Get an edge by giving MCOs a report card

ED managers can gain leverage by giving MCOs report cards, says Jim Augustine, MD, FACEP, CEO of Premier Health Care Services in Dayton, OH, and member of the Benchmarking Alliance, which developed a managed care report card. (See report card in this issue on p. 55.) "Managed care plans put together report cards on us, but we have never thought about giving them a report card on how they treat us," he argues. "The concept of collecting and reporting data on payors is an increasing trend."

A report card is a valuable tool for ED groups, emphasizes Augustine. "It would be most useful as a source of data on how we are to interface with managed care, and identify those payors that globally have poor relationships with providers, have very punitive preauthorization requirements, or who flat out don’t pay." he says.

Having reliable data to rate MCOs can be a major advantage for EDs, Augustine stresses. "You will be able to compare your data with other EDs and say, we either do or don’t have problems here," he says. "This could help us level the playing field with payors and give us more leverage in coming negotiations."

Here are things to consider when creating a report card for MCOs:

Share data with other entities. "First you need to assess whether there is an audience that cares [about MCOs] in your community," says Augustine. "There may be business coalitions or governmental entities who you can work with to draft standards for the report card. That can either be done at your ED level, group level, or with other ED peer groups or a local chapter of the American College of Emergency Physicians (ACEP)."

The data could be shared with participating ED groups, emergency medicine groups in the state, the state medical association, the media, other MCOs, legislators, and the department of insurance, Augustine suggests. "It should also be shared with local, major employers, who would be very interested in how EDs would work to develop care—very helpful during open enrollment periods," he says. "Suggest that the employers use their negotiating power to open up discussions with managed care."

Meet with local employers to discuss MCOs. "Unless you take the opportunity to work with them, they will think you are nothing but a cost center," says Augustine. "Tell them how much money you save them, and how good you take care of their employees. Discuss with them the nature of your business, and how well you do it."

Employers may be completely unaware of how well MCOs are performing, Augustine stresses. "They often don’t know how well they perform clinically. For example, how easy is it for you to send one of their employees to an orthopedist for follow-up care?" he says. "Some have poor networks, and there is a great deal of difficulty. We may have to refer the employee back to his or her primary care provider, and it may take a couple of visits to get them to the orthopedist. The employer may not realize any of that."

Address denials. "You can share with local employers the fact that 50% of their employees have their visits denied when they come to the ED," Augustine suggests. "That means the employee has to pay out of pocket, including serious problems like auto accidents, which is an emergency situation, but the MCO says it’s not," he says. "Tell them, We think you ought to know that the next time you are going to negotiate your contracts.’"

Consider antitrust provisions. "You have to consider antitrust provisions in collecting data. Because if you begin to share information about charges and pricing you are into a problem area," warns Augustine. "We feel that outside entities would be better suited to do data collection, and make sure it doesn’t include information on pricing."

Make sure data is reliable. If you collect data, make sure they are reliable and there is an objective nature to them, Augustine advises. "Otherwise, an MCO could allege that you were libeling or slandering them, so those are some significant considerations. The American Hospital Association, ACEP, or Emergency Nurses Association (ENA) may be appropriate bodies to pull data from hospitals that may be considered competitors, and allow data to be collated."

Only collated data should be reported, Augustine emphasizes. "You will need to produce a reporting scale for each issue, so it allows data to blend well from different institutions," he says. "For example, if there is not a uniform definition for denials, you will get unreliable data."

Address HEDIS standards. The results could also impact the MCO’s national rating scores, such as the Health Plan Employer Data and Information Set (HEDIS) standards, published by the Washington, DC-based National Committee for Quality Assurance (NCQA), says Mike Williams, president of the Abaris Group, Walnut Creek, CA.

"This is the national benchmark for all plans. The NCQA just released a draft of HEDIS 2000 standards, which is an update of this performance measurement tool, used by more than 90% of the nation’s health plans," says Williams. "They also have standards for Medicare plans, which many EDs have problems with."

If an ED physician group looks closely at the HEDIS standards, they can gain leverage with regard to specific issues, Williams notes. "Learn about the standards and how they are applicable to your practice," he urges. "This is another tool that we can use when [we’re] frustrated about managed care. We are empowered to help the plans, therefore they will be interested in working with us on other issues," he says.

Certain HEDIS standards can be useful during future contract negotiations, says Willliams. "Discuss your willingness to work with the plan on meeting these standards," he suggests. "For example, they can say, As a group, we could help you meet the HEDIS standard if you will just pay us faster."’

ED managers should be familiar with this national rating system, Williams stresses. "There are service delivery standards that can only be met by EDs," he says. "For example, there is a whole series of standards for response and treatment of asthma patients that specifically address ED visits."

Another standard involves adult access to preventive/ambulatory services. "This includes how the plan will provide services for patients after hours. So if there is a low-cost alternative in the ED for ambulatory access, the plan can get credit for that," says Williams.

By helping MCOs meet these standards, plans will have an incentive to meet the ED’s needs, Williams explains. "You can gain leverage by cooperating with the plan and helping them meet the standards," he says. "As you are negotiating contracts, reinforce the plan by looking good on the report card, especially if the ED has a significant membership in the plan."

HEDIS standards can be accessed via the Internet, Williams advises. "Right now we have HEDIS 3.0 standards, but we are moving toward 2000 standards, so ED managers should be familiar with those," he says. "That way, you can evaluate what potential opportunity your particular ED might be able to respond to." (Both the existing and new draft standards can be downloaded at http://www.ncqa.org.)

Give input for national standards. If ED groups develop standards for local MCOs, they could be adopted as the national standard, says Williams. "ACEP worked with Kaiser Hospitals to develop the prudent layperson standard, and that became an adopted standard by American Association of Health Plans," he notes. "This has been adopted in 15 states as standard for payment. It represents an ED physician-driven issue that has become a national benchmark."

There is tremendous interest in access for ED patients, Williams notes. "The Cardin bill has just been introduced again, so it is a great time for emergency medicine to design standards that are either legislative or voluntarily adopted by health plans," he says.

Rate reimbursement behavior. Grade managed care plans on the basis of reimbursement behavior, advises Lorne Johnson, MD, FACEP, president of health Access Associates in Davis, CA. "For example, in California, we find that many of the plans still discount, downcode, and delay their payments to emergency physicians both in and out of contract," he says. "Out of contract, they often pay a contract rate, and tell the patient that under state law, the emergency provider is not allowed to balance bill, and that is not true, so they misinform patients."

Involve local businesses. "The standards can be adopted by businesses who are purchasing health care services, when they choose one plan or another," says Williams. "This is not something that is done overnight, but groups need to network together. A group has a lot more leverage on a single issue than separate entities. In some communities, going to business coalitions who are interested in health care will give you significant leverage."

Surveys can be shared with local organizations, suggests Johnson. "In California, a business group on health was working on standards for disclosure information standards for health plans, and they specifically have a project on health plan member ID cards," he explains. "So the California ACEP chapter did a survey of cards and shared this information with the group."

Concerns about emergency care access information printed on the back of various health plan cards was noted, with the recommendation that cards print the following two statements:

• In case of emergency, call 911 or obtain emergency care in the nearest appropriate facility.

• Prior authorization for emergency services is not required.

Ask patients for input on MCOs. ACEP’s Emergency Medicine Practice Committee developed an 11-question checklist for consumers, reports Johnson. (See checklist in this issue on p. 56.) "This is a patient-based report card regarding emergency access. It can be used as a feedback information tool to reflect patient dissatisfaction with access barriers and delays in care resulting from managed care plans," he explains.

Create a checklist for physicians. A checklist for physicians was also developed by ACEP. (See checklist in this issue on p. 57.) "This would be valuable for a group working in a transitional environment where managed care is making aggressive moves toward contracting emergency services," says Johnson. "We need to get more aggressive in other parts of the country that are still going through the early stages of managed care maturation. EDs could benefit from this analysis of how a plan should be evaluated."

Address access to care. "Kaiser has a statewide hotline with an ED physician available 24 hours a day to make prompt decisions. So under that report card category, they would get an A," says Johnson. "Network plans might not score so high, since the representative would more likely be the patient’s primary care physician. Therefore, by and large they don’t understand the requirements of the law, and there is much more variability in the quality of the response."