Three years ago, anyone who guessed that managed care would mean no preauthorizations, health plans soliciting physician input and a cooperative, almost conciliatory corporate culture would have been laughed out of the business.
No one's laughing now.
This is serious business. It's make or break time for the health plans, and HMO executives are in the hot seat.
So they're turning to physicians--the very ones who they angered and alienated.
Top executives at the nation's biggest insurers, AetnaUSHealthcare and UnitedHealthcare, see themselves as developing better relationships with physicians and patients. The antagonistic, uncooperative culture of the past several years won't resurface, they say. The insurers say they are moving to replace the poisonous atmosphere with more physician involvement and better relationships with physicians.
But physicians aren't sure whether to believe what they're hearing. They're unsure whether the good intentions will last as long as it takes for the ink to dry on their contracts. And they're unsure whether a leopard can, indeed, change its spots.
The following profiles highlight the efforts of two industry giants to regain physicians' trust, improve relationships and simultaneously create better healthcare. Some of those on the front lines are willing to give them a chance.
Others say they're already seeing better days. And still others think it's simply a lot of talk and little action.
United: A new approach to managed careWhen UnitedHealthcare eliminated most of its preauthorization requirements, physicians and the organizations representing them were stunned. The move ended, at least for United's network, a hallmark of managed care.
While the announcement surprised physicians and industry observers, it also caught other health plans off guard, leaving them to answer questions about why they weren't following United's lead.
In the 14 months since United's announcement, plans have pledged to become more physician friendly. But none has gone as far as eliminating preauthorization requirements.
Instead of preauthorizations, physicians will see retrospective analysis of their treatment of United enrollees. It's unclear whether that will become a thorn in the doctors' sides. But United officials insist it won't be, that the analysis will be for educational purposes only. It's part of their ongoing commitment, they say, to becoming more physician friendly. And those commitments and actions, say United officials, are the difference.
"It's one thing to say you're going to think about being physician friendly," says Chief Medical Officer Archelle Georgiou, M.D. "It's another to actually do it."
Georgiou says the new approach involves three key points: eliminate the hassle, make it easier to get care and keep people from falling through the cracks.
She says physicians are noticing a difference and telling United officials that it's easier to work with them. To back up the anecdotal information, they have commissioned a formal physician satisfaction study. Even without the results, Georgiou says in the first 12 months after its policy change, United saw a 73% decrease in denials of coverage and a 26% decrease in complaints to the company's consumer affairs department.
"We view the decrease in incoming phone calls as a proxy for decreasing the hassle," she says. "They have to call us less because fewer services require a call. Over the course of the last year, we've seen a 28% decrease in incoming calls. That's about 1.2 million calls per year doctors don't have to make.
"With incoming calls as a proxy, as well as pure denial statistics, all indicators are quite positive that we've eliminated a hassle."
But not all physicians are convinced it's happening and remain skeptical about the outcome and the motives.
"So far, all I've heard is a lot of rhetoric," says Thomas Reardon, M.D., immediate past president of the AMA. "What we want to see is change."
Some physicians have told the Medical Association of Georgia that they haven't seen much change in United's practices, says Paul Shanor, MAG's executive director. But he doesn't want to dismiss them outright. "We've had good conversations about the programs and eliminating (preauthorization)," he says. "We just want to make sure they're doing it."
"We've had fewer and fewer people applying to medical school because it's no longer fun to be a physician," Shanor says. "You can't provide the care you know is needed. It's frustrating."
And it's that frustration that's leading United and others to make significant changes, one analyst says.
"It's clear they're not only doing it, but that other insurers are (starting to do) it as well," says Paul Ginsburg, president of the Center for Studying Health System Change in Washington. "I think United either did a brilliant or an inadvertently brilliant job of doing it. My sense is that this is a real change. Plans have figured out that their old mechanism . . . wasn't paying off financially. It certainly was hurting relationships with physicians, which adds another cost to the strategy.
"This is a different approach to managed care. What's hard to know is, is this just a difference intended to save money or part of a backing up of management in general."
Physicians' skepticism should be expected because they have been promised changes before that didn't happen, he says. Even when physicians do notice a change such as United's, they are not likely to stop complaining anytime soon, Ginsburg says.
"I would think it's just a matter of time and a matter of more companies doing it before it becomes clear to physicians," Ginsburg says. "There's such hostility between physicians and health plans . . . to the degree that even if physicians see these (changes) they have other gripes with these plans. The plans are eager to improve their relationship."
How these changes will impact costs won't be known for years, Ginsburg says. Even if this approach turns out to be more expensive, it's unlikely plans that eliminate preauthorizations will return to them, he says. But what physicians will see is more profiling of their practices. "In a sense, (the plans will) be using it to drop physicians from their network rather than just going back to the physicians in each instance."
Georgiou says the profiling of physicians isn't designed to be a punitive system but rather to ensure enrollees are getting needed care--both preventive and disease management.
The company has created a database to track 50 million years worth of data, she says. The database allows United to look at utilization management and track enrollees' care. United officials plan to give physicians retrospective data on patients in a way that "helps guide their thinking," Georgiou says. "It's educational and confidential."
Not all United plans and contracts have eliminated the preauthorization requirement because some contracts haven't come up for renewal, she says. Some state laws require the contract to expire before changes such as this can be made, although the majority of contracts have eliminated it.
Physicians tell United that they are frustrated with having to call for approval for some procedures, including inpatient admission and home healthcare, Georgiou says.
"It's not so we can scrutinize their clinical decision," she says. "It's our way of knowing that . . . their patients benefit from the care coordination process." It's too early to know whether retrospective analysis will result in punishment of doctors. But physicians and the organizations that represent them have been leery of such proposals in the past.
While the focus was and continues to be on the elimination of preauthorization, the company's approach is actually much larger than that, says United spokesperson Roger Cruzan. One of the goals of the Care Coordination program, the name United gave to its decision to revamp its plans, is to ensure patients get appropriate care, he says. And, Georgiou says, they've put that plan into action.
One of United's enrollees was admitted to the hospital for an asthma attack. When the health plan's nurse called the patient after she had been discharged, the nurse discovered that the patient couldn't use a standard peak flow meter because she was blind. The patient couldn't read the numbers on the meter and therefore couldn't track her breathing capacity. So United's nurse--whose previous job was to approve or deny preauthorization requests--tracked down a Braille peak flow meter.
"It's more than just saying we're going to stop doing something. It's changing the whole philosophy, the way we're organized and the direction of the company to make the changes that are going to impact customers and physicians," Cruzan says. "I think we've got to make sure we distinguish between words and actions."
Aetna: A leader makes up for lost timeDuring an AetnaUSHealthcare retreat a couple years ago, Duke University basketball coach Mike Krzyzewski told employees that those at the top of their game often forget the obligations of being No. 1.
Whether he knew it or not Krzyzewski's speech was prophetic: For the past 10 months, Aetna has spent time and money reconnecting with patients and physicians and sending the message that the nation's largest insurer knows its obligations as king of the hill.
When the board of directors brought in healthcare outsider William Donaldson as
chairman and CEO, Aetna quickly began remaking its public image and working to regain the trust of physicians.
"What you see here is really a commitment on the part of the organization, a very strong recognition of the important role that physicians play in caring for members, and commitment to strengthen the relationship," says John Kelly, M.D., head of the physicians relations unit. "The important message is that this is part of the corporate mission and corporate commitment."
It's a culture change that is sincere and won't be limited to the nation's largest insurers, at least not for long, says Paul Ginsburg, director of the Center for Studying Health System Change in Washington. "It's clear that they're not only doing it, but that other insurers are doing it as well. My sense is it is a real change. Plans have figured out that their old mechanism . . . wasn't paying off financially. It was certainly hurting relationships with physicians and adds another cost to the strategy."
Aetna's previous management, he says, "seemed almost to take pride in alienating physicians." Now, Ginsburg says, the new leadership is trying to make up for lost time.
Aetna, which covers nearly one in 10 Americans with health insurance, promised to essentially eliminate the all-products clause in its physician contracts in some states, to get more physicians involved in advisory boards and to move away from corporate-controlled medical decisions. Aetna also has eliminated capitation for some or all primary care physicians in at least five states. Officials will make similar moves on a market-by-market basis, they say.
The efforts appear to be having some effect. "On the surface, the promises Mr. Donaldson made, it seems like he's keeping them," says Frank Scarpa, M.D., a general surgeon in Greenwich, Conn.
In May, Donaldson had his first public meeting with physicians when he spoke to the Connecticut State Medical Society. He was brutally honest about not only the company's position in the market but also what Aetna had done wrong.
Since then he has met with other state medical societies. He told investors that the company will face tough times before it sees better financial results.
The choice of John Rowe, M.D., as AetnaUSHealthcare's new president clearly backed up Donaldson's desire to improve relationships with physicians, say some observers. Rowe spent more than a decade as head of an academic medical center and has, as one medical society president put it, seen the dark side of managed care.
And the resignation of CMO Arthur Leibowitz, M.D., signaled further the desire to break from the company's past and start again, say others.
As much as Rowe's presence, Leibowitz's absence and Donaldson's decisions may impress physicians and even serve to calm their fears, it is the people on the front lines who will work with physicians to right the company's perceived and actual wrongs. Those doctors, Aetna officials believe, can influence patient perception of how the company is improving. More importantly, they say, those physicians need to know Aetna is serious about the change.
"There are a number of changes underway, changes in the focus and the attitude and the process," Rowe says. "One of the things I feel strongly about is that while we recognize we have many important constituencies and many important customers . . . the company is focusing on the people that we serve."
"We believe that will be interpreted by the physicians very positively. Those are the people the physicians focus on, as well."
But officials know they can't do it alone, Rowe says.
"Our approach implies and requires, on our part, a partnership (with physicians) based on respect and trust and a mutual concern for the people whom we both serve."
To lay the groundwork for that partnership, Aetna has and is taking several steps: hiring a new chief medical officer, changing the reporting structure for regional medical officers to give them more autonomy at the local level and remaking the corporate processes to involve more physicians, Rowe says.
Aetna also is exploring a dispute resolution process that is "coherent and built around a much better day-to-day working relationship," Rowe says.
"Ultimately it leads to a change in the content of our interactions. We haven't accomplished that yet."
Rowe says data from Aetna's quality research division will let physicians give patients summaries of medical literature relevant to their conditions, such as prostate or breast cancer.
"We have 20 million loyal people we serve," Rowe says. "We have these unique assets that should be able to add value. The only way we can effectively do that is not to put ourselves between the patient and physician but to engage the physician in the environment which is replete with up-to-date medical information. That's a very important goal for this company."
While Aetna has made their intentions clear, some physicians and the organizations that represent them say the Blue Bell, Pa.-based insurer must prove itself through actions.
"There are still major issues out there that would keep me from calling (Aetna) a physician friendly company," says Paul Shanor, executive director of the Medical Association of Georgia. "Our doctors don't think they're there yet."
Not until health plans realize it's financially beneficial to be physician friendly will doctors see true change, Shanor says.
While some of the promised changes have been more than expected, talk is cheap, says Thomas Reardon, M.D., immediate past president of the AMA.
"The proof will be in their actions," Reardon says. "So far what we've heard is they haven't made those changes. So far, all I've heard is a lot of rhetoric. What we want to see is change."
Aetna officials say they know their new corporate mentality won't change physicians' minds instantly.
But Kelly, the head of Aetna's physician relations unit, says change is what the physicians will get. New programs, electronic payment systems and new telephone systems have helped, he says.
"Every one of our medical directors, every one of us sees strengthening that relationship (with physicians) as a critical part of our mission," Kelly says. "All of us are focused on that. Collectively we have committed to meeting with physicians, with as many as possible, of expanding our advisory efforts and taking advantage of physician input."
Under the old USHealthcare model, Aetna's medical directors used to meet with network physicians at least once a year, says Jay Krakovitz, M.D., regional medical director for the mid-Atlantic and acting CMO.
They need to get back to that, he says. But more importantly, doctors and health
plans need to stop sniping at each other.
"I'd like to see a truce declared between physicians and health plans. I'd like to have every doctor wake up tomorrow and realize they're going to be 75 years old and be a patient and to ask them what they are doing so that the doctor examining them when they're 75 is smiling," Krakovitz says.
Walker Ray, M.D.United and Aetna's promises of reform haven't paid off for patients, says Walker Ray, M.D., an Atlanta pediatrician.
"I don't think patients have seen any change," says Ray, who along with the Medical Association of Georgia met with the insurers' representatives this summer. "Business ethics is being substituted for medical ethics . . . We are not rallying against managed care per se but the abusiveness of managed care."
United appears to be "genuinely concerned about better relations," but their policy changes "appear to be more window dressing and more rhetoric than actual change," Ray says.
Ray says he was dropped from the Aetna network when he wouldn't participate in capitated HMO plans; Aetna required physicians to participate in all products. Aetna recently promised to drop the all-products clause from Georgia contracts.
"The things they mentioned that they were going to do were rather minor concessions," Ray says. "And they didn't quite understand when we didn't jump up and applaud and hug them."
George Rodgers, M.D.If other insurers are going to survive, they will have to follow UnitedHealthcare's lead, says George Rodgers, M.D., a cardiologist and president of a 25-physician cardiology group in Austin, Texas. He says he thinks those plans soon will have no choice but to change.
The major difference between United and the other insurers with which his group does business is the lack of hassle, he says. Doctors no longer have to call for approval for most procedures, Rodgers says.
"The (United) employees who were the gatekeepers are now the facilitators. It not only goes better, but it's facilitated instead of being blocked," he says.
"What we experienced before was a frustration. Ninety-eight percent of the time if the patient and doctor agreed on a procedure it would be approved anyway. It was a waste of time."
Karen Laugel, M.D.Karen Laugel, M.D., says she's given health plans their chance, and she's taking her concerns to lawmakers.
The Stratford, Conn., pediatrician attended the Connecticut State Medical Society meeting in May during which Aetna CEO William Donaldson laid out his vision for the company. She is still skeptical about any changes and has had problems with Aetna. She canceled her contract with the company and took her problems to the news media.
After she heard Aetna was dropping its all-products clause, Laugel met in early October with Aetna's regional medical director. Laugel laid out her concerns with the company's new contracts, which she says still contained all-products clauses and cut physician reimbursement.
"The medical director turned out to be a yes man. He said he'd take it back to his office," she says. It took a while to get a reply from Aetna, she says.
Laugel says she is still talking with Aetna representatives. "It's very clear to me who has the power," she says.
Allen Pearlman, M.D.Electronic payment and instant approval makes AetnaUSHealthcare easier to work with than most other plans, says Allen Pearlman, M.D., an internist in Dallas.
The insurer has touted its electronic payment system, E-Pay, and promised physicians quick and accurate payments if claims are submitted electronically.
That, coupled with the company's instant coverage authorization process, has made Pearlman's practice run more smoothly. Office staffers swipe an enrollee's insurance card through a computerized card reader, and Aetna immediately verifies whether the patient is covered and whether any procedures or tests are covered under the patient's plan. If Aetna says a patient or procedure is covered and later discovers it isn't, Aetna will still pay the bill, Pearlman says.
He would still like to see better reimbursement and hopes more insurers follow Aetna's lead. But he's happier than he's been in a while. "That's the most important thing in my mind: the ease of use."
Max Medary, M.D.In the old days, health plan bureaucracy would have gotten between Max Medary, M.D., and his patient. But not this time.
The Celebration, Fla., neurosurgeon was treating a UnitedHealthcare patient for spinal fluid on the brain when he found a tumor. Eventually, Medary assembled a team of four surgeons, and the man required several follow-up operations, extensive rehabilitation and care at home.
"(United) was supportive from day one," Medary says. "I was absolutely shocked. This case particularly exemplifies the lack of red tape."
More health plans will have to adopt this approach, he says. He still runs into red tape with other insurers on a daily basis. There are some patients that simply require more care, but that doesn't mean doctors should be frustrated while trying to care for them, he says.
Paul ShanorInsurers need to realize that prompt pay isn't a case of physicians being demanding, says Paul Shanor, executive director of the Medical Association of Georgia. Physicians deserve to be paid promptly, he says.
Georgia has the strictest prompt-payment law in the nation, giving insurers 15 days to pay clean claims or face stiff penalties. The state's insurance commissioner has fined several of the largest health plans thousands of dollars over the past year. Physicians still haven't seen much improvement, Shanor says. But he is optimistic that will change.
Patients and physicians are so acutely unhappy with health insurance that it's unlikely companies that make physician friendly changes would ever revert to letting MBAs and high school clerks determine healthcare, he says.
"It's taken them a long time to get the (bad) reputation that they have," he says. "You don't lose it quickly. They have to earn (our trust). We'll be watching to see if they earn physicians' trust. They don't have it now."
Dennis BuhringWhen AetnaUSHealthcare purchased Prudential, Dennis Buhring worried after the working relationship soured. The chief operating officer of Physicians Associates of Florida in Orlando, Buhring says things have improved in the past nine months. Aetna brought in a new regional team that works well with his group. The group cares for more than 135,000 Aetna enrollees, a significant portion of the group's patient base.
"I have seen a change in attitude and communication," he says. "They can call us. We can call them. Another key is just stability, of having good leaders for more than six months."
But he also says the company needs to eliminate preauthorization, especially for routine referrals.
"If this could catch on, we'd all win. Everyone just wants to do a good job," he says. "The intentions are wonderful. You have to keep working to make sure it happens. The insurers have to say, 'We are able and willing to make it work with you, to make the system better for you.' I can see it. I can feel it. We're eager, and I hope it's contagious to other plans."
Paul Handel, M.D.The health plans need new leadership, and some of the top ones have taken that step, says Paul Handel, M.D., chair of the Texas Medical Association's council of socioeconomics.
"Their performance to this time has been absolutely abysmal. My hope is that with the new leadership, there's a new approach, a new direction taken by the company. Certainly at this time, there's the potential for a lot of good will."
UnitedHealthcare's care coordination has potential for making that company more patient centered and physician friendly, he says, but it still needs to be monitored. "There needs to be considerable administrative simplification," Handel says. "We are working continually with the carriers to reduce the preauthorization list."
The country's mentality toward healthcare also must shift, he says. "It's, 'I don't want to pay for my own maintenance. Let someone else pay for it.' If someone else pays for it, No. 1, it's a lot more expensive and No. 2, everyone's a lot more unhappy."