In an environment increasingly critical of managed care, some health plans have received a nod from on high.
A new survey of managed-care organizations' best practices by HCFA shows that companies are working hard at improving care while reducing costs. And they're getting results.
While managed care's top regulator has lately taken a tough stance, warning against abuses such as physician "gag clauses" and incentives to deny care, A Collection of Best Practices of Managed Care Organizations is an acknowledgement by HCFA that HMOs and insurers employing managed-care techniques are doing some things right.
But there's plenty more to do. According to the report, "HCFA will consider the directions and strengths reflected in these activities in developing its policies and practices regarding managed-care organizations."
HCFA also is calling for "additional, more extensive and rigorous studies of best practices among managed-care organizations." Those plans are defined as organizations that integrate the financing and delivery of healthcare. Companies in the survey employ best practices in managed fee-for-service plans as well as HMOs. HCFA concedes its survey is by no means exhaustive; other health plans' best practices have yet to be identified and reported, the agency said.
In seeking to improve managed-care options for Medicare and Medicaid beneficiaries, HCFA began by developing a model of a managed-care organization, including 35 activities falling into three categories: organizational and managerial, clinical and administrative. HCFA then asked 43 people with expertise in managed care-from government, industry, trade associations, think tanks and academia-to identify managed-care organizations employing best practices.
The sources identified 32 organizations, and HCFA chose 18 as "broadly representative" and invited them to participate in the survey. Eight of the 18 participated (See chart for the plans and the best practices they were cited for). The last of the survey results were received in March 1994.
For example, United HealthCare Corp. was cited for three practices, including performance measurement. "Before you can manage something, you have to measure it," said Lee Newcomer, M.D., the company's chief medical officer. United draws on a database with information on physician visits, hospital stays and pharmacy use.
That has allowed improvements such as determining which cardiac patients were not getting a beta blocker to ward off a second heart attack, and then contacting their doctors to make sure the drug was offered, he said.
HCFA's report is designed to be useful to industry executives who want to learn from their peers. Each best practice is reported in the same format, using an outline that includes notable results, critical success factors and lessons learned. Most best practices include information on cost of implementation.
When survey results were analyzed, HCFA came to several positive conclusions.
"This small sample of (managed-care organization) activity reflects considerable efforts by organizations nationwide to operate their organizations effectively and efficiently," the agency said.
HCFA found well-established total quality management programs and "an intense focus on . . . clinical performance and attention to value."
Many best-practice reports also emphasize "the importance of the early and active participation of physicians to the success of innovative clinical and medical-management efforts," according to the report.
"Some (managed-care organizations) report substantial financial benefits from their best-practice activities, while others report benefits not yet quantifiable," it said.
The report also found:
Some organizations are using data-based outcomes measures to select and pay providers.
Preventive-medicine programs save money.
Utilization management is being continually refined through advances including case-mix severity adjustment.
Artificial intelligence and information networks are being successfully applied.
HCFA also found that the operating results of one social HMO, Minneapolis-based Health Partners, "continue to show that SHMOs can save state funds, satisfy beneficiaries and produce more appropriate care using the same resources."
Nine SHMOs currently provide seniors with community-based long-term care on top of regular healthcare benefits (Dec. 9, 1996, p. 14).
The report is available from the National Technical Information Service, 703-487-4650, for $31 plus a $4 handling fee. Order number is PB96-189279KCL.