The Managed Care System in the U.S
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PPO, HMO and POS are often summarized with the term ‘Managed Care’. Managed care is a good health outcome relatively than medical intervention. Not every visit to a doctor is required; nor is every test conducted, every medication prescribed, or every placement in an intensive care unit going to produce an effective outcome. Ideally, medicine must be ruled by rationality and efficiency in the choice and accomplishment of evaluations and treatments. This means that the variability between providers not simply should be but can be eliminated, and the only factors that must make a difference in deciding who to treat and what treatment to accept is the nature of the patient’s disease or injury.
An HMO is a health insurer that presumes responsibility for providing comprehensive health services to a properly enrolled population in return for a predetermined payment. HMOs come in several shapes and varieties. The traditional “group” and “staff” model HMOs still lean to contract with or employ an exclusive provider network. The newer “network” or “IPA” models contract with individual providers or groups of providers who retain similar contractual relationships with other health plans.
HMOs lean to “lock-in” patients. That is, unless they are eager to pick up the entire bill for going outside of the contracted network, HMO enrollees receive services simply from contracted or employed providers. Out-of-pocket costs to enrolled members are usually very low, usually either $5 or $10 a visit. But, as many consumers object to the lock-in feature, over seventy five percent of HMOs now offer a point-of-service (POS) option, which gives patients the option of looking for the care of a doctor outside of the HMO network for a price.
HMOs “point of service” (POS) option, which permits HMO members to go out of network whenever they choose and pay a particular co-insurance amount out of their own pocket. In its use of financial incentives for patients to obtain care in the designated network of providers, the POS option resembles a PPO. The major difference is that the in-network care normally takes place in an HMO’s cost-control environment, together with the use of gatekeepers and capped payments to physicians.
Patients joining an HMO entered a totally separate system for their health care. For some, mainly the young and healthy and those who had grown up in these programs, the alternative was pleasing. But for several individuals who had ties to personal physicians or who were more comfortable visiting customary solo or small group practices, care in a “clinic” was improper and they resisted the change.
A PPO is a much looser arrangement than an HMO and bears more semblances to traditional insurance, mainly in using fee-for-service payment to physicians. Patients can see any provider in the network, and pay simply a modest portion of provider charges. PPO members can also see providers not in the network, but for a considerably higher out-of-pocket payment. PPOs, thus, may offer more choice of provider but usually at a higher price, particularly to the consumer.
PPOs placed more reasonable restrictions on patient choice. For instance, in a typical PPO insurance product, patients usually pay 20 to 30 percent of the charge for going outside of the contracted network of providers, whereas a patient going out of network in an HMO has to pay the whole bill.
For employers willing to relinquish the benefits of self-insurance, the POS option offers substantial appeal. As it produces most of the cost savings associated with HMOs while preserving the safety valve for members to have a broader choice of providers, POS has been the longest growing managed care product in recent years. At present, over 75 percent of HMOs offer a POS option, (Dial and others, 1996) and perhaps 20 percent of Americans with employer-based insurance are in plans with a POS option, a raise from just 4 to 5 percent a few years ago.
The definitions suggest perhaps two core disparities that seem particularly important for our purposes here.
First, in HMOs, physicians are usually under much greater pressure to control costs. In PPOs, physicians are more expected to find—as in the old system—that they make more while they do more.
Second, HMOs usually involve a much tighter and more corresponding organizational structure. Amongst other things, this means that they can have more capacity—for better or worse—to apply the tools of managed care. It is for this reason that consumer concerns about managed care generally focus on HMOs. However, PPOs usually use one of the managed care tools that doctors resent most, specifically, utilization management programs that review and sometimes refuse the clinical recommendations of physicians. HMOs are often singled out and criticized for cost-control activities also performed by PPOs and even by more traditional, full choice insurers.
For many employers and individuals, HMOs, with their closed provider networks, were too preventive.
In addition to providing more choice of provider, PPOs proffer some employers another major advantage over HMOs. Due to details of insurance law, PPOs (but not HMOs) are much attuned with self-insurance. When self-insuring, employers technically do not purchase health insurance at all. Instead, they set sideways a pool of funds and directly pay their employees’ medical bills.
The advantage, as numerous employers see it, is the freedom from state insurance regulation that often mandates specific benefits or inflicts consumer protection procedures that normally increase the cost of coverage. The downside is that self-insurers are typically limited to using PPO products. And since PPOs still use the fee-for service payment mechanism, they are capable to use only some of the management tools that HMOs classically employ. Not surprisingly, purchasers have found that their costs for PPO care have fallen between those of customary insurance and a tightly run HMO.
Many health care analysts thought PPOs would provide as a transition from traditional insurance to HMOs. It was generally assumed that they would wither away as HMOs proved more cost effective and as employees came to believe the new restrictions. But as of their attractiveness to self-insuring employers and their compatibility with the public’s demand for choice of doctor, they have not simply survived but actually flourished.
However, through traditional HMOs, PPOs, POS plans and their variants, managed care now offers purchasers a broad variety of options. For those purchasers most concerned about cost, there are plenty of firmly managed HMOs around, many offering logically broad networks of private physicians whom their employees already see. For those employers who think HMOs offer too little option of provider, the POS variant provides a type of relief valve. For those who desire to avoid state insurance regulation, or who want a product that looks more like customary insurance, PPOs are widespread and ever more use many of the cost-containing techniques linked with HMOs.
Moreover, employers do not have to choose amongst many plans to offer their workers these options. Most PPOs now proffer a menu of products, so employers can pick one insurer and get a diversity of choices, thereby substituting choice within a plan for choice among plans. Moreover, as the POS option provides an opportunity for a covered employee to go to any provider, although by paying for the privilege, many employers no longer feel the require to accommodate employee demands for access to their own physicians by offering a choice of plans.
Those HMOs that tend to have restricted relationships with a group of physicians are expected to engage in different kinds of collaborative educational programs that raise the inherent capabilities of physicians to practice capably and cost-effectively.
In the larger and looser networks that distinguish IPA-model HMOs and PPOs, building collaborative relationships has proven much harder. In these less integrated managed care models, plans lean to rely on financial incentives or the more disturbing tool of preauthorization to control utilization. As a consequence, these plans may be capable to reduce the numbers of unnecessary procedures, but have less capability to improve the overall quality of care delivered.
Health plans have taken other steps to widen their networks. Responding to consumer demands for a wider choice of providers, group and staff-model HMOs have required adding networks of small groups and individual physicians. Network HMOs have provoked more providers into their networks. Whereas broader networks make plans more striking to consumers, they are at odds with strategies to raise market power through product differentiation.
HMOs have also sought to react to consumers’ demand for additional choice by developing point-of-service (POS) options. The viewpoint of Medicaid managed care has led HMOs to contract with community health centers and other providers that provide the low-income populations that they seek to add.
Pressure on premiums has provoked plans to increase efficiency through stronger management of care. This has, in order, led health plans increasingly to delegate this function to physician organizations. Plans contract with multi specialty group practices on the base of capitation. Some have expectant the development of independent practice associations to serve as intermediaries between physicians and health plans, fundamentally outsourcing the function of managing exploitation. In addition, plans are putting in the development of data systems to monitor practice and to support clinicians’ attempts to perform more effectively.
Information systems are also central to the growing use of preventive services. Plans have also prolonged the role of primary care physicians, expecting them to hold a larger scope of practice before referring patients to specialists. In some areas of the country, HMOs have constricted with organizations to provide services in a specific specialty, for instance, oncology, on a capitated basis. But this has not happened in areas in which multi-specialty group practices are strong. These organizations have long underlined the synergies of having diverse specialties in the same organization.
Critics of managed care programs have spoken two main concerns concerning their extension to Medicare. The first is that HMOs’ rationing of medical services will corrode the quality of care provided to beneficiaries. The elderly need, on average, considerably more medical treatment than the younger, employed enrollees who have traditionally constituted the bulk of HMO memberships. The fear is therefore that HMO cost-containment strategies, such as reducing hospitalization and limiting access to specialists, will have particularly adverse effects on health care for the elderly ( Gillick 1987).
Under provision may be a greater dilemma in POSs than in indemnity insurance, as prepayment and capitation give stronger incentives to constrain exploitation of medical services than does FFS payment. POSs can also have non-financial barriers to access, such as obtaining the authorization of gatekeepers for specialist care, which pose problems for the elderly.
HMOs in which the elderly do not characterize a substantial percentage of enrollees can lack the experience in managing their health problems and fail to widen special programs to put up their needs (Newcomer, Harrington, and Preston 1994; Schlesinger and Mechanic 1993). These concerns were fueled by a study from the Rand Health Insurance Experiment that found worse health outcomes for other susceptible population sicker, low-income patients in prepaid than in FFS settings (Ware et al. 1986).
Elderly patients with chronic illness can be at particular risk in HMOs. The supposed safeguard against under provision in prepaid plans is that it is in their financial interest to give early, proper medical treatment to patients in order to evade the subsequent higher costs linked with untreated illnesses.
HMOs keep patients healthy, in other words, as they will bear the costs of not doing so ( Luft 1981). This logic, though, does not hold for chronic conditions, as the costs of not providing such care can not fall on the plan, but instead can be shifted to family caregivers, public insurers, and social agencies (Schlesinger 1986).
For example, home care that is not provided by a health plan can be provided by a patient’s family, whereas seriously ill elderly patients can be placed in nursing homes at cost to Medicaid. As a result of not having to bear all these costs, HMOs can underprovide care to chronically ill elders.
The reliance of managed care plans on primary care gatekeepers can also adversely affect care for the chronically ill. There is proof that primary care physicians lack sufficient expertise to diagnose and treat some chronic conditions (Mechanic 1994; Schlesinger and Mechanic 1993; Gillick 1987). This problem is compounded by POSs’ disinclination to pay for medical care where the norms of treatment are blurred, as they often are with chronic illness. The absence of clear standards is used by health plans to validate not paying for “unnecessary” medical services for chronically ill patients. But critics note that it cannot be assumed “services are unnecessary simply because norms of treatment are badly defined” (Schlesinger and Mechanic 1993: 129).
Finally, the inconsistency of costs for the chronically ill puts pressure on capitated providers that have higher-cost patients (Kane 1995; Schlesinger and Mechanic 1993; Gillick 1987). Under such payment arrangements, physicians have incentives to underprovided services, persuaded patients to disenroll, or avoid taking on chronically ill elders as patients ( Schlesinger and Mechanic 1993).
The second concern is regarding PPOs that capitated payment will lead to federal overpayment of HMOs, opposing any potential cost savings to Medicare. PPOs contracting with Medicare receive a capitation payment based on average expenditures for non- PPO Medicare beneficiaries. Medicare expenditures, though, is highly skewed; 10 percent of beneficiaries accounted for 70 percent of program expenditures at a per-person average of $28,120 in 1995.
The average Medicare expenditure in 1995 for all beneficiaries was $4,020, and 18 percent of beneficiaries accounted for no program expenditures (Kaiser Family Foundation 1995). If PPOs disproportionately enroll healthier beneficiaries and evade the most expensive 10 percent, this positive selection will allow them to make large margins on capitation payments based on average Medicare expenditures.
Medicare could lose money on PPOs if the capitation payment exceeds the medical expenditures that comparatively healthy beneficiaries would have had under Medicare FFS ( Iglehart 1985, 1987; Brown 1983). In theory, risk adjustment that alters payments to imitate enrollees’ expected medical expenditures can avert this outcome, but concerns have persisted over the sufficiency of Medicare’s AAPCC risk-adjustment system.
A steady rhythm of media criticism often suggests that all managed care works pretty much the same way. Nothing could be beyond the truth. Organizations tailor everything from their marketing posture to their relationships with doctors to fit what they think purchasers and consumers in their local markets will want and to what they think will turn a profit. Moreover, the shape of managed care changes and develops, often in ever faster cycles. Analysts are always pointing to trends, and many assertively predict which types of plans or arrangements will prevail in the immediate future. But, as often as not, they’re wrong.
Today, if one trend stands out, it is hybridization. HMOs used to be classified into four types or models, known as staff, group, network, and independent practice association (IPA). The classifications were based on the nature of the relationships between the insurer/HMO and physicians. But in current years, these categories have become less useful, and sometimes even misleading. Today, most HMO plans are probable to be a mix of one or more of the models. And any one insurer can operate several different hybrids in different markets—even in the same market.
Plans also diverge by how they operate the strategies they employ, and the tools they use. Some health plans cautiously manage the activities of their providers and assume an active role in the management and organization of health care delivery. At the other end of the spectrum, several plans perform only the traditional insurance functions, leaving decision making on health care delivery and even substantial financial responsibility to providers or groups of providers. Some plans view physicians and hospitals as partners, whereas others consider them vendors with whom the plan should bargain.
Still, in a world of hybrids and variation, there are several core constants. There is logic to managed care that finds several form of expression in almost all plans, and there are certain tools of managed care that almost all plans will utilize, at least to some extent.
One way of looking at managed care is as a mirror image of the fee-for-service system. Preferably, fragmentation is replaced with organization, cost-unconsciousness with cost-consciousness, a blank check with checks and balances, and professional independence with accountability. Most particularly, the fee-for-service incentive to do everything possible is replaced by the incentive to remain patients healthy and to do only what may be essential and appropriate.
The logic relies greatly on more and better communication between nurse, primary care physician, and specialist about which of them must perform what services, about which treatments can work and which may not, about which providers might be doing too much or too little, concerning how to keep physicians up-to-speed, and about how to get patients more aggressively involved in caring for themselves. In sum, the logic of managed care assumes that the management of care will produce a more organized, more synchronized system that does a better job of both keeping costs under control and improving the health of the population to be served.
The Medicare modifications enacted by Congress in 1997 open the door to direct contracting between the Medicare program and groups of providers, called provider service organizations (PSOs). These reforms acknowledged a trend already evident in some markets: organizations of physicians, and sometimes physicians and hospitals, have been seeking to bypass insurers and contract directly with employers. In the new Medicare model, individuals will have a glut of choices, including HMOs, traditional Medicare, and the new PSO.
Employers, providers, and consumers all have good reasons to support and explore this new avenue of health care purchasing. Instead of choosing among Aetna, Prudential, and Blue Cross, the consumer might choose among a large local medical group, a system organized by a local Catholic hospital, another centered on the local university medical center, and even many traditional HMOs like Kaiser.
This kind of delivery-system choice might encourage competition on quality, as it may be easier for consumers to judge the quality of a local delivery system than that of a national insurer. Delivery-system choice may also encourage integration and coordination among providers; achieving higher levels of both would be vital for providers sharing risk and competing as a system.
How we broaden choice to take in delivery systems is another matter. The Medicare approach, by which individuals choose amongst insurers and delivery systems, is one model. California, where insurers offer consumers a long list of group affiliated primary care physicians, is another. An association of large self-insured employers in Minnesota offers still another deviation on the same theme. The coalition pays one HMO an administrative fee. That HMO then manages a menu of competing medical groups, who are accountable for providing a wide-ranging benefits package. Then employees choose among the medical groups, not insurers.
In some forms, the choose-a-delivery-system approach is burdened with regulatory complexities. These will, certainly, be a source of great revenue to health care lawyers across the country. As, purchasers and policy makers will require to make certain that critical consumer-protection measures that now influence licensed insurers do not fall away as control shifts from insurers to providers. Selection of delivery systems will also need that the current focus on comparing the performance of health plans be extended to the performance of providers—an especially complex task.
Still, consumer leaders, unions, and employee groups interested in promoting competition on quality must be studying these kinds of options. Legal complexities do not have to stand in the way.
Consumer understanding of health care trade-offs may start with costs, but should get beyond them. Many other, much subtler trade-offs need to be faced. The most critical of these involve assimilation, quality, and choice. As, systems that are more highly integrated—together with more physician attachment to the system, more coordination of care, better information systems, more use of protocols and guidelines, etc. have greater potential for delivering higher quality care. But included systems offer less choice of physician. Thus, it will be hard to find assimilation, quality, and wide choice under one health care tent. To a point at least, more integration and higher quality can be more compatible with less, not more, choice.
Today, choice is winning the competition. Enrollment growth has been far more dramatic amongst plans offering more choice. Many more incorporated plans have been experiencing much more modest growth.
Until more integrated managed care systems do a better job of proving their value, most consumers will persist to choose choice over integration. But the tendency to undermine assimilation in the pursuit of choice, as seen in some legislative proposals today, should be resisted.
The far more appropriate response would be to move toward employee choice of plan. If employees were free to choose their own plans, they could choose plans with which their personal physician was linked. They might then be less concerned about physician choice within a plan. Under this circumstance, the potential conflict between choice of physician and plan assimilation would be reduced. Choice and quality could go forward, hand in hand.
Information will be the livelihood of the new health care system. Fortunately, a small information revolt is already under way. The quantity of information accessible on performance of health plans, consumer satisfaction in health plans, authorization status of health plans, and even the inner decision-making processes and quality of care delivered by health plans is growing in multiples.
Digital Equipment Corporation, for instance, informs employees about the percentage of primary care physicians who are get on certified and even about the percentage of phone calls to the plan that are answered within twenty seconds. California State employees are told how many of their fellow employees switched from one plan to another and why (Moskowitz, 1997).
The recent release by the NCQA of its Quality Compass 1997 is exceptional in scope and detail, and much of it can be found on the Internet. And overall, the information accessible on health plan performance “report cards” today is far richer and more working than anything available just a few years ago.
Consumer, rather than employer, choice of plans would support this revolution, creating a far larger market for such information, and offering rich opportunities for intermediaries, like new publications, web sites, or consumer groups, that might produce and distribute more consumer-oriented information.
A revolt is also taking place in the generation of information on what works and does not work in health care delivery. The initial 1970s studies on practice variations are now part of a real “atlas” of such data, and the quality and quantity of such information will continue to develop and expand. Here, too, a government role is essential. Sophisticated research on clinical outcomes is expensive. Health plans or delivery systems are not probable to undertake major efforts on their own. Even while they do, they have an interest in keeping what they learn proprietary. Yet, keeping clinical advances and knowledge private does not offer public interests. (It may even violate medical ethics.)
Consequently, if the public values such research—and we must—government is going to have to pay for it. And since the private sector is not expected to disseminate research findings, government will require assuming responsibility for this function as well. Alternatively, of course, government could need that all plans contribute a small fraction of premiums collected to fund and disseminate research. But, either way, government has to see that it happens.
All through the managed care revolution, most physicians and their organizations have fought a cynical battle. They have objected to the tools, the restraints, the pressures to reduce costs, and the loss of physician sovereignty that managed care arrangements impose. They have fought with public relations efforts, by backing legislation that would guarantee those more rights vis-à-vis managed care plans, and with efforts to weaken public confidence in the new system.
In doing so, doctors have sometimes muddied the difference between patients’ interests and their own. Over time, this will not serve them well. If each time physicians are seen as “patient advocates” they are also professed as advocating policies that benefit themselves, leadership opportunities and public confidence will be hard to come by.
Admittedly, the new system poses stiff challenges for physicians, especially those intent on maintaining a binder to a patient-first ethic. Under fee-for-service, there was little conflict for an ethical physician. Putting the patient first in a capitated payment system, however, might affect the physician’s income; it could yet risk alienating health plans upon which physicians should rely for business.
But physicians require starting directing managed care rather than just opposing it. Their constructive criticism and efforts to push the new system toward enhanced quality are sorely needed and could prove a massive asset to consumers. Physicians need to point out where managed care strategies pretense dangers for consumers. They need to take the lead in developing tools and methods that will better facilitate all concerned to compare plans and providers on quality-related measures, together with outcomes of care.
Doctors could conduct and publish their own surveys on health-plan quality. And most significant, they need to blow the whistle on plans that inflict policies that undermine quality of care or consumer rights, a duty which includes their willingness to walk away from bad plans. Again, consumer choice would help here. Patients could follow their physicians, and leaving a plan would not essentially mean losing patients enrolled in the plan.
Recently, some physicians have seemed more agreeable to change and thereby have tried to influence the future of managed care. For example, a 1997 Wall Street Journal article reported on a pair of cardiologists in Minneapolis who were chafing under an HMO’s rules regarding cardiac catheterization.
Like doctors across the country, they felt they were being second guessed and micromanaged. To fight back, they developed and tested in thorough clinical conditions a protocol for determining which patients in fact need catheterization. Their evidence was so convincing that the health plan had to change its policies, and family practice doctors and emergency room physicians got a new state-of-the art set of guidelines for recognizing heart attacks in the bargain (Winslow, 1997).
In the larger scheme, more physicians can be recognizing that managed care, traditionally viewed as limiting physician clinical independence, also holds the potential for restoring it. In seeking to develop integrated systems competent of accepting capitated payments and the risk that comes with them, many physicians are recognizing that the re-establishment of physician autonomy can demand the acceptance of financial accountability.
To us, the merging of independence with accountability is not a compromise. It is a step forward. And today, the majority progressive physician groups recognize it as such. Rather than fighting insurance company oversight, they are seeking capitated payments from those insurers.
The most insistent of them— especially large medical groups and physician-hospital organizations—are seeking “full-risk” capitation, which means they accept full accountability for all the care the patient may need. In doing so, they assume the responsibility to deliver cost-effective care. More significant, as the ability to measure and compare quality improves, these integrated medical organizations must emerge as the strongest marketplace competitors. Not only will they be best positioned to deliver high quality, they will also have a greater capability to demonstrate it.
Health plans demand the authority to choose their providers, place strong financial pressures on their physicians to practice in a different way than they did under fee-for-service, and make preauthorization decisions that may establish whether patients are able to obtain medical services their physicians recommend. Yet, if something goes seriously wrong with the care provided, health plans typically argue, effectively, that they had nothing to do with it—finally, only physicians practice medicine.
For the most part, state and federal law, based mainly on the broad scope of the ERISA statute, has supported this health plan posture and, as a result, health plans have generally been protected against lawsuits accusing them of wrongdoing. Thus, where alleged negligence occurs, patients can have little recourse but to sue the concerned physicians and other providers, even if the policies, procedures, or decisions of the plan were a main contributor to the poor outcome in a case.
In my view, managed care organizations must be liable for the policies they have and the decisions they make, provided that it can be established that these policies and decisions directly harmed a patient. For instance, if a physician misses a diagnosis because the protocols imposed by the plan did not comprise (and the plan would not pay for) a test the physician thought should be run, the plan must be liable. If they direct patients to a surgeon with inaptly bad outcomes on certain procedures, they must be liable for bad outcomes that result. Like physicians seeking more self-sufficiency, plans seeking more control should accept the accountability that goes with it.
Such a policy might serve as a useful deterrent against the affinity to push cost containment and limitations on access and services to a point where they might intimidate a patient’s well being. And by allowing another means by which patients could seek protection, assigning managed care organizations legal liability for negligent performance might also lessen the need for some government-imposed rules on how managed care organizations deliver care.
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