Facing Managed Care

Managed care may be nothing new to providers on both coasts and some areas of the northeastern United States, but in other parts of the country (typically the Midwest and South), it has not had the same impact. What should these providers know about managed care?

First, make no mistake: Managed care is coming, say many experts.

"Some people think that if they ignore [managed care] it will go away," says Caral Edelberg, President of Medical Management Resources, a consulting firm based in Jacksonville, FL. "It’s not going away. It’s here to stay."

Providers of emergency medical services in areas without much managed care penetration can benefit greatly from talking to their counterparts in California, Washington, and Florida, Edelberg says. They have been on the forefront of the health care revolution for years.

"It’s not like you’re going to have to go out and reinvent the wheel," she says.

One thing emergency physicians facing managed care changes have to do is make a commitment to cost-efficiency.

"The biggest change is that someone is going to be asking questions about how you do everything," says Gregory L. Henry, MD, immediate past president of ACEP and Clinical Professor in the Department of Emergency Medicine at the University of Michigan. "Payers are going to be looking for providers who pay attention to cost—no one did before. It seemed like we always picked the most expensive way to do something because it meant more money. That’s being challenged."

Emergency physicians, in particular, need to assume more administrative responsibility under managed care, says Edelberg.

"When you are accredited by a managed care organization, you are part of their group," she says. "You are more than just a clinician; it’s a double responsibility."

Physicians must pay attention to both the costs and the quality of the care they provide. "As an emergency physician, you have to be cognizant of the physicians you have referred a patient to, the lab work and x-rays you’ve ordered, types of prescriptions you write, and whether they are covered," she explains. "If prescriptions are covered and you are writing one that is more expensive, then that will have an impact on your organization."

And you not only have to pay attention to it, you have to track it, she emphasizes.

Having the data to back up why they practice medicine the way they do is vital to every emergency physician group, whether fee-for-service or under some other arrangement, she says.

"Everybody says, ‘We want to provide efficient, quality care,’" she says. "No one says, ‘Hey, my care isn’t really that great.’ You have to prove that you’re able to do it. It’s not enough just to have the data. You have to quantify the data through practice parameters.

"You have to show [that] we don’t order labs or x-rays that are unnecessary, we try to prescribe cost-effective medications, and we try to get them in and out of there fast."

Clinically, physicians have seen their practice change very little so far due to managed care, says Henry, but this is beginning to change.

"Most of the [MCOs] have been managing costs, not managing care," he states. "They have just been cutting back on the reimbursement."

Some organizations, however, are beginning to look at controlling the costs of care, and, for the ED physician, this will mean the advent of clinical pathways and practice guidelines, he says.

MCOs are bringing some very skilled clinicians on board to negotiate with ED groups, which will force individual departments to develop pathways or be passed over. Decisions about when to order lab tests, what tests to order, what medications to prescribe and when, are largely going to be group decisions.

Physicians will no longer be able to just go their own way and not have it questioned, though many are in denial, he says.

Those unwilling or unable to adjust to the changes will soon find themselves "on the outside looking in," he predicts. "They will replace you."

The doctor next door

Not all of the lessons learned by other parts of the country still apply, says Wes Fields, MD, FACEP, a member of the board of California Emergency Physicians and chairman of ACEP’s section on managed care.

"In a market where managed care is not that big, physicians have a sense that managed care is some sort of monolith—this 100-ton gorilla that is going to come in and take over everything," Fields says. "What they need to realize now, with the network models and capitation, is that they will most likely be dealing the physician across the street, not calling some company three states away."

Relationships between PCPs and emergency physicians will change, and there will be some disagreement on the care required to treat patients that will probably cause problems, but they will probably still be dealing with someone they already know, Fields says.

Liability issues

Though PCPs will be assuming most of the control for the care of their patients, they do not assume any of the liability when their patients present to the ED.

If an emergency physician discharges or transfers a patient at the request of the PCP and there is a bad outcome later, under COBRA/EMTALA, the emergency physician is liable, not the primary care doctor, Fields says.

"Everybody knows what to do about the high-acuity cases, the multiple traumas, the incredibly severe injuries," he explains. "It’s those cases that fall in the in-between areas. What do we do about those?

"It’s always been a problem of emergency medicine that is being complicated now by managed care contracting."

Many emergency physicians have taken a leading role in trying to remedy some of the problems emergency medicine has with managed care, says Edelberg.

She recommends that physicians become active in their state ACEP chapters to work on legislation at the state level.

"Emergency physicians have done a lot to clarify these issues and are still doing a lot," Edelberg says. "The ACEP leadership has just been remarkable on so many different levels, with the state colleges, with the educational programs they do. They’ve really represented the membership well."

Fields says such work will not just benefit the emergency medical community but is necessary for the rest of the country as well.

"What about the 40-60 million Americans out there with no health insurance at all?" he asks. "We have a responsibility to do the best we can for them too. We have to come up with a structure that makes as much sense for them as it does for the HMOs."