Emphasis on 'care' in managed care picks up steam

It's not just about financing anymore

Money isn't everything in managed care. If you did a double-take at this statement, or dismissed it as a Pollyanna-esque ideal, hear us out.

As a market's managed care maturity increases, savvy practices are concerned not only with how they are compensated by managed care organizations, but with how they can assume care management functions that traditionally have fallen within the realm of MCOs. Physician's Managed Care Report asked Matthew Baker, FACMPE, president of the Medical Group Management Association's managed care assembly and chief operating officer of Maryland Healthcare Associates in Clinton, MD, about his take on this and other changes in the managed care world.

PMCR: MGMA represents over 18,000 physician practices across the country and thus has a good sampling of leaders. What current managed care hot buttons has your committee observed?

Baker: It's hard to put your finger on one thing, but the questions our members are asking are: (1) Should I take risk? and (2) How should I manage risk? It's going beyond just getting a per member per month fee and taking on full medical risk, assuming responsibility for not just your costs but for things like hospital and ancillary services costs.

PMCR: How have these changes come about?

Baker: Managed care has gone from a novelty to a mainstream concept. It's not just about California anymore. Capitation penetration rates in many markets are exceeding 40%. Although the focus early on in managed care was as a compensation mechanism - how to make health care cheaper - the emphasis now is on managing the care. It's no longer just about dollars and cents; it's about medical management.

PMCR: How do you accomplish this?

Baker: There are several ways. By identifying your members who are high-risk - members with diseases like asthma or diabetes - you can focus on how to provide services to these members to increase access and satisfaction while saving money down the road. For example, many groups employ case managers. Groups employing disease management strategies may identify and provide preventive measures to deal with diabetic or asthmatic patients. Practices can also provide demand management services, the so-called "ask a nurse" hotlines for patients to call in and get some treatment options before heading to the emergency room automatically.

PMCR: These are ideals that have been talked about for a while, but is anyone actually doing it?

Baker: Yes. Some names that come to mind are Friendly Hills in California, Aspen Medical Group in Minnesota, and Kelsey-Seybold in Houston. These groups are making these concepts work.

PMCR: These all sound like medical director issues. Are practice administrators really concerned with this, or is it falling to their medical directors?

Baker: That's an important point MGMA is trying to address. Our emphasis is that there has to be a partnership between the business administrator and the clinical leadership. The medical side of course provides the care and knows the best way to provide the care. The business side of the house has to have the data to know where the dollars are going out, which procedures are costly, and what is being done that is both cost-effective and medically effective. It's all about providing the right care at the right time in the right setting.

PMCR: How does this trend affect medical practices that are at financial risk?

Baker: By providing good access, involving the patient in their care, and initiating wellness programs, medical groups are investing in their business. Their customers will be happy, and the incidence of cost or unneeded medical care will decline. By practicing evidence-based medicine, care will be provided that proves to be cost-effective. The end result is a positive bottom line.