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Quality control: the nexus goal of purchasers and providers.

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"Purchasing Higher Quality Managed Health Care Services" was the theme of the National Association of Employers on Health Care Action's 1989 National Health Management Conference, held May 18-19 in Minneapolis, Minn. John M. Burns, MD, FACPE, and John W. Wheeler, MD, discussed the purchaser/ provider partnership that has been developed between Honeywell, inc., and Group Health, inc., in delivering higher quality health care services according to mutually agreed upon standards.

John M. Burns, MD, FACPE, Vice President, Health Management, Honeywell, Inc., stated, Quality is doing it right the first time. Quality is less expensive," he continued, "because you don't have to discard or rework, and you don't have to inspect. The purchaser and the provider must create a nexus and develop a system with standards, demonstrate that care is necessary and appropriate, and work toward quality improvement to break through to superior levels of performance."

According to Dr. Burns, business initiatives should describe health care, not illness care, and develop specifications for that care.

* Prevention and education should become a primary goal, to keep people healthy and to educate them to selfcare and to not seek medical care unless necessary. Investment in education/prevention is a cost of doing business.

* Cost sharing by employees is universal--modified to reward appropriate behavior.

* Benefit plans are administered through contracts that require quality standards in peer review and utilization management.

* Both direct and indirect costs are identified managed. Indirect costs of disability plus wage replacement are at least four times the direct costs of illness. It may be smart to increase direct costs to lower indirect costs and thus the total costs of illness.

John W. Wheeler, MD, Associate Medical Director, Group Health, Inc., agreed that purchaser and provider working together as partners can develop standards that lead to quality. He stated, "Physicians now and in the future will no longer be the sole decision makers in regard to treatment modality, and that is appropriate. We have to be partners to make the health care delivery system work."

Dr. Wheeler outlined the essential principles of the Honeywell and Group Health agreement:

* The plan will be physician-directed and interactive.

* Patients' responsible actions should be aided by use of copayments for services they initiate.

*Physidan-directed care considered necessary for chronic and serious medical problems should be delivered without copayments.

*Quality standards of care determined by appropriateness and necessity should be the basis for chronic care management in all areas of high costs and/or high utilization.

* Physicians should not be placed in positions of determining benefits. Care decisions should be made on the basis of medical criteria, without regard to benefits/coverage.

* Preventive care and health screening should be encouraged and should be available without copayment. Plan design and benefits should be easily understood by participants and should encourage participation in the plan.

Dr. Burns stated that there are essential elements of high-quality health care. High-quality care should:

* Produce optimal improvement in the patient's physiologic status, physical function, and emotional and intellectual performance, consistent with the best interests of the patient.

* Emphasize promotion of health, prevention of disease or disability, and early detection and treatment of such conditions.

* Seek to achieve informed cooperation and participation of the patient in the care process and in decisions concerning that process.

* Be based on accepted principles of medical science and the proficient use of appropriate technological and professional resources.

* Be provided with sensitivity to the stress and anxiety that illness can generate and with concern for the patient's overall welfare.

* Make efficient use of available technology and other health system resources needed to achieve the desired treatment goal.

*Be sufficiently documented in the patient's medical record to enable continuity of care and peer evaluation.

T H E A U T H O R

Ruth H. Stack is President, National Association of Employers on Health Care Action, Key Biscayne, Fla.
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Title Annotation:medical care
Author:Stack, Ruth H.
Publication:Physician Executive
Article Type:column
Date:Jul 1, 1989
Words:641
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