Less managing in managed care may mean more care, and costs

The Outlook

March 30, 1997|By M. William Salganik

OXFORD HEALTH PLANS, a New England HMO with 1.7 million members, last week announced a number of steps it said were designed to offer "wider choices, better information and broader decision-making power to the consumer."

In particular, it said some members would be offered direct access to care by specialists, without having to obtain approval from a "gatekeeper" physician. It also said it would aid consumer choice by giving members "performance profiles" on specialist teams, including success rates for particular procedures.

HMOs and similar managed care plans have controlled health costs by controlling patient access to the system. Can managed care plans manage less?

The fastest growing type of managed care plan has been point-of-service plans, in which patients can pay a deductible and co-payment and choose physicians freely. Is the industry moving to more choice and flexibility?

Ron Pollack

Executive director, Families USA, a Washington-based national organization for health consumers

I don't think one can look at the industry in a monolithic fashion. Some companies will play a leadership role in giving choices and in quality. Others are more oriented to the bottom line. I believe the Oxford announcement can have a salutary effect on portions of the industry.

I think there's an interest on the part of consumers to have their primary coordinator of care be a specialist. This is true of people with specialized health problems, with cancer, with multiple sclerosis. A number of the plans are recognizing that.

Consumers, I think, are very wary of some of the processes involved in determining whether they can see a specialist. When the primary care physician calls the health plan [for authorization to refer to a specialist], they're often talking to a nonphysician who reads from the protocols in a cookbook fashion. The more thoughtful plan executives are recognizing that the doctor can make decisions, that medicine is an art as well as a science, and that you can't practice cookbook medicine.

John W. Welch

Principal, Washington office, Foster Higgins benefits consultants

The fundamental tug here is between cost management and employee choice. From an employee's point of view, the Oxford announcement is going to be met positively, with "Wow, I can go to any specialist I want without going through that darn gatekeeper." The primary care physician is seen as a barrier, not as a manager of care.

Some plans are already experimenting with no gatekeeper. A lot of plans allow women to go directly to an obstetrician-gynecologist. Some plans have, in effect, granted authority to the primary care doctor to refer to a specialist without approval by the plan.

There are certainly instances where the patient doesn't need to go to a primary care physician, where primary care is adding no value and is adding layers to the cost.

The key rub is: With the loosening comes the fear you have lost control over utilization. That's a big concern. Actuarially, you would argue that a more open model would cost more over time.

John H. Wider

President, CIGNA HealthCare Mid-Atlantic

Is managed care becoming less managed? The answer is yes. It is moving somewhat in that direction, without giving up on those things have have brought about improvements. Costs have been moderated nationally in good part by what managed care has done, in part by limiting access. Now, managed care has been accepted by physicians, and they are in some ways modifying their behavior.

CIGNA has taken a unique position in terms of how it works and partners with physicians. We are careful in selecting physicians who have the same philosophy we do, and we give them a great deal of authority. They can refer to any specialist in the network without checking with us. We're trying to provide our physicians with information they never had before -- how the care they are providing compares with their peers.

Jonathan Weiner

Professor of health policy and management, Johns Hopkins School of Public Health

The essence of managed care is a delicate yet explicit balance between cost, quality and access to care. No one balance is right for every consumer or every employer. This is the essence of the decision we face as patients. Although it is clear that increased patient choice and freedom will lead to higher costs, some are willing to pay this expense.

Knowing that this freedom is appealing, plans like Oxford will certainly attract patients in the short term. The question is: Will their costs be competitive over the long term?

We really know very little about the trade-offs between access, cost and quality. Many plan managers are basing their decisions on common sense and seat-of-the-pants planning. The proprietary nature of the products doesn't lead to good information sharing.

Pub Date: 3/30/97

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