MEDICARE MANAGED CARE : How Physicians Can Make It Better - 10/09/11
Résumé |
Managed care is the dominant form of health care delivery in the United States today. Sixty million individuals are enrolled in health maintenance organizations (HMOs), and another 90 million are in preferred provider organizations.13 Despite this level of penetration, the majority of the Medicare population remains insured, as it has since inception, on a fee-for-service basis.
Medicare was initially designed to cover only acute episodes of illness; therefore a fragmented payment system seemed acceptable. As seniors live longer, however, the need to develop coordinated medical programs to deal with chronic, often debilitating disease states is becoming more apparent. Currently, seniors represent 13% of the population but account for more than one third of all health care expenditures. In the year 2030, it is expected that their numbers will increase to 23% and that the need to control health care costs will be even greater.17
In an attempt to control anticipated increased health care costs, the federal government is providing the senior population with an increasing number of incentives to encourage their movement into managed care programs. In fact, the movement of seniors into managed care has already begun; Medicare managed care enrollees over the past 3 years now account for approximately 5 million covered lives, or 14% of the entire Medicare population. In the past year, Medicare managed care enrollment has grown by an average of 80,000 beneficiaries each month.13
As the conversion to managed care takes place, the federal government, in an attempt to ensure adequate provision of patient services, is closely scrutinizing those corporate entities entering the playing field. To encourage an increase in health care coverage, especially to the vulnerable groups identified in Medicare, the Physician Payment Review Commission (PPRC) is recommending that the Health Care Financing Administration (HCFA) pursue demonstration projects in a broad range of innovative and effective health care delivery approaches.13
Congress has proposed that provider-sponsored organizations (PSOs) enter the managed care arena to compete with existing HMOs for the Medicare population. The PPRC has suggested that PSOs may play one of three roles in the market:
1 | Contract directly with licensed HMOs and other health plans to provide services. |
2 | Contract directly with self-funded employers' plans. |
3 | Compete directly with existing HMOs to enroll members. |
The PPRC has further recommended that where the PSO becomes a risk-bearing entity, the plan would be required to meet the same standards of financial solvency as other currently existing plans. The PPRC also stated, however, that plan participation should be monitored to ensure that state and federal requirements do not impose unreasonable barriers to market entry for PSOs or other health plans seeking to participate in Medicare.13
The term PSO has been employed to include a spectrum of health care entities that are owned, governed, operated, managed, or supervised by physicians. The PSO may vary from a low level of integration, as occurs in a physician-hospital organization, to that of a fully integrated delivery system, in which the entity owns all practice assets, and all revenues flow to the providers.
Several factors are currently operative that provide physicians entering the evolving managed care arena a window of opportunity:
1 | The HCFA is requiring managed care organizations to provide expanded patient services, such as preventive care and wellness programs, at a time when price competition between companies is becoming more intense. Yet these companies are still expected to provide a significant financial return to their investors. In many parts of the United States, established plans with good track records are being underbid by highly invested new plans, forcing the former to restrict services to remain competitive. Concomitantly, employers and their enrollees are increasingly sensitive to price, resulting in companies and individuals frequently changing plans, thereby interrupting continuity of patient care and rendering preventive health care initiatives meaningless to the departing enrollees. |
2 | The current negative public perception of profiteering by corporate HMOs has resulted in a public backlash.3 This reaction is evidenced by federal and state legislative initiatives, legal actions accusing HMOs of denying care, and an outcry over gag rules and financial incentives that make physicians reluctant to advocate certain diagnostic and treatment approaches. The public is essentially linking denial of care with excessive profits for HMOs. The public is becoming incensed by reports of HMO chief executive officers making huge financial windfalls while denying medical care to patients. To inflame the public further, managed care companies have openly talked of the amount of the premium dollar devoted to health care as the medical loss ratio, which some companies boast has been reduced to 70% of each premium dollar.3 |
3 | Two changing attitudes are now coalescing: (1) public dissatisfaction with corporate America's attempt to fix the current health care system and (2) physicians' willingness to accept cost control measures in exchange for regaining control of the practice of medicine. |
If physicians are to take advantage of this window of opportunity and successfully enter the managed care marketplace, they must identify the major deficiencies in the current model and fashion a new product that divests itself of the excessive profit orientation of current corporate HMOs. The reduction (or elimination) of the profit motive will allow a much needed reemphasis of medical services now lacking in current models.
Market-driven health care, as it currently exists, attempts to limit patients' choices, provide financial incentives that encourage practitioners to limit medical utilization, and narrow the benefits package to exclude certain medical services.7 Because patients are frequently unable to predict which future services they may need, they are at a disadvantage when identifying the strengths and weaknesses of various plans. The patient's awareness of the varying conflicting financial incentives imposed on the physician by managed care systems brings into focus the question of whether the physician is truly acting in the best interests (as an advocate) of the patient. This potential conflict of interest threatens the trust between physician and patient, a perception that always has been considered a necessary prerequisite to providing optimal medical care.10, 11, 14, 15, 16
In an attempt to remain cost competitive, for-profit corporate HMOs may attempt to attract only the healthiest patients possible. Considerably less effort has been expended in dealing with either the more complex disease states requiring multidisciplinary intervention or the appropriate care for the multitude of chronic diseases that particularly afflict the aging population: diabetes, hypertension, arthritis, chronic lung disease, congestive heart failure, and cancer.6
Corporate managed care attempts to limit costs by reducing patient hospitalization and elective surgical procedures. Various strategies have been used to achieve this goal: capitation arrangements, selective financial incentives to physicians, and gatekeeper arrangements to constrain therapy and specialty referrals. Perhaps the most effective mechanism employed to constrain expenditures involves utilization review, which may take the form of precertification, concurrent review, second opinions, or case management for high-cost enrollees. Although useful in their ideal form, these strategies often result in significant frustration for both the physician and the patient in the pursuit of what may often be appropriate medical care.14 The boundaries of necessary and appropriate care are often so indiscernible as to allow unreasonable manipulation by case managers in determining appropriateness of diagnostic procedures and treatment choices. Confounding this issue is the frequent lack of appropriate grievance mechanisms for patients or their physicians in their discussions with case managers.15 Many physicians regard the possibility of summary dismissal, which may be exercised without due process, as the most onerous financial disincentive imposed by corporate for-profit managed care organizations.
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| Address reprint requests to: Gary M. Roggin, MD, FACP, FACG, PA, Camalier Building, 10215 Fernwood Road #401, Bethesda, MD 20817 |
Vol 26 - N° 4
P. 763-771 - décembre 1997 Retour au numéro
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- MEDICARE MANAGED CARE : Why Is It Coming?
- Gail R. Wilensky
- CAPITATION : Theory, Practice, and Evaluating Rates for Gastroenterology
- Michael L. Weinstein
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