Clinical Integrity

The intrusion of managed care into the patient/physician relationship is a major cause of physician dissatisfaction with the current health care delivery system. Employers and the government alike are alarmed at the unsustainable growth of health care costs and are putting incredible pressure on health insurers and the Medicare and Medicaid programs to control costs. As a result, health insurers and government-sponsored health care programs are trying to find any means possible to reduce the costs associated with the provision of health care.

While your practice is undoubtedly sympathetic to these concerns and is committed to finding ways to practice more efficiently, you must also balance this against ensuring that your patients continue to get the care that they need. Cost-cutting must not be allowed to result in either having to de-select your sickest (and most expensive) patients or risk the de-selection of your practice from various health care networks.

The following information is intended to assist you in dealing with various care management strategies employed by third-party payers. The goal is to ensure that these strategies do not improperly interfere with the medical care that you know your patients need.

Benefit management companies
Many health insurers are paying additional attention to the most expensive types of services that are being provided to their members. They believe that strategies to cut costs in areas such as pharmaceuticals, radiology and mental health could significantly reduce their bottom line.

One method of more closely monitoring the use of these services is by contracting with a third party or benefit manager. These companies specialize in the review, approval and sometimes the provision of these services. The job of the benefit manager is to ensure that only genuinely necessary services are provided to patients. However, you may see a benefit manager as one more barrier to providing your patients with needed services.

Care coordination
Most Americans rely on one or two physicians for the bulk of their day-to-day health care needs. But when acute or chronic illnesses strike, they often rely on larger health care teams consisting of primary and specialty care physicians, hospitals, clinics, nurses, and a plethora of other health care workers. Coordination of effort among all of these entities is of paramount importance to ensure proper patient care. Tools and programs to coordinate the activities and communications of the health care team are therefore necessary.