Content area
Managed care organizations have 2 increasingly important and effective tools to improve the perception and show the reality of how they manage care: computers and the Internet. Computers allow these organizations to systematically and quickly improve decisions made about complex problems, including medical care, by prompting clinicians to consider clinical alternatives that are not immediately obvious. By using the Internet, multiple clinicians and caregivers can have shared access to guidelines and patient records for specific patient management. The long-term value of Internet tools will be to enable physicians and other care givers to regain a more active role in the planning and coordination of patient care without assuming the full administrative burden.
Full text
Computers and the Intemet have become vital tools in an ill-perceived process.
If some prominent news accounts are to be believed, managed care companies are so out of touch with good medical practice that a "clerical person" is the one who makes decisions about the patient's healthcare. The myth of "faceless bureaucrats" and "accountants" vetoing doctors' care decisions is just that-a myth. And yet, it has persisted, proliferated, and taken on a life of its own.
Is it any wonder that the public has developed such an impressive array of misperceptions about how managed care decisions are really made? On the other hand, the fault does not lie entirely with the news media. We in managed care need to do a better job of describing how managed care decisions are made and of responding openly and honestly to misinformed critics.
We have two increasingly important and effective tools to improve the perception and show the reality of how we manage care: computers and the Internet.
Before we explore the value of the Internet, let's return for a moment to the myth about faceless bureaucrats and omniscient clerks. The fact is, while most insurers use trained clerical staff to take the initial telephone call from a physician's staff, these "intake specialists" only have authority to gather information and approve requests.
Decision-makers
If the physician is on a list of well-performing doctors (seldom, if ever, based solely on cost), then the intake specialist can quickly inform the caller that the care will be approved for payment under the patient's benefit plan without clinical review. Industrywide, automatic pre-approvals for referrals and treatment are hovering around 90 percent or more, and one major insurance company recently announced it would waive pre-approvals, though not prior review, all together.
In the minority of cases where more information is needed to make a decision, clinical discussions take place with nurses from the health plan speaking, most often, with the physician's office or nursing staff.
Finally, if serious questions remain about treatment plans, a health plan physician or panel of physicians discuss the case directly with the patient's doctor. Neither intake specialists nor nurses deny payment for care for clinical reasons. This action of last resort depends entirely upon physician-to-physician contact-a fact that we in managed care have done a poor job of bringing to public awareness.
Furthermore, most states have laws that make it possible for patients to appeal denials to independent "external review" panels of physicians who specialize in specific health fields. Proposed federal legislation could expand external review to encompass all states.
How Computers Help
The second error often made by critics of managed care is in assuming that computers have no role to play in improving the quality of care in this country.
Computers allow us to systematically and quickly improve decisions made about complex problems, including medical care, by prompting clinicians to consider clinical alternatives that are not immediately obvious.
Helping to steer physicians to follow "best practices" for their specialties is an area of nationwide interest, and computers make it possible to sift through massive databases to help specialists create, refine, and update sound, evidence-based treatment guidelines.
Some variability in treatment of "exactly" the same clinical condition is normal and necessary because of subtle differences in patients, the availability of local resources (like skilled nursing facilities and outpatient surgery centers), and the experience of the physician. But the variability in practice is greater than it need be. For example, when almost one in five hysterectomies are medically unnecessary (down from more than one in four a decade ago), we still have far too many women being put through risky and expensive surgeries.
Not only do computers make it possible to develop clinical guidelines, computers also can move information quickly between key decision-makers-vital information about a patient's condition, lab results, treatment history, and alternative care plans. We in medical technology have refined software for rapid information retrieval so the managed care clinicians can focus on using their clinical skills instead of the administrative skills needed to retrieve this vital information.
Potential of the Internet
Use of the Internet for sharing patient information between payers and providers has been slow to develop. This lag is because of several reasons, including concerns about patient confidentiality and the lack, until very recently of Internet products that integrate seamlessly with existing medical management software. The first-generation of Internet software now emerging is focused on supporting the workflow of the care manager, who has generally been at the hub of the payer's decision-making process.
It is the care manager who coordinates care and shares verbal or written guideline information with the primary care physician, the home health nurse, the outpatient physical therapist and other patient caregivers. By using the Internet, multiple clinicians and caregivers can have shared access to guidelines and patient records for specific patient management.
But the long-term value of Internet tools will be to enable physicians and other care givers to regain a more active role in the planning and coordination of patient care without assuming the full administrative burden.
Shared access provides the foundation for innovations in care management, but only if the key decision-makers use it. The trend is encouraging: Cyber Dialogue estimated in July 1999 that 55 percent to 65 percent of physicians were already using the Internet in their offices, and the American Medical Association and other professional groups have launched programs to actively encourage Internet use. Some managed care organizations have joined in by creating incentives for providers who demonstrate that they are actively using guidelines they have made available on the Web.
Saving Money
Internet usage can also reduce the time and expense associated with updating clinical content. Managed care organizations are required to implement content and/or software product upgrades up to four times per year. With an Internet-based approach, the MCO's cost and effort to update will be reduced or eliminated. And guideline vendors will be free to update content as often as is clinically warranted.
Most guideline vendors offer access to research summaries, supporting bibliographies and white papers for providers who desire more detailed research data. Today, this information is generally mailed or faxed after receiving a provider's request.
In an Internet-based approach, the detailed information can be accessed on the spot, at the time the question forms in the provider's mind.
And, finally, the use of the Internet permits involvement by one additional, very important stakeholder-the consumer. All of the guideline vendors are creating or implementing strategies to provide "lay" access to appropriate guideline content. Because the leading vendors are just now introducing their first generation of commercially available Internet guideline tools, it may take several rounds of upgrades for them to refine their approaches to capture all of the benefit while avoiding the potential problems inherent in the use of any new technology.
Reason for Optimism
With all these changes on the horizon, there is real reason for optimism, although the decision-making process is not perfect and it will take time to improve it. Unfortunately, there will be mistakes made by all sides, just as mistakes were made before managed care was introduced. Keep in mind that no study has ever shown that quality of care has declined in any substantial way under managed care, regardless of the anecdotes you hear. The Internet can speed communication and enable all parties to share key information.
Computers can play a major role in collecting and managing information to track what is really happening and why. Computers also can help change medical practice to reflect what we learn from analyzing the past. Safer and more effective treatment decisions can be made with the help of computers to organize patient records and to make suggestions based on the accumulated storehouse of clinical data about best practices in medicine.
'The long-term value of Internet tools will be to enable physicians and other caregivers to regain a more active role in the planning and coordination of patient care.' - David St. Clair
David St. Clair is chairman and chief executive officer of MEDecision Inc., Wayne, PA.
Copyright Nelson Publishing Feb 2000