A dozen benefits from the managed care movement. (Managed Care on Trial).

PEOPLE ARE LIVING longer than ever, our infant mortality rate is the lowest on record, and immunization rates and screening rates for mammography and Pap smears are at all-time high. At the same time, inflation of medical costs has slowed remarkably; some companies have even reported a reduction in medical costs in recent years (particularly in 1994-95). The value of health care dollars spent is at new heights, while our nation's health is at an unprecedented pinnacle. All this has been accomplished as more and more people are moving into managed care plans--there is a connection to quality and cost that is difficult to deny.

Today all forms of health care coverage, including PPOs, POS (point of service) products, and even indemnity plans are benefiting from initiatives developed, for the most part, within HMO model types. This article describes a dozen significant advancements in health care delivery that have come about through the evolution of managed care. The managed care movement:

1. Established standards and indices of performance

In establishing standards and indices of performance, managed care has provided a firm foundation for the pursuit of excellence outside the HMO model. The National Committee for Quality Assurance (NCQA), which grew out of managed care efforts, has developed performance standards and measurements called HEDIS (Health Plan Employer Data and Information Set) and, most recently, standardized member satisfaction tools to assess performance. The NCQA now accepts the reporting of HEDIS information for POS model types and has modified the standards so they can apply to evaluating physician service organizations, integrated delivery systems, and behavioral health organizations.

The NCQA has established more than 50 rigorous standards in the following areas: quality management and improvement, utilization management, credentialing and recredentialing, member rights and responsibilities, preventive health services, and medical records. When evaluating objective measures, HEDIS looks at effectiveness of care, such as immunization rates and the percentage of low birth weight babies. They review access and availability, for example, what percentage of children receive primary care? They examine the use of services, such as the frequency of selected procedures. Lastly, they analyze the cost of care by evaluating rate trends.

Any health care organization interested in measuring itself using objective indices could start by using HEDIS-like performance measurements. The HEDIS Customer Satisfaction Survey can also be used as a template to assess patient satisfaction. It asks, for example, how easy it is to get care quickly, how well claims are processed, and how well the doctors communicate.

2. Developed the science of access and availability

Health care delivery systems can determine the number of primary care physicians and specialists they need, the best location for facilities, the most convenient office hours, and the optimal approach to scheduling based on the science of access and availability.

The study of the appropriate ratios of primary care and specialty physicians to populations was a product of managed care--demonstrating, for example, that a health care delivery network needs more of some specialists, such as allergists, than it does others, such as neurosurgeons. Analyzing patient preferences and patterns helped providers realize they needed to extend scheduling and offer evening hours or weekend availability.

Managed care was also the impetus for geo-access mapping software that matches an employee population by zip code with a list of health care providers, showing how convenient a particular plan would be to those employees. Geo-access mapping can answer simple questions such as: What percentage of a company's employees would have access to two or more primary care physicians within five miles of their homes?

3. Instituted practice guidelines 

Early in the managed care movement, it became clear that there was remarkable variation in the way similar patient populations were being cared for from one state to the next, and even from one county to the next. This variation in care could not be explained based on the case mix of the patient population. Managed care found the answer to reducing this variation in practice guidelines.

Today, several thousand practice guidelines have been developed by nationally respected professional societies and non-profit organizations, as well as health-related divisions of the federal government. These practice guidelines, or algorithms, provide a framework of appropriate treatments and services for patients who fall into certain categories by clinical condition or diagnosis. Guidelines are reviewed by network experts and participant providers to allow for some local or regional modification and then disseminated throughout provider networks.

Implementing clinical guidelines has been supported by using clinical leadership endorsement, tying clinical guidelines to utilization management, building disease management programming, and creating incentives. Physicians adopt clinical guidelines for all their patients, regardless of the insurance coverage or product selected.

4. Enhanced the credentialing and recredentialing process

Historically, hospital peer review committees were responsible for initial credentialing and periodic recredentialing of their staff. This "good old boy" network was often criticized for inadequately policing itself. The managed care industry began to require health care delivery systems to "primarily' verify providers' credentials through direct access to medical schools and state medical boards. This led to the development of a credentialing verification organization (CVO) industry. In fact, NCQA certifies CVOs using a list of standards and a site visit audit tool.

A few years ago, Congress established the National Practitioner Data Bank to track the malpractice litigation history of all practitioners, along with any sanctions or termination of licensure. It is more difficult for a physician to establish a poor track record in one state and move to another with anonymity. Accessing this databank has been built into the credentialing process.

Perhaps more important than the initial credentialing of physicians is the continual re-evaluation of providers within a health care delivery system. Today, it is routine for health plans to evaluate the performance of primary care physicians and high-volume specialists every two years, granting those physicians who score well an opportunity to continue to participate in the provider network. In some highly evolved health plans, it is possible to pay doctors differently based on their performance. The reassessment includes member care evaluations, member surveys, transfer rates, grievances, utilization review, pharmacy management review, and disease management report cards. This format can now be used by all health care delivery systems for periodically reassessing their provider base.

5. Incorporated centers of excellence into member care plan

Patients used to access their local health care delivery system for care and rely on their local network of providers to refer them elsewhere if necessary. They rarely left their local or regional health care delivery system for care.

Managed care organizations recognized that better patient outcomes could be obtained by identifying and using "centers of excellence" for highly intensive care treatments, such as transplantation. By sending a high volume of patients to these centers, there was also an opportunity to negotiate discount pricing. With the money saved through this contracting, as well as from reduced complications and adverse events from using these centers, MCOs could offer this high-tech, high-touch approach to care. It is now standard to build a "centers of excellence" component into case management services for almost any health care product, including indemnity.

6. Applied benchmarking

Other industries have long understood the value of benchmarking--looking for examples of best practices that can be successfully copied and integrated in organizations. But the health care industry was slow in recognizing the benefit of applying best practices.

As provider groups consolidate and competition accelerates, the need to improve practice performance has become even greater. Practice management, fueled by managed care, applies the concept of benchmarking to improve the delivery of care at the provider or practice level. This effort positively affects the patients who seek care at a participating provider's office, regardless of health care insurer or model type.

The managed care industry has promoted similar efforts among health care organizations. By providing feedback and performance reports, benchmarking efforts are identified and highlighted to institutional peers. Instead of asking what went wrong, managed care is getting providers to attend to what was done correctly.

7. Pushed for outcomes measurement

Managed care brought some degree of competition to a field unaccustomed to operating in a more traditional business climate. Health care delivery systems became interested in outcomes measurements in the hopes of achieving an edge over competitors.

MCOs also sought to measure outcomes to better understand the value of dollars spent. To accomplish this goal, data warehousing was initiated, and the science of data mining was applied to health care information. Data mining led to the ability to assess providers with report cards on their performance compared to peers and offered remarkable opportunities in quality improvement. While most of the data, even today, on outcomes measurement is generated within the HMO, the quality improvements that take place through provider feedback benefit all model types.

8. Advanced disease management

While there are unique concerns between individual physicians and their patients, there are also broadbased services and treatments that all patients with a similar condition or illness need to receive. The ability of health care delivery systems to identify people and intervene with ways to help them and to measure the impact of such efforts is the essence of disease management.

Early on, this effort was confined to HMO model types identifying groups of patients, such as diabetics or asthmatics, and intervening with clinical pathways of care. More recently, however, disease management programming is available as an overlay on almost any product or model type. The recognition that care pathways established by nationally recognized professional societies and academic medical circles can be applied in a systematic fashion to a population of appropriate patients has led to health care improvements in and outside the HMO environment.

9. Promoted demand management

Many years ago, any discussion within a medical school regarding consumer empowerment was rare. Today, it is a prominent topic in health care delivery. The concept of "shared decision-making" has been an important component of managed care.

If patients are involved in selecting treatment options, they are more likely to be compliant, leading to better patient outcomes. In addition, if patients are active participants in their care plan, they are more likely to be satisfied with the services rendered. The managed care industry used a multimedia approach to getting information to the consumer in real time, including developing 24-hour nurse access lines, health education websites, and medical videos. These multimedia efforts are now widely available to consumers and health care organizations.

10. Applied technology assessment

Years ago, anything an individual provider recommended would be covered by the traditional insurance package. In the managed care industry's push to create some clinical sanity in the benefits package, technology assessment was born. The job of technology assessment is to see that patients receive all the treatments and therapies that are potentially available and effective. It also helps protect the patient from care that has not been proven to be effective. The application of technology assessment now extends well beyond the world of HMOs.

11. Initiated early maternity management

Recognizing better outcomes based on earlier maternity management, managed care organizations worked to initiate maternity care within the first trimester of pregnancy. As a consequence, more and more pregnant women are seeking care in the first trimester of their pregnancy, regardless of model type

Comprehensive maternity management programs were originally built into the HMO product to reduce prematurity and low birth weight among infants, as well as to reduce the cost for care. Maternity management programs identify, in a systematic fashion, pregnancies that are deemed to be high risk and refer the patients to tertiary care centers and specialists. The impact of such programming is remarkable. Aetna's L'il Appleseed Maternity Management Program has experienced as much as a 40 percent decrease in the number of days infants spend in intensive care nurseries per 1,000 births. In addition, it has documented a significantly reduced incidence of low birth weight and very low birth weight deliveries compared to the national average (5.1 percent and 0.71 percent compared to 7.08 percent and 1.3 percent respectively).

12. Integrated care and benefits

Patients traditionally would access specialty care without a primary care physician's assessment. Today, however, the majority of patients seek their primary care physician's opinion first--a crucial part of integrating health care and developing a "medical home" for a single medical record. Beyond the value of the primary care physician, the industry has also recognized the importance of coordinating pharmacy benefits and behavioral health in managing patient care.

Conclusion

The last 25 years have seen a remarkable transition in health care delivery. This transition was spurred by the emergence of managed care, which began in 1973 with passage of the HMO Act during the Nixon Administration. The managed care movement has not only influenced the care of the membership it has attracted over the years, but has also affected the care of all Americans through a multitude of health care delivery breakthroughs and applications..

Raymond Jay Fabius, MD, CPE, FACPE, is Senior Corporate Medical Director for National Accounts and Chief Medical Officer for Intelihealth (the consumer health website subsidiary) at Aetna US. Healthcare in Blue Bell, Pennsylvania. He has been giving presentations nationwide on the benefits that managed care has brought to health care. He can be reached by calling 215/775-6694 or via email at [e-mail].