November 11, 1999
PULLS MBAs LICENSES TO PRACTICE MEDICINE
In a story making national headlines
this week, UnitedHealthcare (UHC) has announced that it is giving
doctors the final say on treatments for their patients.
(November 8 and later)
GOOD MEDICINE AND
Itís hard to overstate the
significance of UHCís move. This is a sentinel event in the shift
from managing cost to managing care!
Itís the right thing to do AND will
prove to be an excellent business decision.
Itís another sign of the ending of
the era of "MBAs
United is calling its new approach
"Care Coordination". Here are some key elements:
final decision on medical necessity will rest with the treating
Physicians will still be required to notify UHC if a patient
enters the hospital, requires home health care, or needs certain
staff may still ask for more information or suggest less-costly
emphasis will shift to working with patients who suffer from
chronic conditions and to having an increased role in teaching
patients how to take care of themselves.
focus will shift to grading doctors over the long term. UHC will
continue to monitor quality and cost effectiveness of
physicians, and will have the option of dropping physicians from
its provider panels.
Whatís really different here? UHC
will no longer "Just Say No" to a physicianís chosen course of care
for an individual patient.
Improved public relations. UHC is seeking higher ground as the
tidal wave of health care consumerism sweeps the country.
Increasing amounts of health care information are being made
available to consumers over the Internet. Consumers deeply
resent when their health plan says "No" to doctor-recommended
care (even though in practice this occurs infrequently). UHC is
positioning itself as a more humane health plan.
Improved marketing. Picture Harry and Louise sitting at the
breakfast table poring over their choice of a health plan.
"Well, Harry, we can pick Care Coordination or MBAs Practicing
Medicine. What do you think?"
Reduced liability. Plaintiffs attorneys have been filing
lawsuits claiming that patients have been injured from denial of
care decisions made by the health plan. Care Coordination puts
the decision back with the physician and patient.
Reduction of medical monitoring costs. UHC calculates it has
been spending $90 million more to look over doctorsí shoulders
than it has saved by doing so.
Improved relationships with physicians? Letís wait and see.
What risks does UHC undertake with
the Care Coordination model? Very few.
The biggest risk is runaway medical
costs. However, in a pilot program in Tennessee, UHCís costs fell
8%. Worst case scenario...Care Coordination doesnít work and UHC
goes back to MBAs Practicing Medicine.
MANAGEMENT TO PHYSICIANS
Whatís really going on here? We
believe that UHC is implementing a strategic decision to shift
medical management decisions to physicians (where they belong). In a
nutshell, UHC is changing its approach with physicians from sticks
The "sticks" approach of controlling
physicians hasnít worked very well. As noted in an
edition of E-Care Management News, physicians direct over 70% of
medical expenditures. However, no one has figured out how to tell
physicians what to do. In a survey of health system executives, 59%
said the greatest barrier to clinical integration was "Lack of
physician support" (Modern Healthcare, August 30, 1999 p. 58).
We suspect UHCís thinking goes
something like this. "We havenít figured out how to control the
docs, and nobody else has. Yet, weíre being held accountable for
THEIR medical decisions. NCQA evaluates OUR quality, yet 37% of our
physicians donít prescribe ACE inhibitors for heart failure
patients--even though every guideline says this should be done. We
take the heat from the public, the press, shareholders, and the docs
themselves. Well...we might as well give the docs the accountability
for their medical decisions and let them share in the heat and the
glory. And...while we know physicians say they want the right to
make medical decisions, we know they donít have all the information
and systems needed to do this...so we better be prepared to continue
to support them."
The subtle, yet critical, difference
in UHCís new approach is the REQUIREMENTS on physicians. Physicians
will still be receiving both short-term and long-term feedback about
how UHC views their patterns of care. The real difference is that
physicians will no longer be REQUIRED to follow UHCís mandates.
Those who understand the mindset of physicians will recognize the
wisdom of this approach.
And whatís to prevent physicians from
providing too much medical care? The eyes of NCQA, the public, and
the press will now also be looking at physiciansí performance and
demanding accountability for their medical decisions. The message
for physicians could become "be careful what you wish for--you might
As compared to other health plans,
UHC has made significant investments in information systems and
disease management programs. This positions UHC favorably in its
identify high cost, high risk
patients and place them in appropriate care/disease management
support doctors with medical
management infrastructure (information systems, 24-hour nurse
support lines, clinical guidelines, etc.)
If UHC is successful, physicians will
want this support instead of viewing it as a challenge to their
UHCís Care Coordination approach
shifts the playing field. Under the model of MBAs Practicing
Medicine, the health planís relationship to physicians is one of
using sticks to beat doctors into compliance. Under UHCís Care
Coordination model, the health plan is offering carrots to
doctors--useful guidelines, suggestions, helpful staff that
physicians can view as support rather than punishment.
Will other plans follow? Most of them
donít have the information systems and disease management programs
in place that would allow them to undertake abandoning the MBAs
Practicing Medicine approach. However, relentless public pressure
will eventually force them to follow UHC.
Good medicine, good business. Hats
off to UnitedHealthcare for their bold move!
GROUPS SEEKING STANDARDIZED EVALUATIONS
Nine medical groups in California are
working together to develop a common data gathering and quality
report card approach.
Download file (Medscape
This effort is worth watching. Itís
an example of physicians banding together to take control of a
critical process which is now in the hands of health plans.
NCQA DESERVES SOME
Accreditation agencies have a tough
job and receive much criticism. The National Committee for Quality
Assurance (NCQA)is no exception. We would like to bring to your
attention a few NCQA efforts under the heading "Catch somebody doing
"QUALITY PROFILES", A SHOWCASE OF 38 MODEL QUALITY IMPROVEMENT
NCQA will distribute 10,000 copies of
a free 262 page publication,
Quality Profiles. The publication presents 38 model quality
improvement initiatives in the areas of womenís health, preventive
care, chronic illness, behavioral health, and service.
NATION'S BEST HEALTH PLANS WITH INTRODUCTION OF NEW "EXCELLENT"
NCQA has identified
40 health plans it terms "excellent" by virtue of their
commitment to clinical excellence, customer service and continuous
PERFORMANCE MEASUREMENT: NCQAíS ROAD MAP FOR A HEALTH INFORMATION
Building on a NCQA commissioned
report, Schneider et. al. develop an integrated
health information framework for the future.
Seven features are essential to this
framework: (1) it specifies data elements; (2) it establishes
linkage capability among data elements and records; (3) it
standardizes the element definitions; (4) it is automated to the
greatest possible extent; (5) it specifies procedures for
continually assessing data quality; (6) it maintains strict controls
for protecting security and confidentiality of the data; and (7) it
specifies protocols for sharing data across institutions under
appropriate and well-defined circumstances.
Health plans should anticipate the
use of computerized patient records and prepare their data
management for an information framework by (1) expanding and
improving the capture and use of currently available data; (2)
creating an environment that rewards the automation of data; (3)
improving the quality of currently automated data; (4) implementing
national standards; (5) improving clinical data management
practices; (6) establishing a clear commitment to protecting the
confidentiality of enrollee information; and (7) careful capital
planning. Health care purchasers can provide the impetus for
implementing the information framework if they demand detailed,
accurate data on the quality of care.
PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?
This question is thoroughly examined
report that reviews 76 (yes, 76) studies on the topic
Sorry to give away the ending, but
the article doesnít provide THE answer to this complex question.
E-CareManagement is an
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careóthe paradigm shift from ďmanaging costĒ to ďmanaging careĒ.
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