It's time for the managed-care industry to focus its attention on specialty care.
Specialty care accounts for the vast majority of healthcare costs, but from a clinical perspective, it remains virtually unmanaged. The need for management can be seen by just looking at one specialty, cardiovascular disease, which represents the largest area of expense for health benefit plans:
The incidence of disease is great, increasing the financial impact. Some 900,000 deaths-43% of all deaths each year-are attributable to this disease, and 1.5 million people suffer heart attacks each year in this country. Some 56 million have some form of the disease, and many of those aren't aware of their condition.
Since 1978, most cardiologists entering private practice were trained as interventionists, and it shouldn't surprise us that the rate of invasive procedures has grown dramatically. Annually, there are 900,000 cardiac catheterizations, at an average cost of $4,820; 500,000 angioplasties, costing $14,870 each; and 400,000 surgical bypasses, at an average cost of $43,370.
While utilization review programs have been used for more than a decade, the cost and number of cardiac procedures have skyrocketed.
The problem is this: Specialty care isn't managed as much as it is discounted in price (typical of preferred provider organizations) or avoided because of the decision of a gatekeeper, usually a primary-care physician in a health maintenance organization, whose job it is to treat patients and refer them to specialists only when it's absolutely necessary.
To further discourage referrals, an HMO may pay primary-care physicians under a capitated arrangement, leaving the doctor at risk and responsible for payments to specialists. Thus, capitation creates a strong disincentive to make referrals, leaving patients at risk for poor quality care and worsened conditions, even death.
To date, no one has developed a qualitative clinical outcomes system that captures clinical data on a broad range of patients. The claims systems used by third-party administrators and managed-care organizations are designed to track procedure and charge data, but they're woefully lacking in their ability to collect clinical details to permit the evaluation of care from a clinical perspective.
Even such systems used by hospitals are designed to report the frequency of procedures rather than their clinical appropriateness. In fact, our primary question should be why are procedures taking place and should they be occurring, not just stopping at finding out how many are done.
While managed care has succeeded in capitating the physician fee component and even bundling physician and hospital costs, it hasn't addressed the real issue of "Are these procedures necessary, and why?"
On the one hand, there's the potential that factors related to overutilization will be included in the capitated fee. On the other, consumers can't help but wonder whether they can trust a managed-care system that's so focused on cost that it may not pay enough attention to the quality of care that its providers are delivering.
Let's relate this dilemma to cardiovascular care. Early detection and treatment of coronary disease is essential to preventing a problem or surviving an episode. Are those covered by managed care really best served by a primary-care physician who not only is less qualified than a cardiologist to detect and treat the disease, but who also may have a financial disincentive to refer enrollees to a cardiovascular specialist?
Further, are managed-care organizations unfairly requiring primary-care physicians to make life-or-death decisions, increasing their exposure to malpractice litigation.
Instead of blindly accepting the reasoning that quality of care can't be determined, we should focus on collecting the clinical detail that will make measurement possible.
The good news is that there is hope, but it will require all of our efforts. We must elevate our thinking to demand more from a system that consumes so much of our resources. Key components that need to be addressed are clinical pathways, data collection and review procedures.
First, standard detailed clinical pathways must be developed and approved for use on a national basis. These pathways can't just be limited to invasive procedures, but must include the entire continuum of care.
Second, providers must be required to collect clinical data that's currently not part of the HCFA 1500 or UB82 form. Even better, perhaps a data-entry process can be developed that allows a physician to enter data once and, as a byproduct, provide both clinical detail and billing information.
Thirdly, we must do away with the 1-800-DAMN THE DOCTOR mentality that permeates the utilization-review practices of managed-care organizations. Instead, physicians' clinical decisions should be reviewed based on consistent pathways with allowances for varying clinical conditions within the pathways themselves. Physicians then will retain the necessary freedom to use their judgment while developing the ability to monitor the results of their decisions over time. The goal should be to look for the best practices and outliers.
Clinical information should be used to validate quality care. If a provider demonstrates a more effective pathway with the same or better clinical outcomes, then the pathway can be adjusted. On the other hand, if a physician's decisions are shown to fall outside the norm, then the process can inform and educate them so that they can evaluate and modify their practice patterns.
Ordinarily, all this would be a tall order. But with so much talk of reform, there's a unique opportunity to push forward with this type of meaningful change.
Whatever the reform approach that's adopted, the issue of clinical information will be crucial. Without a system for keeping up with the clinical criteria used in a physician's decisions, we're sentenced to remain in the dark when attempts are made to evaluate the appropriateness of care.
After all, there's a pervasive feeling that the inappropriate utilization of services is a far greater problem than the pricing of those services. If so, reform shouldn't give short shrift to this area.