Tuesday, July 20, 2010

Managed Care and Accountable Care Organizations

I recently received the following note from a mental health clinician I know to be clinically excellent and fair-minded as well:
I am aware a number of providers are disturbed with their experiences with [XYZ Managed Behavioral Health Organization] and I wanted to share my experience. Basically, the reviewer was belligerent from the get-go and I had no chance to present my experience. I felt like a defendant on the witness stand with the D.A. confronting me. I still don't know the result of the review, but it certainly was unprofessional and unfair to my patient and painful to me.
I thought of Yogi Berra - this was deja vu all over again!

In the 1990s I studied managed mental health care the way an anthropologist would - I sat with clinicians as they spoke with managed care reviewers and sat with managed care reviewers as they spoke with clinicians. What my observations showed was good people brought into conflict by a flawed technology that came into being to fill a vacuum my colleagues and I had created.

We clinicians were schooled to believe that it was unethical to consider anything other than the interests of our individual patients. This was often said with a kind of smug theological certainty, with the implication that only a moral imbecile or callous monster could disagree. "Doctor," I often replied, "that's an admirable view. Since it's unethical to consider anything but the interests of your patient, that means if your patient needs a heart transplant and you are the only good match, you would be a donor."

In these exchanges I often thought of my hero from college days - Socrates. The colleagues I had this exchange with felt I was pulling a fast one on them and trying to make the worse appear the better cause. For defending the aims of managed care as ethical I was at risk for being fed a jug of hemlock.

In all of my practice years I never experienced third party telephonic review. In my public sector role we had an explicit budget we had to work within. And in my not for profit capitated medical group role we again managed ourselves within the budget set by the capitation we received.

Since costs must be contained, there are only four choices for a health system. (1) Manage via the market, with individuals buying their own care. (2) Provide insurance, with each doctor/patient dyad deciding what should be paid for. (3) Enlist medical expertise in allocating funds via what is now called "accountable medical organizations." Or, (4) ask insurers to do the job for us via third party review.

When clinicians responsible for providing care to their patients and reviewers responsible for managing the available funds are connected by an 800 number, the kind of fiasco my colleague describes is inevitable. Clinicians tell each other about unreasonable reviewers. Reviewers tell each other about feckless clinicians. Distrust builds.

The reviewer described in the note I received could have been a bad apple put into the wrong job, but also could have been a well-intentioned person, who had seen many examples of bad practice, and was overly vigilant.

In the 10 - 15 years since physicians and the public revolted against managed care we've come closer to recognizing that if we don't want the economy to go down the tubes, costs must be managed. In the next 10 - 15 years we'll see a burgeoning of "accountable medical organizations," in which clinicians and patients learn to co-manage resources. The required new learning won't be easy, but if we do the job well we'll be following the Institute of Medicine's urging to cross the quality chasm!

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