November 11, 1999

UNITED HEALTHCARE 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.

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(November 8 and later)

GOOD MEDICINE AND GOOD BUSINESS

It’s hard to overstate the significance of UHC’s move. This is a sentinel event in the shift from managing cost to managing care!

It’s the right thing to do AND will prove to be an excellent business decision.

It’s another sign of the ending of the era of "MBAs Practicing Medicine".

UHC’s CARE COORDINATION PROGRAM

United is calling its new approach "Care Coordination". Here are some key elements:

	The final decision on medical necessity will rest with the treating physician.
	Physicians will still be required to notify UHC if a patient enters the hospital, requires home health care, or needs certain medical equipment.
	UHC’s staff may still ask for more information or suggest less-costly treatments.
	UHC’s 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.
	UHC’s 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.

What’s really different here? UHC will no longer "Just Say No" to a physician’s chosen course of care for an individual patient.

ADVANTAGES AND RISKS

	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 doctors’ shoulders than it has saved by doing so.
	Improved relationships with physicians? Let’s 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, UHC’s costs fell 8%. Worst case scenario...Care Coordination doesn’t work and UHC goes back to MBAs Practicing Medicine.

SHIFTING MEDICAL MANAGEMENT TO PHYSICIANS

What’s 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 to carrots.

The "sticks" approach of controlling physicians hasn’t worked very well. As noted in an earlier 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 UHC’s thinking goes something like this. "We haven’t figured out how to control the docs, and nobody else has. Yet, we’re being held accountable for THEIR medical decisions. NCQA evaluates OUR quality, yet 37% of our physicians don’t 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 don’t 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 UHC’s 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 UHC’s mandates. Those who understand the mindset of physicians will recognize the wisdom of this approach.

And what’s to prevent physicians from providing too much medical care? The eyes of NCQA, the public, and the press will now also be looking at physicians’ performance and demanding accountability for their medical decisions. The message for physicians could become "be careful what you wish for--you might get it."

As compared to other health plans, UHC has made significant investments in information systems and disease management programs. This positions UHC favorably in its abilities to:

If UHC is successful, physicians will want this support instead of viewing it as a challenge to their authority.

UHC’s Care Coordination approach shifts the playing field. Under the model of MBAs Practicing Medicine, the health plan’s relationship to physicians is one of using sticks to beat doctors into compliance. Under UHC’s 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 don’t 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!

CALIFORNIA MEDICAL 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 registration required).

This effort is worth watching. It’s 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 CREDIT

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 something right".

NCQA ISSUES "QUALITY PROFILES", A SHOWCASE OF 38 MODEL QUALITY IMPROVEMENT EFFORTS

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 women’s health, preventive care, chronic illness, behavioral health, and service.

NCQA RECOGNIZES NATION'S BEST HEALTH PLANS WITH INTRODUCTION OF NEW "EXCELLENT" ACCREDITATION STATUS

NCQA has identified 40 health plans it terms "excellent" by virtue of their commitment to clinical excellence, customer service and continuous improvement.

ENHANCING PERFORMANCE MEASUREMENT: NCQA’S ROAD MAP FOR A HEALTH INFORMATION FRAMEWORK

Building on a NCQA commissioned report, Schneider et. al. develop an integrated health information framework for the future.

See commentary

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.

WHY DON’T PHYSICIANS FOLLOW CLINICAL PRACTICE GUIDELINES?

This question is thoroughly examined in a report that reviews 76 (yes, 76) studies on the topic

Sorry to give away the ending, but the article doesn’t provide THE answer to this complex question.

E-CareManagement is an e-newsletter that tracks a major change in health care and managed care—the paradigm shift from “managing cost” to “managing care”.  This e-newsletter is brought to you by Better Health Technologies, LLC (http://www.bhtinfo.com).  BHT provides consulting and business development services relating to disease management, demand management, and patient health information technologies.

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