Industry Execs See ‘Empowered’ Patients, Plans as ‘Integrators’ of Services
Two weeks ago, the Health Care Management Program of the UCI Graduate School of Management hosted its annual Health Care Forecast Conference, bringing together academics, analysts and healthcare industry execs for two days of speeches and seminars.
One panel looked at “The Future of Managed Care: Market Outlook and Trends.” The comments here are excerpted from that discussion.
DR. ROBERT J. MARGOLIS
CEO, Health Care Partners, Los Angeles
Under the general heading of “What Do They Want,” for purchasers, they want reduction in cost. That’s been clear. We just heard a whole segment on how hard it is to get money out of tight-fisted purchasers. They’re demanding access to information, especially information under which they can make a value equation and a choice equation.
More importantly, we’ve asked what our consumers want. Clearly choice, unfettered access, is really critical. Useful information, from lots of different venues and useful means and user ease and ability to access it easily. Caring and empathy, especially when they’re in interface with direct healthcare providers. Hassle-free systems. And all of this combined with enormous expectations of confidentiality, despite the amount of information flow that’s going to be present in this new world.
Full record access. I think many are starting to come to the recognition that patients believe that the health information in their records is theirs. It should be theirs; it should be theirs to transport and to divulge only to people if and when they have proactive permission from the consumer.
But despite all of this systemization that’s required, there’s an expectation of personalized, individualized care where every patient understands or every consumer believes he or she is different and has different needs and different wants and so the requirement to individualized care is absolutely critical.
On the payer’s side, the health plans want uniform and reliable delivery systems, whether that be organized medical groups, IPAs or through individualized contracts. They want a seamless interface, meaning that it’s transparent to the consumer as to whether it’s a health plan or provider organization. And member loyalty. They want the members, the millions of members that belong to health plans, to feel loyal to their health plan and not flip around from one to the other.
What we’ve come to believe is that a consumer-empowered healthcare system is the future.
There’s absolutely no reason why next year,a year from today,most employees should not be able to enroll in their health plan, choose their physician and or physician group and IPA , understand the background biography (likes and dislikes, history of the physician they choose), make an appointment, receive their orientation materials, and pre-register all from their desktop in one motion. There’s just no reason. We don’t have anything like that in our system today. It should be there.
All referrals, authorizations, claims, and eligibility should be electronic a year from today. There should be no more paper and faxes on those kinds of operations. That’s a big piece of the hassle for both consumers, patients, and certainly for the doctor and staff side and I’m sure at the plan side as well. It just shouldn’t be there.
I think there are studies that show that over 50%,and I would suggest that it’s more like 70% to 80%,of people that come in to interface with us as providers and doctors do not need to see the provider doctor, if they had an alternative way that they found appropriate and they found useful to access the information or the other information needed.
So how do we do that? Instructed self-care, organized group care, Internet interaction, chronic home-care monitoring devices that work through the Internet to give the physicians updates on chronic-care management. Physician e-mail on a confidential basis,a big opportunity. Organized physician or provider-supervised chat rooms. … And a lot of chronic home care. As well as a patient-owned and accessible medical record.
We need to have it in a fully interactive conversation with the consumer. The consumer needs to be able to tell us that they need to come in and see the physician and,if we create this open access model that we just talked about, which is being created around in certain other venues,then we expect that our physicians are going to actually have less than 25% of their slots booked at any one time on the day in question. And that the patients will be able to come in and access the providers and that we’re going to be interactive with our consumers and targeting things such as reminders or full lab reporting via e-mail. As a matter of fact, I think there’s video-conferencing where the physician is actually going to be on the web-based TV giving video instructions to the patient after a visit perhaps. There’s going to be healthcare diaries that we’ll be able to help the patient implement and oversee.
DAVID OLSON
Senior VP, Foundation Health Systems, Los Angeles
We think that the critical word going forward is “choice,” and the second critical word is “quality.”
We think that consumers in the age of the Internet are going to demand more choice in every walk of life, and that includes healthcare. And we’d better be,all of us,be ready. …
Having spent many years in the hospital business, I think I learned first hand that the healthcare system as it exists today is a very inefficient user of the capital that has been applied to it. And we have to do a better job of that. We may not have unlimited resources, but we certainly have abundant resources, and we have plenty of resources to meet the needs,the healthcare needs,of this population in this country today. We don’t manage those resources very well. And one of the things that certainly is a challenge for managed care going forward is to play a critical role in managing those resources. So that people do get all the healthcare that they need and we can solve the problem of the uninsured. …
Is there really a business here? Is there really a business with managed care? We believe there is and I’m going to talk a little bit about that.
I think first of all, in some way, shape or form, all care is managed in some way. We think we have a role to play in that, in arranging care, in finding providers, and in developing the kind of information resources that consumers are going to need to get the care they need.
As boomers move into being heavy healthcare consumers, they’re going to be very demanding consumers. There’s been a lot of research about that, and I think the healthcare system in general has still got some work to do to prepare for the age of consumerism. I think managed care can play a role in that. I think that when we come right down to it, providers, physicians and hospitals, and payers, we all need each other. We all need to work together if we are going to solve these problems and meet the needs of consumers.
We believe that some regulation of patient rights is good if we want to remove the mistrust that exists today. And if we can remove that, by exposing ourselves to some limited form of liability with exhaustion remedies, that’s fine. What I think we’re going to find is that there are not going to be a whole lot of lawsuits, that people are going to use the appeals and review processes that will be made available to them in this reform and will result in people believing that they are going to get the care they need when they need it. …
I think that as we move to do all this, I think as a health plan, we don’t want to intermediate. We want to integrate services. We want to use technology to integrate services so that we are an integrator of services for consumers, not strictly an intermediary where we’ve often been criticized as being just a middleman.
The fact of the matter is, we ought to be able to, within a matter of two or three years, get to a point where there’s an electronic submission of a claim, the claim is adjudicated electronically and it’s paid electronically. So you could submit a claim and get it paid within a matter of minutes. And there’s no reason we can’t get to that.
DR. GORDON NORMAN
Medical director, PacifiCare of California, Cypress
On the commercial side, we, too, expect higher pricing, and more member cost-sharing, particularly in the pharmacy arena. A variety of plan designs and operations to try to innovate to provide wider choice and flexibility. Renewed emphasis on member satisfaction, and again, trade-offs in autonomy versus quality control.
We expect sub-networks developed within network model plans, with performance disclosure,creating a network within a network, if you will,and broadening our centers of excellence concept way beyond just transplants, advanced reproductive therapy, etc. to involve active channeling to hospitals and facilities that demonstrate risk-adjusted, severity-adjusted outcomes that merit that channel.
On the provider side, I think we’ve all witnessed the very painful, unsuccessful attempt at national consolidation. Provider groups we see refocusing on their local operations, though there will continue to be some statewide and market-based consolidation. We do see slow information systems and infrastructure investment. Capital is obviously clearly part of the problem, but not the only part of the problem. Technology standards, governance issues are also involved. We think there will be a refocus on fundamentals such as consistent service levels and healthcare quality management now that empire-building has moved to the back burner. …
What we see next from the employer’s side is some increased emphasis on value purchasing at the large and national account level, as prices do escalate into the double-digit premium (growth) range. Whether that will drill down further into smaller accounts is yet to be seen. There will be selective contracting for improved outcomes. There will be more business-to-business as opposed to vendor or contractor relationships, we think, between employer and the plan. And a new emphasis on total productivity, so the plans not only look at the group medical benefit structure, but also attack absenteeism, short-term and long-term disability, workers’ comp, etc.
On the consumer side: Some increased price sensitivity as their price-sharing increases. More informed, engaged and certainly empowered,some would say, demanding,consumers. The ability for self-service through the plan, self-care options, flexible incentives, that hopefully will begin to blunt the insatiable appetite for healthcare.
On the health plan side: More plans adopting the infomediary role that David described very nicely. Promoting world-class service through organized systems of care, demonstrating improved outcomes, reducing unnecessary variation, rationalizing excess capacity, and documenting return on premium investment.
In terms of the future outlook,fundamentally, I think there’s no viable alternative to managed care in some form with the modifications we’ve been discussing here.
As boomers move into being heavy healthcare consumers, they’re going to be very demanding consumers. There’s been a lot of research about that, and I think the healthcare system in general has still got some work to do to prepare for the age of consumerism.
, David Olson
