Managed care’s new face means changes for access
Upfront collection effort key
The Portland, OR-based Providence Health Plan appears to be on the leading edge of a trend in managed care that likely will impact collections and customer service for access managers. There is even more impetus, it seems, for what is already becoming an access imperative — upfront calculation and solicitation of the patient’s share of the bill.
"Essentially, the [managed care] environment is that the funding arrangements with providers are changing," says Barbara Christensen, regional director of sales and marketing for the health plan. "In our market, the component where providers are capitated and at financial risk has lived its life. The way we’re changing is because providers don’t want to be at financial risk and consumers would like to control more of their care. "It is not a matter of managed care is dead,’ but rather who’s at financial risk and what is the role of the consumer in all this," Christensen adds.
Effective July 1, she notes, the health plan puts new products on the market that shift the risk from the provider to the health plan. With those new products, consumers pay for a bigger share of their care, Christensen says. "There is still easy access and no financial barriers to preventive care, like well-baby visits and immunizations and we are continuing to have a copayment [for those visits]," she explains. "But for specialty services and laboratory and X-ray, we now have coinsurance where the consumer has to pay for [a percentage of] the services." The consumer’s share, Christensen adds, is generally 20%. In exchange, she says, the plan member has access to any specialist in the Providence system and no longer has to have a referral from a primary care physician.
A shift in responsibility
Such arrangements are becoming more prevalent throughout the managed care industry, Christensen notes. Where historically the hospital’s bill has been "covered in full," more responsibility for payment is now shifted to the consumer, she adds. For that reason, Christensen suggests, hospitals — specifically their access personnel — will want to be aware of what the patient’s financial obligation is. "I would also say that the deliverers of health care services — whether the lab or inpatient or outpatient — will have to be prepared to tell people what the services cost," she points out. "Now that people are responsible, they’ll want to know coming in how much it will cost."
These changes, Christensen says, make the health plan — now called an exclusive providers organization — closer to a hybrid of managed care entity and traditional insurance company. Although this type of company "is a trend industrywide," she notes, "how quickly the market moves depends on cost. Employers are very cost-sensitive right now and this could be beneficial [to them]. Nationally, medical cost inflation is in the double digits and it’s not sustainable that employers can absorb that [increase] year after year."
Its research, Christensen says, has told Providence Health Plan that what it is doing "is very positive for the consumer. All our market information tells us that consumers want more choice and control and that physicians want less risk. This allows us to get more flexible production and diversification into the market." As part of its role now, the health plan is responsible for providing the strategies that manage medical quality and cost, she explains. "Those strategies become a critical component of our program. They had been so historically, but some of that responsibility had been moved to the physicians. Now the health plan takes that back."
Because the physician is no longer at financial risk for results, Christensen adds, "we can do things like have a hospitalist — a physician based in the hospital — doing case management on our patients, and we don’t have to worry about different physicians applying different criteria."
Companies had success with the traditional managed care model for years, she notes, "but physicians no longer want that responsibility and medical inflation has been such that it has lived its life cycle. I believe that consumers need to be part of the equation, just like with any other service they buy. As long as health care is privatized, most consumers don’t have any problem paying for part of the service, but they do want to be able to choose."
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