Managed care companies: Adore them? Pity them? Do away with them? Or reform them? Whether you love them or hate them, this article will give you a glimpse nside a managed care organization. You’ll learn how many of them are organized to deal with the daily dilemma of reducing costs while trying to improve quality.
Yes, there have been abuses in managed care organizations, and there’s plenty of room for improvement. But managed care is also taking a lot of heat for problems they didn’t create. Managed care is caught in a crossfire between employers who want to keep costs down, patients who want the best possible services, and physicians who don’t want any care to be managed at all.
Think about it like this: Have you ever gone through a time when you didn’t have enough money to pay all your bills? When your kids needed clothes, your refrigerator was empty, or you needed to replace a broken-down car? What did you do? Probably, you limited what you bought and tried to get the best possible deal. Perhaps you settled for something that was pretty good, but not the very best. Managed care today finds itself in a similar situation, as it too is on a restricted budget. There’s a limit to the premiums that employers, consumers, and government agencies like Medicare and Medicaid are willing to pay.
Costs Are Rising
Yet health-care costs keep rising. New technologies, like magnetic resonance imaging (MRI), for example, are expensive. Frequently they don’t replace older technologies like X-rays; they just add an additional cost. And as the baby boomers age and start requiring additional health care, the situation will worsen.
What’s ‘Best’ Is Debatable
To add to the complications, there is only limited evidence on which medical treatments are truly effective. Part of the problem stems from the way medical records are kept. In most settings, health-care record keeping is no more advanced than accounting was in the days of Charles Dickens. For example, in the typical medical office, treatment results such as blood pressure levels are recorded on thousands of pieces of paper in hundreds of individual patient charts. Even two physicians who work together every day have no accurate way to measure who is more successful at treating high blood pressure, diabetes, or other common ailments.
For many major illnesses, nationally accepted guidelines have been published by professional groups, but even these are sometimes based more on professional opinion than hard research. Thus, it is difficult to know for sure what treatments are truly the most effective and that therefore must be covered. And even for treatments that are effective, they don’t necessarily work in all patients.
What Can be Done
What’s a managed care company to do? Many managed care organizations use two departments, under the supervision of the medical director, to muddle through the cost versus quality dilemma. These departments are utilization management and quality improvement.
The goal of the utilization management staff is to limit the amount of care that is given. If a patient has an expensive condition (such as a heart transplant) a staff member may be assigned to that patient to monitor the use (and cost) of health-care resources. Typically, this is the department that physicians or their staff contact for “pre-authorization” before admitting a patient to a hospital. Also, this is usually the staff that oversees the referral process.
Generally, quality improvement departments are supposed to make sure that patients get as much of the very best care that they need. The staff is responsible for monitoring the process of delivering health care (for example, the percent of patients who have had necessary tests and immunizations). More recently, they also have been examining the outcomes of health care, such as blood pressure and diabetes control. This, however, can be a very time consuming (and expensive) task. It sometimes requires that a managed care nurse go to each physician’s office and page through the paper records to gather the data (such as blood pressure levels) necessary to measure whether quality care has been provided.
The quality improvement department also makes sure that each doctor has a copy of the latest care guidelines for each major illness (though there is in fact little they can do to be sure that they are following these recommendations). The work of the quality improvement department must meet criteria set by independent organizations such as the National Committee on Quality Assurance.
The role of the patient in the cost versus quality debate is coming under increasing scrutiny. Studies repeatedly show that nearly half of patients with chronic illnesses like high blood pressure don’t take their medications as prescribed. No matter how skilled the physician, or how good the medication, the quality of health outcomes will suffer if patients do not follow their doctor’s advice. Smoking, lack of exercise and obesity–factors under the individual control of most patients–also contribute to higher health-care costs.
Many managed care organizations have launched disease management programs in an attempt to improve these patients’ behaviors. The idea also is to help manage patients with complex medical conditions like diabetes and asthma. Some experts, however, say that patients who do not take good care of themselves should have to pay higher health insurance premiums.
If more patients participate in the disease management programs offered by managed care organizations, patients will be healthier and unnecessary hospitalizations will be avoided. And if their utilization management and quality improvement departments each do a good job, patients will get the best quality care at the lowest possible cost.
Article By: Dulce Tom DeLoughry, Ed.D., Medical Writer