 |
 |
 |
 |
 |
 |
|
| ||||||
|
|
Home > Resources > eNews > Apr 2000 |
|
|
|
|
The Managed Care Insider eNews Volume Two Number 4 April 2000 PART TWO 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 New Medical Management Model By Paul Reich, M.D., Chief Medical Officer, Scheur Management Group United Healthcare started it and many more plans are considering modifying pre-certification processes so that requesting physicians have the final say. So, if a medical director of a health plan and a primary care physician disagree on the need for hospitalization to treat an illness, the Physician's view point will rule. It certainly makes sense, since the physician knows the patient best, but experience has shown that physicians are slow to integrate new methods of managing patients into their practice patterns, even though evidence in peer-reviewed journals suggests that a less expensive treatment yields the same or better results. Plans, rather than risk wasting financial resources, refuse payment for care they know to be inefficient and thereby incur the wrath of the physician community. Several factors can mitigate the risk to plans that wish to give physicians more say. First, they can modify their contracts with members and not cover services that might not be cost efficient or beneficial. As an example, albeit one that has evoked great emotion, bone marrow transplants for advanced breast cancer were often specified as a non-covered service in HMO contracts. Besides managing by benefit inclusion, plans can profile their physician network and deselect those physicians who practice inefficiently, giving the remaining physicians leeway to decide what's best for the patient. This profiling requires severity of illness adjustment and careful application to networks so that the physicians have a chance to explain their behaviors. Finally, since out-of-network providers of medical services account for much of the cost overruns, processes must remain in place to limit use of these providers or bring them under contract with acceptable fee schedules. Physicians have been operating under managed care rules for awhile now and it is likely that loosening controls in regions where managed care is prevalent will have a limited adverse effect. Case management of sick or chronically ill patients will also control costs by guiding physicians toward efficient practices and by limiting use of out-of-network providers. This will still allow maximum use of benefits, and even benefit exceptions, to avoid complications and their costly therapies. Despite these and other factors, costs will likely increase in a more open medical management model, which means that some of these costs must be passed on in the form of increased premiums. Those employers who pay these increased premiums will realize that they have happier employees -- ones who are not in the middle between their health plan and physician when it comes to deciding what's best for them. ---------------------------------------------------------------- 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. Because our theme this issue is medical management and managed care, we have included sites which cover these areas. http://www.mgma.com/ Medical Group Management Association (MGMA): Trade association website with resources and information for physicians and other health professionals http://managedcare.medscape.com/Home/Topics/ManagedCare/ManagedCare.html Medscape's Managed Care resource information covers a multitude of topics including clinical management, practice guidelines, and pharmacy benefits http://www.ahrq.gov/research/mgdnote1.htm The Agency for Healthcare Research and Quality, formerly the Agency for Healthcare Policy and Research, offers a report on the managed care industry with discussions of trends, and changes http://www.ajmc.com/ The American Journal of Managed Care ---------------------------------------------------------------- What's New at SMG? On April 5th, the Baptist Health Systems in Birmingham, Alabama signed a letter of intent to transfer Health Partners SouthEast to our affiliate company, Venture Health Partnership Group (VHPG). See details at our website http://www.vhpg.com VHPG chairman, Barry S.Scheur, was featured in ads throughout Louisiana as he delivered his vision for the future of managed care. You can access this ad online at http://www.vhpg.com/vhpghome.nsf/webcontent/mediakitbssad.html ---------------------------------------------------------------- Rate Us! We need you to rate this ezine. It's easy! Just go to http://www.scheur.com/smghome.nsf/webcontent/ezinearchives.html and click on one or both of the rating sections. We appreciate your taking the time to do this. ---------------------------------------------------------------- End of PART TWO 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 |
|
Scheur & Associates, Inc. One Gateway Center, Suite 810 Newton, MA 02458 Copyright 2003, Scheur & Associates, Inc. All rights reserved. |
