Managed Care 101 in 2010 (Part XII): "One Cannot Manage What One Does Not Measure"

Dr. Steven Safyer has said: There should be a "clarion call to action for universal health coverage. But expanded coverage needs to be coupled with comprehensive change in how health care is provided and how it is reimbursed. Simply insuring the 45 million uninsured under the current system is economically unsustainable and doesn’t cure what really ails the system.”

He continues in his Letter to the Editor, (NY Times), “To improve care, reduce the burden of illness and be cost-effective, access to primary care emphasizing prevention, wellness and disease management must be financed adequately, and all health records must be made electronic and universally portable. Our technological infrastructure allows us to withdraw money at an A.T.M. in the world, yet two physicians practicing in the same neighborhood have no way to gain access to or share crucial patient information.... Let’s hope that the next administration will see the wisdom of acting—not just talking—so Americans get the care they deserve, at the right place and time.”

----

Steven M. Safyer (the writer), is medical doctor, is president and chief executive of Montefiore Medical Center Bronx, NY, Oct 31, 1008 “Improving Health Care.” NY Times, Letter to the Editor; Pub. Nov 5, 2008

Now just what happened with managed care?

In the '80s, private health plans became known as health maintenance organizations (HMOs). They were touted to be the "savior for Medicare" in that they "could provide the same or better services as traditional fee-for-service Medicare, but because of managed care they could do it at a lower cost." In 2003, Congress with its surfeit of Republicans, substantially increased government payments to HMOs, resulting in Medicare paying 13% more than it did for comparable services under fee-for-service (FFS). The added payments averaged more than $1,100/patient/year, and were supposed to reduce the burden of cost-sharing and offset the cost of vision and dental care. Nevertheless, they appeared to help the marketing effort more than they helped "make health care more efficient, increase outreach, cost savings, benefit and thereby outcomes."

"The managed-care plans still arguably do a better job than traditional Medicare at coordinating care and eliminating duplicative services." With more than 10 million people (almost 25% of all Medicare beneficiaries) enrolled in HMOs, you would think the coordination of care would have improved; however, it did not for the fastest growing part at least—private-FFS plans. "They simply piggyback on the traditional Medicare program, relying on the same doctors and hospitals while using their subsidies to offer cost savings or extra benefits to enrollees."

----

"Medicare’s Too Costly Private Plans." Congress must remove unjustified subsidies to inefficient private health insurance plans that have added to the cost and complexity of the Medicare program....November 29, 2008

What's missing? Ans.: True medical management

Before discussing how to get to affordable, efficient and effective healthcare for all, allow a brief digression about the pharmaceutical industry's influence on healthcare. I probably have a different view from most about medical marketing. In fact, I am all for the pharmaceutical industry making presentations and visiting me on my turf from time to time. I consider the research they apprise me of, so long as they have had no or at most an arm's length relationship in its sponsorship. In other words, I find that some of the marketing can be useful. However, if a physician is so easily influenced that pens, coffee mugs, and a lunch or dinner to hear a presentation causes that person to prescribe in a certain way, we've got a different problem.

The drug pitch is viewed with suspicion, resulting in the better drug being dismissed for its cost, rather than its cost-benefit. Per a GSK rep, recently, "That a patient with congestive heart failure should be well monitored in an effort to reduce morbidity, keeping them out of the hospital, as it were, is, perhaps, the best example of 'low hanging fruit' for managed care I can think of. It's a no-brainer—deliver better, more accessible, timely care (even after-load reduction) and the patient doesn't crash as easily. In other words, the use of Coreg rather than a alpha OR beta blocker means less cardiac risk." What happens behind the scenes in the HMO's 'Pharmacy and Therapeutics' committee is that the objective evidence is reviewed and if the data are not overwhelming, they go for the cheaper product—every time. It does not matter if the generic tastes horrendous—who's monitoring the compliance, anyway?

Even direct-to-consumer advertising can have value in educating the customer. My point is let's focus on the real issues in healthcare. Making the pharmaceutical industry a scapegoat serves no purpose except to distract us from more important issues. The practitioner must weigh the pros and the cons of any therapy, consider benefit AND cost, be cognizant of trends, standards, and guidelines.

Redesigning healthcare

If we were to design a healthcare system that was egalitarian and appropriate in accessibility, reasonable and efficient in terms of the use of resources, and cost-effective and cost-beneficial in terms of the quality of care, we would need to know who does what, where, when, and how well. That is the measure of efficiency and effectiveness we seek.

Data can be translated into information with which we can manage what we measure and we can realign the incentives. Recognizing (rewarding) who's doing the right thing at the right time should be the basis for continuous quality improvement, appropriate utilization, and risk management in managed care.

Dr. Safyer makes the point that happens to be the guiding principle of manage care. As I said in last week's post: "one cannot manage what one does not measure and the obverse, one cannot measure what one does not manage" ...but, again, who is measuring? Who’s managing?

Also see:

Cutler, David M., Mark McClellan, and Joseph P. Newhouse. “How Does Managed Care Do It?” Rand Journal of Economics Autumn 2000;31(3):526-548.

"Identifying, Categorizing, and Evaluating Health Care Efficiency Measures," by Issuu, Pub.; pp. 48-58

To my readers: Is managed care, per se, too costly or interfering? If so, what's the alternative?

---------------------

PS: By the way my dental problem was thought to be a staph infection. That, to me, raises the issue of MRSA. Guess what? The oral surgeon did not do a culture—Why? "It is not cost-effective." What would have happened if the infection was resistant to the apical procedure and the clindamycin he put me on?