Fed up with rising costs, employers are demanding more say in how healthcare is delivered. In the Twin Cities, a group of major employers is wielding its clout to change the framework of healthcare.
The Business Health Care Action Group, a coalition of 22 companies with more than 100,000 employees, decided to provide a guaranteed chunk of business to an integrated delivery system that was committed to working directly with employers to improve care.
The group requested proposals and agreed on a uniform health plan.
They began contracting with an HMO, Minneapolis-based HealthPartners, and two major medical groups, Park Nicollet Medical Center, St. Louis Park, Minn., and the Mayo Clinic of Rochester, Minn.
The arrangement-now in its second year-is nudging the Twin Cities medical community toward further integration and improvement of clinical practices. It also is putting physicians and purchasers of care face to face.
"It's the first time purchasers have come together and clearly articulated a different way we want to see medical care delivered. The medical community has fallen all over themselves trying to meet our expectations," said Ann Robinow, director of strategic projects for the Business Health Care Action Group.
At a cost of slightly more than $1 million, the providers contracting with the coalition created the Institute for Clinical Systems Integration, where business representatives are included on teams of physicians and other providers that formulate clinical guidelines to improve efficiency and quality.
Sixteen guidelines are being implemented this year by the 20 medical groups affiliated with HealthPartners, including Mayo and Park Nicollet. Another 10 guidelines will be ready in 1995, said John Sakowski, the institute's chief administrative officer.
Mr. Sakowski said the larger groups had some improvement initiatives under way, but 13 or 14 smaller medical groups didn't have the resources to establish guidelines on their own. "It just brings everybody along much quicker," he said.
Initially physicians were paid on a fee-for-service basis to track base-line costs. Capitation-fixed payments per enrollee-is being phased in.
Business participation has been well received, Mr. Sakowski said. "All the businesses said was, `We want to be a part of it. We want to sit in.' I think that appealed to the physicians-that it wasn't a judgmental thing," he said.
Fred Hamacher, vice president of compensation and benefits for the Dayton Hudson department store chain, served on a guidelines team for lower-back care. He couldn't address clinical issues, but he did offer ideas on how back injuries might be avoided in the workplace.
The joint effort has fostered a sense of partnership, said Mr. Hamacher, who is chairman of the coalition and also happens to suffer from lower-back pain. Before, he dealt only with insurance plans. "The provider and the purchaser never had a chance to meet," he said.
Now they're collaborating. For instance, physicians refer smokers trying to quit to a company's occupational health nurse for support, said Leif Solberg, M.D., a family physician with Group Health, a multispecialty group practice.
"I've learned that it's a lot better to work together than separately," said Dr. Solberg, who has served on three teams.
The guidelines are aimed mostly at improving care; cost savings is secondary. Results have been difficult to measure, Ms. Robinow said, although a program to treat uncomplicated urinary-tract infections without physician appointments is expected to cut the cost of that treatment 28%.
The message is out that purchasers want integrated, accountable networks, said James Ehlen, M.D., president of a competing system, Minneapolis-based Allina Health System.
Allina is developing its own guidelines, Dr. Ehlen said, but it also owns Coon Rapids Medical Group, whose physicians participate in the institute.
"We're going to have to collaborate across competitive lines in order to not duplicate effort and to make sure we have a cohesive system," Dr. Ehlen said. "I think the key is the impact that the purchaser is now having on the priority thinking of healthcare organizations."