“1 (800) Mother May I” — sound familiar? If you’ve been around long enough, you probably have vivid memories of some of the headaches associated with managed care — and consequently the humorous phone number reference.
A general perception of managed care as nothing more than a barrier to getting services has, unfortunately, left an almost indelible imprint on many — and the result has been a steady decline in its popularity. But before you give managed care its last rites, you may want to revisit its benefits and improvements. The fact is, managed care programs have made significant changes in recent years, and have data to show how they help control health care costs, while improving the quality of care.
Managed care includes all aspects of health care delivery — encompassing all services and practitioners who have direct impact on patient care. It integrates care to ensure patients get the appropriate amount of care when they need it and in the best setting to suit their circumstances — in this way, it is actually capable of customizing patient care.
Managed care also looks at how health care resources are utilized and finds ways to ensure they’re used appropriately. The goal is quite simple: to keep people healthy and to keep health care costs down.
Although this has always been the goal, the approach to reaching it has changed. In the past, the thought was front-end controls were the way to achieve this. The mistake was that these controls were too broad — everything had to go through the plan. The result was a system that was inefficient and, in many ways, a bottleneck to care.
Those days are gone. Managed care has learned from its mistakes, and become lean and nimble. The goal hasn’t changed, but the approach has. The old barriers are gone; routine tests and other care such as taking an x-ray of a suspected broken bone, for example, are appropriately left to the discretion of the physician. Today, the aim is to free-up the process for more routine care and for keeping people healthy, while managing cases that are more complex and costly.
You can think of managed care organizations as being good stewards of your health care resources. By working closely with employers, physicians and members, and by collecting data and using tools like predictive modeling to identify high-cost, high-risk patients, they can monitor health care usage trends. Certain categories, such as emergency room visits, inpatient hospital stays and pharmacy, are closely monitored, as they are typically areas where equally effective, lower-cost treatment and/or prevention options may be available.
There are certain areas that warrant tighter front-end controls, not only to monitor costs, but to ensure patient safety as well. Take experimental treatments as an example. Medical technology is exploding in growth, the scientific community is finding exciting new treatments at a breathtaking pace and the public wants access to these treatments.
But before we go rushing to be included in the latest research, it’s important to set standards that outline the safety and clinical efficacy of the treatment. Managed care helps us do this.
Managed care is like the control tower at an airport. The health plan is able to take a macro-view of how patients are being treated across all areas of the health care system. The goal is to encourage collaboration among all these areas, because by working together, we almost always find ways to improve care, while reducing cost. Everyone wins.
Before you give up on offering a managed care plan to your employees, take another look. Managed care has made some very positive changes. Now that it has, it’s poised to handle the health care challenges of the future.
Rachel Godwin, BSN, MSA, CCM, CPHQ, is director of care management for Care Choices, a nonprofit health care organization and a subsidiary of Trinity Health. Care Choices HMO is ranked as No. 7 among 257 commercial plans nationwide and is the top-rated plan in Michigan, according to U.S. News & World Report/NCQA “America’s Best Health Plans, 2005.”
