You can’t stop managed care, but you can use it to patients’ advantage

Make HMOs your allies, not your adversaries

Health care providers and managed care: It’s been a rocky marriage at times. News stories tend to focus on cases in which patient care is diluted in deference to the bottom line. And providers are forced to cope with the vagaries and demands of a system whose tenets frequently run counter to their medical training. 

But like it or not, managed care is here to stay, and for clinicians, it’s become a matter of get along or get out. That makes it paramount to build a smooth working relationship with health maintenance organizations (HMOs), preferred provider organizations, and hybrid payers. 

Realize first that managed care is a business with a clear profit orientation, says Janice Stanfield, RN, CETN, ET, an independent wound care specialist and nurse consultant in Los Angeles. "They want us to provide services at a significantly lower cost and see that we can effectively manage our limited resources and still come out ahead." 

Under managed care, providers are making a difficult shift from autonomous entities to members of organized, contracted groups, adds John Sheridan, president of John Sheridan Associates, a health care management consulting firm in Cleveland. "As that happens, the provider becomes more accountable for his or her care plans, for following through on those care plans, and for demonstrating positive outcomes as a result of those plans," he says. 

Sheridan and others familiar with the obstacles and back alleys of managed care — from both the provider and payer perspective — advocate several strategies for clinicians to establish and maintain stable and rewarding associations with managed care companies. These include: 

Document patient conditions and needs. 

First and foremost, managed care wants you to fully document each patient’s condition and stipulate the blueprint for care. Nothing demonstrates your ability to do this better than a detailed care plan that you follow closely and modify appropriately as a case evolves. 

"Anything providers can do to demonstrate that they are accountable — first to the patient and second to those who pay for the care — and that the patient has received the full value of his or her health care dollar is viewed favorably by managed care," Sheridan explains. 

HMOs share a common and usually ill-conceived opinion that clinicians are lazy when it comes to nonclinical obligations (translation: paperwork). It’s up to physicians and other professional caregivers to prove this false. HMOs really bristle when they encounter physicians who tell them to "get out of their hair," Sheridan says. 

Document outcomes. 

Another element for building solid alliances with HMOs is to document clinical outcomes: Show that you can achieve faster healing rates than the HMO is accustomed to seeing and that you can do it at a lower cost, says Tamara Fishman, DPM, pediatric wound care consultant at the Primary Foot Care Center and president of the Wound Care Institute in North Miami Beach, FL. "The managed care market has forced clinicians to study outcomes whether they want to or not," she says. Though a large volume of outcomes data on various wound care practices is accessible in the literature, much of the research relates poorly to everyday practice, she adds, which shifts the burden of documenting treatment results to clinicians. 

Understand the source of managed care guidelines. 

Clinicians often chafe at having to adhere to the various care guidelines handed down by managed care, viewing them as restrictions on their ability to deliver quality care. This is especially true in wound care, where consistent treatment doesn’t always result in consistent outcomes, says William J. DeMarco, president of DeMarco Associates in Rockford, IL, a consultant who helps health care providers deal with managed care.

Offer an alternative’

"The most successful relationships between wound care centers and nursing homes have grown out of providers spending the time examining the clinical background of guidelines to see if they agree or disagree with them," DeMarco says. "If you don’t agree, then offer an alternative." 

Once clinicians understand the source of managed care guidelines, they can begin to argue about practice restrictions and discuss real issues, such as what the managed care company can do to ensure successful outcomes, he adds. 

Give them something better. 

If you don’t agree with a particular set of managed care guidelines, grumbling about it will not win you allies or results at the HMO. "Many ambitious people have been able to develop their own systems of care and have approached HMOs and said, We don’t agree with your system. We’d like you to try ours.’ Then they have to prove that it works and that it saves money," says DeMarco. 

Managed care appreciates this type of initiative. "Take it upon yourself to learn about the managed care industry, and approach these third-party payers as businesses and as customers, not adversaries." 

If the end really does justify the means, prove it. 

Many times, and particularly in wound care, effective wound healing entails greater resources upfront. "You might have to spend a little bit of money for a dietitian or an orthotist for a patient with a stubborn diabetic foot ulcer early on instead of waiting and spending far more later," Stanfield says. One patient referred to Stanfield had a wound that hadn’t healed even after $35,000 of medical care. Yet a dietitian or orthotist had not been consulted at the outset, which almost certainly would have benefited the patient and saved money. (See story, p. 67.) 

"Managed care looks aggressively at preventive measures," Sheridan adds. "This is an area in which you can identify criteria for early intervention. A visit to a specialist and an assessment of a rough area on the skin might cost a little more upfront but prevent the formation of a pressure ulcer. "Managed care loves to reward that kind of thing. They’re getting much better at supporting prevention," he says. 

When you need something, ask. 

When a patient needs a service or product not supported by the managed care company, make your wishes known by contacting the HMO’s medical director via telephone or a quick fax. Request same-day turnaround on the decision and make yourself available to discuss the situation. "It’s a pain in the neck, and it’s something physicians complain about, but it’s what you have to do sometimes," Sheridan says. He cautions that this strategy will work only if the clinician’s assessment of the patient’s needs is on target. "You’ve got to really know you’re correct to do this," he says. 

"Explain to the HMO the benefit of what you’re planning on doing, the impact it will have on the patient, and how it will financially benefit the managed care company," Stanfield adds.

They learned to trust us’

When she began working with managed care more than a decade ago, Stanfield recalls sticking to the "rules" more often and avoiding special requests. But once she and her colleagues established a good working rapport with an HMO, they found that payers were a little more lenient about making reasonable policy exceptions. 

"They learned to trust us, and that makes a big difference," she says. "A lot of people are afraid of managed care, but I think that it’s a good thing that can really work well. As long as we keep the patient’s best interest at heart and work as a team, we can accomplish anything."