Endocrinology in the managed care environment
The American College of Physicians/American Society of Internal Medicine has defined managed care as “a system of health-care delivery provided by contracted providers in which the entities responsible for financing the cost of health care exert influence on the clinical decision-making of those who provide the health care in an attempt to provide health care that is cost effective, accessible, and of acceptable quality.”
2. Is there only one type of managed care?
Managed care is actually a spectrum of health-care delivery systems ranging from managed indemnity insurance through preferred provider organizations (PPOs) and point-of-service (POS) plans to various types of health maintenance organizations (HMOs). Collectively, these organizations are called managed care organizations (MCOs). To a greater or lesser extent, all managed care systems attempt to shift financial risk in one way or another to the providers of care.
3. Who is the patient’s initial contact in a managed care environment?
In most cases, the patient’s initial contact is with a health-care provider, conveniently called a primary care provider (PCP). This person is usually a physician, such as a family medicine, family practice, or general practice physician, but often the PCP may be a physician who has specialized in internal medicine or an internist with a subspecialty (e.g., endocrinology) who enjoys practicing primary care in addition to his or her subspecialty or does not have enough subspecialty work to fill his or her schedule. The PCP can also be a physician extender, such as a nurse practitioner or a physician assistant. Some MCOs use physicians in large clinic-type settings in an effort to control costs. In other situations, PCPs function out of their usual private practice offices—in a sense, mixing their private (or non-MCO) patients with their HMO or PPO patients.
4. Do pediatricians and gynecologists function as PCPs?
There has been a movement over the past few years to allow pediatricians to become PCPs for children and for obstetrics and gynecology specialists to become PCPs for women of childbearing years, who often have no need to see other types of physicians.
5. How does the patient make contact with a subspecialist?
A patient is allowed to see a subspecialist, such as an endocrinologist, only with the recommendation of a PCP. Usually, an endocrinologist is not allowed to function as both a PCP and a subspecialist within a given HMO. In these situations, when a fully trained endocrinologist is serving as a PCP, he or she cannot even perform specialty-type procedures and must refer patients to another endocrinologist.
6. What is a meant by the MCO’s “panel” of providers?
After an MCO has established itself in a community, it begins to develop a panel of all the providers it requires, including PCPs, medical subspecialists, surgeons and surgical subspecialists, pediatricians, obstetricians-gynecologists, and dermatologists. Simultaneously, the MCO contracts with hospitals (strategically located around the community that it wants to “penetrate”), nursing homes, home health agencies, physical therapy centers, dialysis centers, outpatient diagnostic centers, clinical (commercial) laboratories, and, sometimes, even outpatient diabetes education centers or dietitians.
The panel of providers is published yearly in a directory that goes by a variety of names (e.g., preferred provider list) and is distributed to all participants of the MCO. This directory is sometimes called the list. It is used by patients to determine which PCP is available for them to use (although in some HMOs, new patients are immediately assigned to a PCP of the HMO’s choice). The directory is used by a PCP to know which subspecialists, diagnostic center, and laboratory to use. It is also used by the MCO itself as a marketing tool to solicit business for itself by proudly showing which subspecialists belong to its panel of providers. It is therefore necessary to be on the list to receive referrals from this HMO. However, your presence on the list as a subspecialist does not mean that you will ever receive referrals. The health care for the MCO is then provided by this entire group of health-care providers, all of whom are under contracts with the HMO to provide the care in the manner and for the price negotiated. Thus, the MCO has managed to do what the health-care system was never able to do by itself—organize all the health care into one unit.
In some cases, the POS option allows the patient to see any specialist, although the reimbursement schedule is different. In addition, the patient’s out-of-pocket expenses (copayment) are often much larger. The POS option differs greatly among insurance companies that offer it.
9. How do MCOs compare with other business units?
When one looks at the managed care system from afar, it is not so different from any other business unit that has to negotiate with vendors to provide services that it cannot provide on its own. Think of a business unit as the cruise ship industry, which negotiates with its own employees, as well as with entertainers, doctors, food suppliers, fuel suppliers, ports, and travel agents, to provide its customers (passengers) a total package for their enjoyment. So have the MCOs attempted to organize the U.S. health-care system. It is clearly a private, non–government-regulated, for-profit (in most cases) system with the primary goal of earning a profit for its shareholders while attempting to contain costs for the entire health-care system. Not-for-profit MCOs are not necessarily any more efficient in providing the care to their members and often have the same fiscal problems as for-profit MCOs.
10. What is the difference between a PPO and an HMO?
A PPO is a plan, as originally conceived in the 1990s, that contracts with independent providers at a discounted fee for service. When the PPO systems first started, their representatives would approach a PCP or a specialist and offer a discounted fee schedule to a physician in exchange for the potential of being specifically referred a group of patients who otherwise would not be able to see that physician. There developed the concept of panels (i.e., the lists discussed earlier), in which a list of accepted providers would be given to patients covered by the plan, who must agree to use only the physicians on such a panel for their care to be covered by the plan. This concept has been modified many times (see question 12).
HMO was originally defined as a prepaid organization that provided comprehensive health-care services to voluntarily enrolled members in return for a prepaid fixed amount of money. Nowadays, an HMO can be a health plan that places some providers at risk for medical expenses or a health plan that uses PCPs as gatekeepers.
11. Are there other types of MCO plans?
As pressure was placed on businesses with large numbers of employees who were not happy with the original types of plans and the costs of the yearly premiums of certain plans, many other insurance options were created.
12. What are blended policies?
