Can business sector's concerns help your staff appreciate managed care?
Surprisingly, payers and purchasers voice similar objectives as emergency providers
What do emergency physicians want from health insurers? Organizations outside the medical community, including business executives and health plan officials, say access to high quality health care for covered employees is their top priority.
Surprising to some perhaps, they also believe providers should be properly reimbursed for rendering appropriate levels of medical care. And virtually everyone thinks that emergency medicine holds a special place in the medical hierarchy. There has to be a safety net for the millions of insured and uninsured who otherwise would fall through the cracks without 24-hour medical care.
Even more surprising to some, when it comes to the objectives of most health care professionals, many insist they are in total agreement with physicians and hospital employees, that health resources should be directed in a manner that ensures the best possible clinical outcomes for patients.
So where is the disagreement?
The Managed Care Emergency Department sounded out a handful of business sector executives and health plan officials on their view of issues relevant to emergency providers' concerns. Here's what we found:
· Utilization and efficiency
While access remains a priority with the business sector, many executives contacted by The Managed Care Emergency Department also feel the health care system is rife with bureaucratic fat, and bogged down by clinical inefficiency and needless over-utilization.
"There is a general feeling that too many physicians out there are still performing too many tests," says Sally Coberly, PhD, director of public policy with the Washington (DC) Business Group on Health, a research group that represents the interests of some 160 Fortune 500 companies.
Managed care has in fact slowed the inflation rate
Fueled by negative media portrayals, the public has cheered over cynical depictions of managed care organizations (MCOs) as ruthless, profit-driven opponents of good medicine. Controversial lawsuits and reports of payment denials have fed the negative stereotypes of insensitive health maintenance organizations (HMOs).
Yet, while some of these portrayals are accurate, managed care has, in fact, helped slow the growth of health care costs, which, in turn, has benefited providers. The improvements have occurred even while hospitals and physician groups have cut costs and become more efficient and prosperous.
Rather than seeing payers as enemies, providers today are more willing to see themselves as allies working toward the same goals of keeping the health care system financially viable.
Physicians who once carped at the idea of contracting with MCOs have changed their views. "Providers as a whole have learned to live with managed care," Glenn Freas, MD, JD, told a Managed Care Emergency Department editor for an article published last May. "It's taken some time, but we've been able to survive this," says Freas, associate program director of the emergency medicine residency program at Allegheny Hospitals in Philadelphia, PA.
Yet at the same time, payers continue to frustrate providers with their frequent refusal to raise payment rates, their opposition to better contract terms, and their repeated claims denials despite protections such as prudent layperson laws. (For a report on the gains made by the prudent layperson standard, see the cover story in this issue.)
"Emergency medicine is one of those high-profile areas of debate for employers and health plans. It's like debating average length of [inpatient] stays, the cost of pharmaceuticals, and patient access to specialists," says managed care consultant Gary Appel, PhD, a vice president at market researcher SMG Marketing in Chicago, IL. "Somewhere in those discussions there's mention of cutting back on emergency department [ED] visits."
· Business sector perceptions of health care
But when asked, business sector officials, including health plan executives, project a different attitude. Publicly, most belie any long-term disputes with emergency providers on prudent layperson or any other issue involving managed care in the emergency setting. In contrast to Appel, most maintain that emergency medicine doesn't pose a problem for payers and purchasers in the same manner that access to specialists or long-term care does.
For one, EDs are viewed differently. Emergency providers are seen more as a needed public health service for acutely ill or injured patients. Regardless of the reimbursement debate, someone will have to render emergency services due to federal laws, and payers will have to contract with emergency providers as part of a comprehensive benefits package.
Business sector says it supports prudent layperson
· Prudent layperson standard
On prudent layperson, the business sector adhered mostly to the company line. "Most employers are supportive of prudent layperson," says Coberly of the Business Group on Health. "You have to be paid for emergency care. And you should be. End of story."
"People want and deserve immediate access to emergency medical care. And when there is a doubt regarding a medical emergency, does it really matter? So it costs a little more, but look at the potential costs of discouraging the service," says Appel.
In Michigan, lawmakers recently passed a measure that establishes a prudent layperson standard for hospital visits. The law becomes effective next month. "The standard will result in more patients being covered," says Tracy Baker, manager of state executive relations for Blue Cross Blue Shield of Michigan in Detroit.
However, Baker stopped short of saying whether insurers in the state support the standard. But she did acknowledge that the rule will provide greater access to providers for patients and will eliminate many disagreements over coverage. (Editor's note: When asked the same questions, other health plan officials either declined to comment or were not available.)
Under increasing pressure from providers and the public, in 1997 the health insurance industry adopted a more conciliatory policy toward the prudent layperson standard. In January of that year, the Washington, DC-based American Association of Health Plans launched an initiative called "Putting Patients First," which included a recognition of the standard.
However, since then health plans have individually differed on its acceptance nationwide. "It's been difficult to get a consensus on what should be left to a prudent layperson under the standard, especially in critical matters. Do we really want to trust a prudent layperson's judgment on what isn't an emergency?," says Baker of Blue Cross.
Employers don't bother with reimbursement rates
The conciliatory attitude voiced in public by payers has coincided with a deepening sense of gloom over the society's negative attitude toward managed care. In a 1995 survey of managed care executives, more than half stated they believed that a public backlash was brewing against the payer industry's over-riding emphasis on costs.
Yet, less than half of the same respondents indicated that the industry has placed too much emphasis on the cost issue, to the industry's detriment. The survey was conducted by executive recruiter Witt/Keifer, Ford, Hadelman & Lloyd in Phoenix, AZ. (For more data, see the chart on p. 99.)
· Reimbursements
Employers are more concerned about holding providers accountable for their negotiated contracts. They are less concerned about specific reimbursement rates, according to Coberly. They are also interested in quality improvement initiatives that can improve their employees' health status and lower costs. "The reimbursement debate isn't something that large employers are caught up in," says Coberly.
However, not all business-sector executives share that view. The nation's growing employer coalitions have moved aggressively into contracting directly with large provider systems. In many ways, they are cutting out the HMOs and performing the same functions without incurring the cost.
"As direct consumers of health care, we are very much concerned about reimbursement rates," says Anne Robinow, executive director of care systems and finance for Buyers Health Care Action Group, a coalition formed by the 30 largest self-insured employers in the Minneapolis, MN, area.
As a result, coalition members have taken a direct interest in managing costs associated with emergency visits. Years ago, the group imposed a tough $75 co-payment for all ED visits, which has given enrollees financial incentives to use lower-cost options such as neighborhood urgent care centers and physicians' offices. Thereby, coalition members have been able to hold reimbursements at levels deemed fair to both purchasers and providers, Robinow says.
The arrangement has worked well in part because the Minneapolis market has had years to adjust to managed care. "Market maturity certainly helps in bridging the gaps between providers and those who pay for health care," Robinow says. "The more mature a managed care market, the more likely that participants on both sides of the system have found a tolerance point."
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