Wearing another hat may not be a bad idea

By Jack Duffy, FHFMA

Director of Patient Financial Services

ScrippsHealth, San Diego

Many providers do not consider the access manager a key component of managing risk. I would like to make a case, however, for upgrading the skills and awareness of every access manager to perform this function.

First, the traditional risk model calls for the physician to be the principal control point for patient care. This model has served us for all of the modern health care era. Times have changed, however, and traditional models are breaking down. At one time, the role of insurance companies was to collect premiums and pay claims. They existed completely outside of the care model.

With the invention of managed care, the traditional model began to crumble. First, managed care organizations (MCOs) began to employ physicians in a variety of roles. The roles of physicians now include those of "gatekeepers," medical managers, staff models, and others. This aligned the financial success of the physician with that of the insurance product. As the staff model moved to other structures, physicians assumed more complex roles than the care of individual patients.

Through the mechanism of prepayment, the physician became responsible for "global" budgets. As a result, physicians could literally run out of money and end up "upside down." Into this changing environment now comes the "hospital partner."

Many hospitals have moved ever closer to their related physician groups by using a variety of mechanisms. These include self-owned MCOs, owned and sponsored medical service organizations, and other forms of practice management.

In recent years, contracts with MCOs have included global risk contracts where the physician and hospital share the majority of the premium payment in exchange for providing virtually all of the care.

In these new roles, the decisions related to access to care become an ever-increasing concern. Will the traditional separation of insurance and care providers withstand the scrutiny of the legal community?

There is a strong possibility that the traditional legal protections associated with the sale of insurance will erode. At that time, hospitals — by virtue of their physician relationship — may be held responsible for adverse outcomes associated with the denial and delay of care. The access manager in the future may have to be aware of how medical decisions were made.

Access managers also will need to be aware of a patient’s status, and know the answers to the following questions:

What are the patient’s appeal rights?

Where is the patient in the appeal process?

This information will feed into a decision process that either allows care to continue or refers the patient back into the community. These point-of-service calls may have a significant influence on future claims and insurance premiums.

I recommend that access managers continue to focus education and research on these areas. Professional organizations should support forums and discussion to keep information flowing to access managers across the country.

(Jack Duffy also serves as consulting editor for Hospital Access Management.)