A manual for managed care physicians: why needed, how developed, and how used.

Virtually every major business organization has evolved some sort of written structure and direction. In the corporate world, there are charters, organizational tables, mission statements, policy manuals, and employee handbooks. The latter generally serve to provide the employee with information about company policies and employee benefits and often include some indication as to the behavior expected of the employee. Due process procedures might also be outlined. Individual departments may supplement this general information with more specific details.

Professional organizations such as the American College of Physician Executives (ACPE) may have a corporate charter for business purposes and generally are governed by a set of by-laws, perhaps supplemented by a set of rules and regulations. In the case of ACPE, these documents define criteria for membership in the College, as well as in ACPE Forums and Societies; levels and/or types of membership; methods for advancement; etc. Professional businesses, such as hospitals, have charters, administrative codes, by-laws, and rules and Regulations on an organizational level that may be supplemented by departmental and/or sectional directives. Professional businesses have two types of staff-professional and lay. In the hospital setting, the need for different rules for each group is generally implicitly acknowledged. The corporate structure sets policies and rules for employees (lay) while the medical staff (professional) has its separate set of by-laws, rules, and regulations addressing professional issues. Physician employees of the corporation are generally subject to both sets of regulations.

Depending on how an organization or business develops and grows, it may or may not have a formal structure and set of rules. As an example, a loose association between two or three physicians for purposes of cross-coverage may become a formal partnership or group. Most likely, there will be an understanding--oral or written--as to coverage responsibilities and financial arrangements. The group may later add more physicians, with contractual issues focused on finances and duties.

As medical practice evolves into larger groups and managed care becomes more prevalent, organizational changes and more structured relationships and responsibilities are needed. New physicians entering into such groups need to be made fully cognizant of the organization, operation, mission, and goals of the group. In managed care settings, new physician employees need to be oriented to the differences between the styles of practice in a managed care setting and the traditional setting that most will have experienced to that time.

Background

To fully understand the "how" and "why" of the development of HMO Blue Health Centers' Physician Manual necessitates a brief summary of the organization.

HMO Blue Health Centers began in 1973 as a group practice, Mercer Regional Medical Group (MRMG), associated with Mercer Medical Center (MMC) in Trenton, N.J. MRMG contracted with Blue Cross of New Jersey (BCNJ) to serve as the provider site for what was then Blue Cross' Medigroup HMO.

In 1980, the legal authority to operate the HMO was transferred to Blue Cross/Blue Shield of New Jersey (BCBSNJ), which expanded Medigroup to cover the State of New Jersey. This expansion took the form of an independent physician network (IPN). The HMO is largely still an IPN model. In 1984, BCBSNJ purchased the group practice, now known as HMO Blue Health Centers (HBHC).

Shortly after I assumed the role of Medical Director for the Health Centers in April 1990, the HMO Blue organization put together a committee to revise and update its Quality Assurance and Utilization Review Manual. As I participated in that project, it became clear that, because of the preponderance of members and physicians in the IPN, information and systems were heavily weighted to the needs and operational details of the IPN. IPN physicians received information on policies, procedures, etc., but there was no formal dissemination of information for HBHC physicians. IPN-specific materials were not necessarily relevant to HBHC physicians. Therefore, materials would need to be developed to address specific Health Centers issues.

As problems arose, I found myself addressing each of them individually with isolated policy statements, memoranda, and educational materials. Appropriate literature (journal articles etc.) was disseminated as a means of education. With the passage of time, it seemed appropriate to codify all this information so that it was known to all and was readily accessible. Although the manual was largely developed unilaterally by the medical director, there was input from other relevant sources.

Contents and Rationale

The contents of the manual are shown in figure 2, page 40. A brief explanation of each item is given below, along with the rationale for its inclusion if this rationale is needed for clarity. The preface to the manual is shown in figure 1, below.

Figure 1. Preface to Physician Manual

This Physician Orientation Manual is designed as a reference for you while working at Medigroup. It is acknowledged that it is voluminous and that only a small section needs to be read immediately so that you can orient yourself. The remainder can be read as desired and/or as needed relative to a given situation. This preface, in an outline form, will describe the composition and use of the manual. Section I: Basic Manual that you should read as soon as possible. It is only 15 pages and describes daily systems. Section II: Appendices relative to Section I for reference. Section III: Useful HMO Blue Health Center-related information. Subsection A is operationally related. Subsection B is more informational. Section IV: Various articles for your information, to be read at your leisure.

Figure 2. Contents of Physician Manual

Preface

Section 1. Basic Manual

I. Introduction II. Mission Statements III. Service Credo IV. The Primary Care Physician V. Incorporated Standards and References VI. Recruitment of Physicians VII. Physician Evaluation/Advancement VIII. Physicion Termination IX. Managed Care Philosophy X. Documentation XI. Duty Responsibilities (See Appendix B) XII. Patient Appointments XIII. Scheduled Time Off XIV. Continuing Medical Education XV. Durable Medical Equipment Requests XVI. Meetings XVII. Emergencies/Codes XVIII. Member Rights and Responsibilities XIX. Member, Primary Customer Needs XX. Confidentiality XXI. Orientation Program

Section II. Appendices

A. Credentialing Standards B. Performance Appraisal C. Self-Evaluation Form D. Grievance Procedure E. Sample Flow Sheet F. Medication Record G. Tickler Sheet' H. Transfer Protocols 1. Hemoccult Documentation J. Adult Screening Criteria K. Documentation Tips L. CME Policy, Procedure, and Documentation M. Pediatric Progress Sheet N. Acceptable Abbreviations O. Medicine Progress Note P. Home Infusion Services Q. Home Oxygen Therapy R. Protocol for No-Show Patients

Section III. HMO Blue Health Center Information

A. Memoranda 1. Comparison of Product Guides 2. Consultation Reports (QA Implementation) 3. Mental Health Services 4. OB Patients/Medical Consults 5. Pediatric Surgery 6. Physician Time Schedule 7. Elimination of DRGs 8. Changes in Hospital Reimbursement/LOS 9. Scheduled Hours 10. Scheduling Time Off 11. E.D. Referrals/Authorizations 12. Referral to Specialist 13. Specialty Referrals 14. Consultants Ordered by Consultants 15. Denial of an Authorization for Out-of-Panel Referral 16. Suture Removal 17. Routing of Outside Provider Reports 18. Prescription Refills

B. Other Information 1. Medication Costs 2. Seizure Patients/Driving 3. Utilization Review Coordinators/ Authorization Responsibilities 4. Utilization Review at MMC 5. Unaccompanied Minors 6. Chart I.D. Stickers 7. Drug Dispensing 8. HIV Testing 9. Reporting Communicable Diseases 10. Lupron Policy 11. Procedures for Chart Coding

Section IV. Articles of Interest and Reference

A. Professional Liability Issues 1. Current Developments in Right of Patients to Refuse Medical Treatment 2. Practice Parameters and the Malpractice Liability of Physicians 3. Professional Liability Matters (Princeton Insurance Company informotion) 4. Physician-Attorney Cooperation Guidelines for Success in Medical Malpractice 5. Medical Malpractice, Liability, and Reform 6. Clinical Issues 7. Alteration of Medical Records Submitted for Medical Legal Review

B. Miscellaneous 1. Child Abuse, Reporting 2. "Cleared for Surgery" 3. American College of Physicians Ethics Manual 4. Defining the Chronic Fatigue Syndrome 5. Prescribing Home Oxygen Therapy 6. Clarifying the Concept of Medical Necessity 7. The Rational Clinical Examination 8. Low Back Pain (4 articles) 9. Does This Patient Have Ascites? 10. Screening for Alcohol Abuse Using CAGE Scores and Likelihood Ratios 11. Practice Parameters 12. Practical Approaches to Office Detoxification 

C. Patient Relations 1. Can I Really Improve My Listening Skills with Only 15 Minutes To See My Patients? 2. Don't Keep This Patient Waiting Again 3. Don't Let Bad Phone Manners Be Your Hang Up 4. Difficult Patients: Uncovering the Real Problems of "Crocks and Gomers" 5. Service Orientation in HMOs 6. When Patients Complain--Point and Counterpoint 7. The Pelvic Examination in Primary Practice 8. Physician-Patient Communication in a Managed Care Environment 9. The Patient's Story: Integrating Patient--and Physician--Centered Approaches to Interviewing 10. The Physician Executive Can Help Improve Doctor-Patient Relationships 11. What Is Empathy and Can It Be taught? 12. Twelve Models of the Physician-Patient Relationship 13. An Overview of Interventions to Improve Compliance with Appointment Keeping for Medical Services 14. From the Eye of the Storm, with the Eyes of a Physician 15. Monday Morning Clinic 16. A "Non-Workloaded" Task

D. Quality Improvement 1. Clinical Practice Guidelines at an HMO: Development & Implementation in a Quality Improvement Model 2. Evaluating Office-Based Care 3. Integration of Quality Assessment and Physician Incentives 4. Measuring the Quality of Ambulatory Care 5. Quality Assurance Programs 6. Quality of Care in a Chain of Walk-In Centers 7. Comparison of TQM and QA

Section V. Medigroup Member Updates: Information to Members

A. Your Primary Care Physician B. Your Health Care Visits C. Scheduled Appointments D. Scheduling and Cancelling Appointments E. Physical Exams--Preventive Medicine F. Subspecialty Care Referrals G. Second Opinion H. The On-Call Physician I. Emergency Room Visit J. Answering Your Questions K. Treatment of Minors L. Treatment of Chronic Conditions M. Tips for Taking Medications N. Member Benefits Coverage--Authorizations 0. Advance Directives P. Minor Surgical Procedures Q. Unneeded Appointments--Resolved Problems R. HMO Blue Reminder

Section I, the Basic Manual, explains that the manual is a basic guideline for matters related to the hiring of, conduct and performance of, and evaluation of full-time, salaried physician staff. It is also a guide to procedural matters that physicians need to know in order to perform their duties and comply with HBHC's rules and regulations. It is noted in the section that, as appropriate, some items may apply to other personnel.

The mission statement and service credo are company developed and are included in order to focus the physician on the company's goals and expectations. The item entitled "The Primary Care Physician," written by the medical director with input from senior management, especially nursing, explains the role of the physician in accomplishing the organization's mission and goals.

Item V includes the physician contract and/or employment agreement; member handbook and related material; employee handbook; employer policies, rules, and regulations; and BCBSNJ policies and procedures.

Item VI outlines recruitment policy and authority; Item VII evaluation and advancement; and Item VIII termination procedures.

Item IX deals with managed care philosophy. It codifies expectations for managed care and some procedural issues.

Item X relates expectations as to specifics of documentation in records. Issues addressed are health maintenance protocols, outline of a progress note, dating of notes, legibility, problem lists, and medication lists. Recommendation is made for the use of flowcharts/checklists to monitor chronic illnesses, such as diabetes mellitus and hypertension. Also addressed is the need for regular and timely review of laboratory and x-ray results, with documentation of such review by initialing of reports, and for action, if any is necessary, to be documented in the progress notes. In like fashion, this item addresses orders, medications, documentation of telephone contacts, and inpatient record documentation. There are obvious quality and legal issues for such documentation.

Item XI deals with professional responsibilities and expectations with reference to timeliness of arrival for office hours, availability during scheduled hours in the event of an open appointment slot (e.g., cancellation), evening office hours, and on-call responsibility/availability.

Item XII clarifies the different types of appointments by specialty--e.g., physical examination, acute problem, follow-up visit, consult, medical clearance for surgery, well-baby visit, etc.-- to assist physicians in scheduling.

Item XIII elaborates policies with regard to scheduling time off and approval for same. XIV addresses time and financial support for continuing medical education. XV discusses coverage of and mechanisms for ordering durable medical equipment for patients.

Item XVI notes that the employer requires mandatory periods of in-service conferences and regular departmental meetings. XVII addresses procedures for emergencies. XVIII and XIX reemphasize the rights and expectations of members (patients).

Item XX deals with issues of confidentiality in general and for minors in particular, clarifying the status of emancipated minors and the emancipating situation.

Last, in Section I is an outline of the orientation program for new physicians. This outline lists the individual by title, with orientation responsibility and the topics each will cover.

Section II comprises a series of appendices containing details relevant to Section I. Most labels are self-evident and require no narrative elaboration. However, some comments are in order. Appendix B, developed 12-18 months after my arrival, has already been revised. Appendix G is a checklist for routine repetitive adult services, such as physicals, PAP smears, immunizations, etc., but it also provides for monitoring of two common diseases, diabetes mellitus and hypertension. For each diagnosis, certain specified repetitive services are listed vertically to the left, e.g., for diabetics, retinal exam, vascular exam, check for foot ulcers, etc. Across the top of the page, the columns are labeled by year and the date of evaluation is recorded in the intersecting box.

Appendices I, J, and M need special comment. The hemocult documentation log was developed by the quality assurance and physician staffs after a trigger incident revealed the potential to overlook positive reports and, more important, the high likelihood that slides were not returned by the patient. The adult screening criteria are essentially those jointly endorsed by the American College of Physicians and the BCBS Association in April 1991, but with some minor modifications. The Pediatric Progress Sheet was developed jointly by physicians and quality assurance staff to provide a format that encourages recording of all relevant details and documentation of detailed return instructions. The latter had been a particular problem, in that physicians consistently failed to document the time frame for the return visit. The present form requires only that a number be written next to preprinted "___days, ___weeks, ___months" or a check mark next to "prn." There is also a defined date and signature notation to ensure their inclusion.

Appendix N is incorporated by reference. Copies of acceptable abbreviations are distributed to work units and administrative areas.

Section IIIA, "Memoranda," provides information unique to our system. Some items are procedural and need not be detailed here. The "Comparison of Product Guides" is an exception. As a subsidiary of BCBSNJ, we function as a staff model HMO, and our primary care physicians PCPs) also serve as PCPs for Blue Choice (a point of service product). In addition, we participate in servicing other product lines with varying copayments, referral patterns, and coverages. Physician awareness of these differences is extremely important so that members receive appropriate benefits with no hassle.

Section IIIB is mostly unique to MMC, but some information is not highly specific. Item 1, "DRG Trim Points," lists common admission categories, high and low trim points, and our cost (at one hospital for one point in time) for each. New Jersey was, at the time the manual was developed, an "all-payer" DRG state. In a managed care setting, lack of awareness of these trim points may result in unnecessary costs. Conversely, knowledge of them can be quite cost effective, e.g., if a patient is admitted because of vomiting and concern for dehydration consequent to a viral illness, discharge before the third hospital day--if safe--and on home IV fluids can result in significant savings, because, under the DRG system, we would pay for two days at a per diem rate rather than the entire DRG fee scale. Once the patient is in the hospital as of the third day, the DRG payment is the same up to 13 days of hospitalization.

Item 2 is a comparison of costs for frequently prescribed medications as brand name products and generic equivalents.

The other items in Section IIIB relate to local issues and policies (numbers 4,5,6,7) or state laws and regulations (numbers 3,8,9,10).

Section IV comprises reprints of articles chosen generally because they address a concern or an issue that had arisen prior to preparation of the manual. Permission to reproduce each article for this manual was requested from the publisher and generally granted at no cost; one publisher charged a nominal fee of $50 and imposed a one-time limitation on reproduction.

The final section (V) is a compilation of member information developed by the medical director, with input from senior management, to address problems and issues that arose because of lack of awareness or improper use of the system by members. The information sheets were included in the manual so that the physicians would have full knowledge of what information was being given to members, which, in turn, affects the interaction between members and staff in the delivery of medical services. More have been developed since the manual was published and will be included in future editions (Appendix III).

Finale

The manual needs to be a dynamic "living document." It will require frequent review and updating. The ideal interval for updating and revising is not known, but it should probably be at least biennial if not annually. This is necessary because policies will change from time to time, there will be new issues, and old ones may no longer be relevant. Concepts, such as those relating to malpractice, physician-patient relations, and quality assurance, are bound to change. And most certainly, DRG and drug cost details will ultimately be outdated.(*) Significant events, such as major policy changes, may warrant an interim review. (*) Since this paper was prepared, legislation in New Jersey has eliminated DRGS and reinstituted competitive per diem rates.

Seymour Herschberg, MD, is Medical Director, HMO Blue Health Centers, Trenton, N.J. He is a member of the College's Societies on Insurance and Managed Health Care Organizations and its Forums on Quality Health Care and Law and Medicine. The author thanks Sharon Hayman, COO of HMO Blue Health Centers, for assistance in reviewing the manuscript and provision of historical information and Diane Gibboni for her efforts in preparation of the original draft of this manuscript and its revisions.