Beyond managed care, access even more crucial
Beyond managed care, access even more crucial
Internet, consumerism are at the wheel
Access managers know well the difficulties of life under managed care — from deciphering insurance cards to navigating the ever-changing rules of reimbursement. The bad news is that the access burden may not be any lighter in the upcoming era of patient-managed care.
The good news, explains Richard L. Clarke, FHFMA, president and chief executive officer of the Healthcare Financial Management Association, is that it will be a more positive experience to work with patients who have more control over and a better understanding of the care they receive.
The switch from physician-managed care to third-party managed care initially had the desired effect of reducing health care inflation, notes Clarke, co-author of a new book on consumer empowerment and the growing role of technology in health care. (Clarke R, Coddington D, Moore K, Fischer E. Beyond Managed Care: How Consumers and Technology Are Changing the Future of Health Care. San Francisco: Jossey-Bass Inc.; 2000.)
However, the restrictions put in place by the government and third-party payers not only created dissatisfaction among physicians, who were less in control of their financial livelihood and their treatment options, and patients, but they also failed to please employers, he says. "Employees constantly complained; there were morale problems, and so it was still no panacea."
Even the managed care companies in some cases have gone into financial distress as employers continued to push for more and more savings and resist premium increases, Clarke adds. "Over the past four or five years, there has been a significant down cycle for managed care companies."
It’s time for change
Because of the pressure from employers and employees, managed care companies have developed a variety of ways that health plans can be designed, he says, further complicating the lives of access managers.
"There’s still a lot of turmoil, and with everybody unhappy — including the managed care companies — we believe there is going to have to be a change," Clarke says. "No system can work that way."
With a stronger competitive market, there is a growing recognition of the power of the consumer, he points out. "Where there is abundance of supply, you generally have more choices. We feel this will happen in health care, which tends to lag behind [other industries], in the same way that Detroit had to start making better cars because of other options available to buyers."
Among the forces driving the trend toward health care consumerism, Clarke says, are the Internet, which facilitates the consumer’s ability to gather information to make cost-effective decisions, and alternative medicine, often a less costly and more consumer-friendly choice than mainstream medicine.
"Now consumers can find out as much about a disease or a condition as a physician can, and can work out a way to find the best provider of care," he adds. "We’re at the cusp of that."
Employers becoming less involved
Another indication of the turn toward patient-managed care, Clarke says, is the fact that employers are increasingly bowing out of detailed decision making when it comes to health plans. "They’re providing a vehicle for the employee to make decisions, just as with the difference between pension plans and 401(k) plans. They might say, The amount of dollars available for the health plan is X. Here is an array of 10. You can buy one of these plans or you can increase your deductible and divert [benefits] to alterna-tive medicine.’"
The book’s authors, he adds, suggest these four ways in which the transition to patient-managed care could happen between now and 2005:
1. The future is shaped by incremental changes, which may not happen as directly or significantly as described in this article.
2. Resources are constrained, as with a significant economic downturn in which the federal government stops having surpluses. Some changes happen more slowly, and the government may restrict flexibility because of cost concerns, pushing the industry back toward managed care.
3. Technology dominates. There is a rapid rate of technological development, especially as it applies to health care, so changes happen even more quickly. Pharmaceutical and procedural advances, such as with genetics and robotics, have an impact on the delivery of care.
4. Consumerism and technology rule. The consumer is king and, using technology, drives the marketplace. All the players are very much in tune with what the consumer needs. This requires anyone who wants to provide services to be very aware of what the consumer needs [and to provide services] at the right place and at the right time.
What it means for access
Because patients in the future are likely to be covered for health services in ways that are even more varied than today, training will continue to be a crucial issue for access services, Clarke says. "Consumers will be much more savvy about what their treatment options will be and will seek organizations that are more in tune with what those options are."
Organizations that don’t respond to the market demands may not make it, he adds. "I also think those that are positioning themselves well, both financially and service-wise, will do better. It will be more obvious to the consumer who is best."
Health care professionals who are committed to the belief that customer service is the benchmark of access management will find themselves in good standing, Clarke suggests. "[Good customer service] will have so much more impact on whether a patient will find the [hospital] experience to their satisfaction. Like any other business environment, if they have contact with a surly employee, they won’t go back."
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