Physician-led care teams are helping to shift the focus of healthcare from cost reduction to better management of patient demand.
Using clinical guidelines and improved patient education materials, the care teams are working to bridge the gap between old and new ways of treating illnesses.
Care providers are seeking new treatment styles because they are caught between the demand for reduced costs from managed-care organizations and payers, and the demand from patients for high-quality medical care and the latest technological advances.
As medical groups take on more risk-sharing contracts, they can clearly see how keeping patients healthy through preventive measures and disease management is to their advantage.
"Demand management is only a part of the spectrum of expanded-care management services that affects what a patient does," says Daniel Temianka, M.D., medical director of quality management for Healthcare Partners Medical Group in Los Angeles. "This approach makes us recognize that patient care doesn't end with 20 minutes in a doctor's office. Social work and education are part of care management, too."
Temianka, who continues to see patients two days a week, says capitation is the force that drove Healthcare Partners to create its care-management programs.
"Any large capitated organization has a vested interest in good outcomes. That's why our group created programs to help patients avoid hospitalization."
Healthcare Partners has more than 400 physicians caring for 300,000 capitated patients.
An outspoken supporter of capitation as "the best way to go," Temianka dismisses the fee-for-service system as one that "rewards doctors when patients get sicker. What would an alien from another planet say about a system like that?" he asks.
Temianka emphasizes the value of patient education in good care management. Indeed, health education, self-care, wellness and prevention efforts are valued not only at Healthcare Partners, but seemingly everywhere.
Increased wellness and prevention efforts were linked to growth in profitability by a majority of the respondents to a 1996 survey of subscribers to Capitation Management Report, a monthly newsletter published by National Health Information in Marietta, Ga. Only 7% of the 227 respondents said increasing wellness and prevention efforts correlated with losing profitability.
Preventive service guidelines were added this year to the clinical guidelines developed by United HealthCare Corp., Minneapolis, which has contracts with about 265,000 physicians.
United HealthCare's demand-management programs are all part of its Optum division. The programs include "NurseLine," telephone counseling and referral services, and Optum Online, an Internet-based personal health information service.
The Optum disease management program, launched last summer, calls for a physician-led team of professionals to work with each patient to develop a comprehensive treatment plan. For example, in the case of a child with asthma, the team would include a respiratory therapist who would not only see the child at the hospital but also visit the child's home to assess the environment.
"For years, physicians have been managing disease situations without including the patient's home and work situations. The comprehensive approach changes that," says Bob Harmon, M.D., national medical director for United HealthCare.
"Research has shown that this will improve health and reduce hospitalizations. We began this approach last summer and don't have data on results, but we expect the results will include better health and reduced cost of care."
Kaiser Permanente, the nation's largest and oldest HMO, established a community health clinic program in Colorado, pairing teams of medical professionals with groups of patients with a common medical problem. The initial focus of the program was health problems of the elderly, but it has expanded to include patients with asthma, diabetes and other diseases.
The financial pressure on risk-sharing physicians makes the need for such programs apparent.
"You can either be a physician or a utilization management person, but you can't be both with the same patient," says Jonathan Shapir, M.D.
Shapir, a radiologist and principal of Imaging Utilization Services of Pembroke Pines, Fla., a division of Radiology Associates of Hollywood, Fla., relies on radiology-specific clinical decision criteria for utilization management support.
The criteria are designed to help with the decision of whether to authorize treatment. For example, a physician first requests an exam, such as a computed tomography scan of a patient's abdomen. The request then goes to a utilization review office where a staff member with clinical training compares the information provided by the physician with the guideline criteria for that exam (24 questions and answers in the case of a CT scan of the abdomen). If the request meets the criteria, the exam is approved. If it doesn't, it is sent to a second physician for further review. Only a physician can deny another physician's request for treatment.
Early indications are that utilization analysis programs can significantly reduce utilization and, therefore, spending. After 10 months of using criteria developed by Marlborough, Mass.-based InterQual, the managed-care organization that Shapir's group services reported a 20% reduction in utilization.
Shapir says physicians are ordering fewer "unnecessary exams." As a result, the percentage of requested tests that are denied has dropped to 10% from 20% at Imaging Utilization Services.
Projecting the results of screening proposed radiology services for a 100,000-enrollee managed-care organization over a 12-month period results in annualized cost savings of $600,000 for commercial enrollees and $1.8 million for Medicare enrollees, according to InterQual estimates.
Like clinical guidelines, the practice of self care is being adapted to the new healthcare environment. There is a growing demand for tools that can help physicians educate patients in self management.
"Probably 80% of medical care that is provided in this country is provided by individuals for themselves," says Don Parsons, M.D., associate medical director for government relations for Oakland, Calif.-based Kaiser. "If you could increase that by 5%, to 85% of the care provided, then you would reduce demand on the medical system by 20%. That would result in a huge cost savings.
"But is cost the only issue? Of course not. Physician-patient relationships are crucial," he says.
Kaiser has distributed more than 2 million copies of The Healthwise Handbook, a self-help paperback that covers 180 health problems, to enrollees and employees. Henry Ford Health System in Detroit gives a customized version of Healthwise for Life to all enrollees of HAP Senior Plus, a Medicare risk program of Health Alliance Plan, Ford's 500,000-enrollee HMO in Michigan.
Although most physicians still use printed materials for patient education, healthcare management organizations also are beginning to provide information and services on line.
"Lack of computer literacy still is a big problem today for both physicians and patients," says Tonya Hongsermeier, M.D., medical director of informatics for InterQual. "But I believe the technology will become simpler to use within the next five years."
In February, United HealthCare of Arizona introduced Health Forums to help personalize the vast amount of health information on the Internet for its enrollees. An enrollee constructs a personal health profile by choosing issues from an extensive menu, and then Health Forums creates a custom home page of links to information on each topic. United HealthCare plans to make Health Forums available to its enrollees nationwide by the end of this year.
In addition, Kaiser will introduce an interactive Web site sometime in 1998.
Health Watch Diaries software developed by Softwatch of New York and Tel Aviv is another Internet-based demand management product. The program allows patients to enter, track and share personal data with their physicians. It also lets them make appointments, and it lets physicians manage compliance on line. The system can be licensed to either a healthcare provider or health plan.
"The disadvantage of the way things are evolving is encroaching anonymity in the delivery of care," says Hongsermeier, an internist who now works full time on information systems technology for physicians.
"One answer is physician-led care teams that involve more people in a patient's care at any one time," she says. "Another is building coping and healing communities of patients and giving these support groups more validation and coordination by physicians and medical teams."