry, we have managed cost by selecting providers based on the best contractual terms and by excluding through medical review those services that are too expensive or intensive. Physicians complain that the bureaucracy of managed care has resulted in their having to employ several people to handle the paperwork, documentation and confusion created by HMOs in the referral, authorization and pre-certification processes. "Let doctors practice medicine" has been a popular battle cry as our industry falls under even greater siege, as more health plans face financial challenges, and as the threat of insolvency looms over more and more troubled provider-sponsored plans. So what is the answer to the conundrum of managing medical care in a way that physicians and customers can support and accept? Or is it simply like one of those Gordian knots that can never be untied? Lots of people are filled with quick solutions and appealing media sound-bites, such as "All we need is proper data," or "Disease management will solve the problem," or "We're eliminating the role of clerks in making medical decisions, as if they really did so anyway." So, without having the wisdom of the Sphinx and not being a particularly good spin doctor, here are, nevertheless, my outspoken beliefs on how we come to a solution for managing the delivery of medical services in an appropriate way: 1. It's not simply about allowing physicians to do what they want. Under fee-for-service medicine, physicians did what they wanted without review and without regard to how the bills got paid, and people chose not to get care or to delay getting the care they needed. Managing care shouldn't mean substituting an HMO's judgment for that of a physician. When it comes to decisions about medical necessity, the managed care plan needs information about what the physician is ordering and, if it has really good Medical Director leadership, it should be able to help the physician understand the choices that may be available to him or her beyond one specific course of treatment. Doctors need to talk with doctors and particularly, when it comes to specialized services, physicians in an HMO medical advisory capacity need to be experts or have expertise available to suggest alternatives or other options to the treating physician. But when the discussion is over and the case is assessed, much like a consultation during medical rounds, the treating physician needs to be able to direct the course of treatment. Even in some circumstances, that course of treatment will have economic consequences to a patient because certain facilities may not be part of a network or certain benefits may not be covered. There is a philosophical stance held by many people that economics and costs shouldn't be part of our health care system. However, at this point in health delivery and health insurance's evolution, they are. Part of the dilemma we face now is that physicians want to be shielded from having to be "business people and benefits experts" so to speak, and having to tell the patient of the economic choices involved with various care alternatives. But the HMO may not be in a position to talk to the patient when a crisis is occurring, and so the patient gets expectations and then disappointments when his or her insurance benefits come up short with limitations. 2. When it comes to medically managing, physicians have been their own worst enemies. The reality of managed health insurance has been upon us for a decade. Several hundred physician- and hospital-sponsored plans were created in the last ten years, supposedly for the purpose of being a friendlier and more compassionate approach to health care delivery and financing. The fact that most of these enterprises were managed inefficiently, didn't get enough start-up capital or worse, ran out of money, and ultimately, didn't compete in the market place is a fact that needs to be acknowledged. Physicians don't like to admit that patients' choices are controlled by the insurance plans where they have chosen to enroll. What physicians need to do is tell those who are instrumental in the selection of employee benefits that certain plans are so restrictive and anti-patient that they shouldn't accept them. Lawsuits against managed care companies aren't the answer - choosing which companies are the least restrictive and deliver care is. 3. The answers to managing medical care start first with giving information to patients about the consequences and the advantages of becoming part of specific health plans. People need to make better choices depending upon their circumstances and medical needs. But, too often, the information they need from health plans isn't presented honestly or in a timely manner. People must take responsibility for becoming educated consumers choosing the benefits program they want, the freedom of choice with which they are comfortable, and the network that utilizes the physicians and hospitals they want. If people choose based solely on price, then they must understand the limitations and conditions imposed by their benefits plan, medical management approach, and network selection. 4. Employers also have a major stake in effectively managing medical care, one which they too often haven't taken seriously enough. Wellness programs, health promotion, and health education need to be incorporated and appropriately incented to give economic benefits to employees that actively participate in changing unhealthy behaviors and lifestyles. The HMO is being too often punished as the villain in managing medical care. Admittedly, many health plans, in their interactions with physicians, adopt a posture that supports such a perception. Late payments, retroactive denials of days and services, and the bureaucracy that too often accompanies referrals are not the keys to effective medical care delivery and management. Information, education, honesty, integrity, communication and evenhandedness are the keys. Let's stop the finger pointing and the sound-biting. Yes, it's a complex problem, but that's what integrating medical care and finance is all about. Let's build the dialogue. ---------------------------------------------------------------- The Managed Care Insider eNews welcomes your response to this column. Email us at Insider@scheur.com ---------------------------------------------------------------- What's New at SMG? On April 24th, Venture Health Partnership Group (VHPG), an affiliate of SMG, announced its cornerstone acquisition, SMA Health Plan of Louisiana, has changed its name to The OATH, Our Promise to Louisiana. Now one of the most financially sound health plans in the state, according to the Department of Insurance's Richard O'Shee, The OATH is about commitment to making change and striving to provide a physician partnered, consumer friendly, service oriented, health benefits company. To find out more, visit http://www.vhpg.com or http://www.theoath.net ---------------------------------------------------------------- E=MC SQUARED BEGINS! Now you can access your own set of managed care experts!... news!... information!... and Ask SMG! at the scheur.com SUBSCRIBERS ONLY site. JOIN US! Our NEW subscriber-based site will afford you access to all of these information resources with a monthly fee of $10 or annual fee of $100. To learn more, visit e=MC Squared now at http://www.scheur.com where you can access information, resources, and find shopping sites for your business needs. ---------------------------------------------------------------- Sites and sounds on the Internet SMG has no ownership of, nor does it endorse the following sites. This information is presented as a resource for subscribers. In keeping with this issue's focus on medical management and the dilemma faced by health plans, we present the following sites as information resources. The American Academy of Family Physicians offers its Annual Clinical Focus reports on diseases and disease management at http://www.aafp.org/acf/ Disease Management and Health Outcomes, the peer-reviewed journal of the Disease Management Association of America, can be found at http://www.adis.com/journals/diseasemanagement/index.html Accelerating Disease Management programs discussed in a Disease Management News article at http://www.mcoexecutives.com/disease.htm ---------------------------------------------------------------- End of PART ONE of TWO, The Managed Care Insider eNews, Volume Two, Number 4. Scheur Management Group (SMG) is one of the most experienced specialized healthcare operations management and business revitalization consulting firms in the country. Our expertise is in time-sensitive analyses, strategic business and market planning, operational re-engineering, and communications, as well as implementation of start-ups, expansions, and new products. The firm's clients cover the spectrum of insurers, managed care organizations, physician groups, integrated delivery systems, hospitals, employers, governmental entities, vendors, and other providers. Contributors to this edition are Barry Scheur and Paul Reich, M.D. Editing and Research by Judith Jaffe. Production Coordination by Nancy K. Belle. TO SUBSCRIBE: visit http://www.scheur.com/smghome.nsf/webcontent/ezine.html or send e-mail 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. Please take a minute to visit our eNews page at http://www.scheur.com/smghome.nsf/webcontent/ezine.html for archives, subscriber information and to RATE our ezine. Get up-to-the-minute health care news on-line at www.scheur.com Go to April 2000 Part 2 |
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