In markets across the country, competing health plans are coming together to collaborate on the development of common physician credentialing forms and treatment guidelines. It's a move that's motivated by the need to boost quality, save costs and improve public relations. And in addition to these intended effects, it's also likely to make physicians' lives a little easier.
"We recognize in this era of managed care that there's a lot of contention and that instead of being divisive, we need to find ways to work with the practicing medical community," says Tom James, M.D., medical director for Anthem Health Plans of Kentucky. "So we first need to start coming together as health plans with some consensus."
James is one of eight medical directors who are doing just that-coming together through the Kentucky Association of Health Plans to look for ways the various plans can collaborate on treatment guidelines. About a year ago, the group agreed on guidelines for cancer screenings, and, in July, it finalized and distributed a unified treatment protocol for deep-vein thrombosis. The group worked with several large IPAs to promote its most recent guidelines, and it also distributed them to 1,500 primary-care physicians.
"The thing that we're trying to do with this is align incentives with as many parties as possible," James says. "We figured this was a win for most parties at the table. It's a win for practicing physicians if we can reduce hassles, and it's a win for the insurance companies if we can reduce hospitalization."
The positive public relations aspect also doesn't hurt, James readily admits. Key to the effort is the strong anti-managed care sentiment expressed in the press. "We have to be able to demonstrate that we can be a positive influence and that we can remove barriers for physicians," James says. "It's not just saying no."
A good example of this type of collaboration is one involving the major health plans in New Hampshire. The five plans have worked together since 1997 under the umbrella of the not-for-profit Foundation for Healthy Communities. The foundation, which is made up of New Hampshire's health plans along with hospitals, providers and health officials in the state, has successfully implemented a comprehensive set of statewide preventive treatment guidelines.
Rachel Rowe, the foundation's executive vice president, says having unified guidelines benefits both providers and payers. It saves some time for physicians by ensuring they don't receive 10 different sets of guidelines from 10 different payers. And it reduces costs for the health plans because they now share the expense of printing and distributing guidelines and treatment protocols to physicians.
The first step in developing common guidelines was reviewing each plan's preventive-care guidelines, Rowe says. "Where there was variation, we went with the most conservative recommendation. (For example) most of the health plans recommended that patients receive cholesterol screenings every five years after age 35, but one recommended starting after age 19, so now for all of them, it's age 19."
An advantage of having common guidelines is that even if a patient switches health plans every year, his or her new plan can offer preventive care with no worry about whether the services will be covered.
Once the treatment guidelines were agreed upon, the health plans had them printed as wall posters and mailed to participating providers. The foundation developed a prescription guide to help physicians keep track of which drugs are covered by the health plans and a unified physician application form.
Previously, New Hampshire physicians went through a different application and credentialing process for each health plan with which they contracted.
In Massachusetts, health plans are working with the Massachusetts Health Quality Partnership, a not-for-profit coalition of healthcare, business and government, to develop about 45 preventive-care guidelines. MHQP already has standardized an obstetrics risk-assessment form.
Previously, the form an obstetrician used to get general information about a patient and determine whether she was high-risk depended on the health plan that covered her. "It was driving physicians crazy to have different forms for different health plans," says Kathy Coltin, director of external affairs and measurement systems at Harvard Pilgrim Health Care.
Coltin stresses that the treatment guidelines are just that-guidelines. They're not written in stone. Concerns that health plans will not pay for treatments that aren't listed in the guidelines are unfounded, she says.
"They're standards, and the way they're presented is as evidence-based recommendations for good clinical practice," Coltin says. "It's written right on the guidelines that these are not intended to replace the clinical judgment of healthcare providers."
And, like its neighbors to the north in New Hampshire and its counterparts in Kentucky, the MHQP is adopting the guidelines of specialty organizations. The American Cancer Association, for example, was consulted on the cancer-screening guidelines, and the American College of Obstetrics and Gynecologists was consulted on pap-smear guidelines.
To ensure that the coalition, which covers about 80% of Massachusetts' health-plan enrollees, does not violate antitrust laws, the MHQP includes representatives from state health agencies. The same is true in Ohio, where the Central Ohio Medical Directors Coalition, which is made up of 10 medical directors, recently elected a representative from the Columbus Health Department to be its chair.
"We are essentially going to act as a consultant group to the Columbus Health Department," says Owen Johnson, M.D., medical director of United HealthCare of Ohio. "So the things we will strive to do will be things that will improve the general health of the people of central Ohio."
The coalition has already developed guidelines for mammography and pap smears and hopes to accomplish the same for asthma and diabetes.
At the national level, Humana, Oxford Health Plans and UnitedHealthcare announced earlier this summer that they would use a single, common application process to credential providers in their networks. As is true of the state efforts, the new process is expected to eliminate aggravation and costs for physicians and plans alike.
According to MMI Companies, a Deerfield, Ill.-based healthcare risk-management company, physicians spend an average of $75 in staff costs and two to three hours on each application. Health plans spend an average of $100 to $250 per application.
"We all have a common goal, and that is to deliver quality care to the people who buy our products," Johnson says. "I think we do that in many ways individually with our own quality improvement programs, credentialing programs, customer service programs, etc. But there are many common factors (within those programs) that are a real problem for practicing physicians.
"If we can get rid of some of those by sitting down and saying these things can be agreed upon and supported, it can eliminate some of the hassle factor for physicians."
The efforts at collaboration, however, are about much more than making nice with physicians; medical directors are the first to acknowledge how they benefit from such partnerships. Harvard Pilgrim's Coltin points out that the National Committee on Quality Assurance requires data on many preventive healthcare measures, yet physician compliance with certain quality measures was declining because they were overwhelmed by the amount of material they were receiving.
"(Collaboration) is just one of the many ways to try to gain compliance with certain performance measures and make sure the physicians understand what's expected of them. If they do follow it, we'll all do well on our performance measures," Coltin says.
Supporters of unified treatment guidelines realize that getting physicians on board the guideline bandwagon is no simple task, in part because in many markets physicians are reluctant to listen to anything health plans say.
To ensure physician acceptance, the New Hampshire and Massachusetts medical directors included state medical societies in the development of their guidelines. In Kentucky, James says, the support of several large IPAs has been essential. And in Ohio, Johnson believes the involvement of the Department of Public Health will soften physician resistance.
Gary Sobelson, M.D., a Concord, N.H., family practitioner, acknowledges that some physicians don't want to work with health plans, period, but that the guidelines are an easy starting point for future cooperation.
"There are some doctors who are simply going to be uncomfortable with anybody publishing guidelines and giving information," Sobelson says. "But this is the area we call the lowest hanging fruit-the stuff we can actually work on together. It's easy to find common goals in this area, it's stuff we were both already working on."