Surviving Managed Care© Newsletter
| Volume 1, Number 1 Spring, 1999 | Vision and Eyecare Business Information For The Millennium |
In This Issue:
Surviving Managed Care ©
Managed Care news and business information for eyecare professionals and administrators.
Gil Weber, MBA
www.gilweber.com
Objectives:
To identify important managed care information resources on the World Wide Web; to assist eyecare professionals and practice managers find specific information for the administration of managed care contracts and patient populations.
Managed Care Information on the World Wide Web
As practitioners and practice administrators find themselves involved in an increasingly volatile healthcare environment, their needs to access specific, accurate, and current managed care information and data become acute. In some markets the changes and dynamics are so rapid that one can't wait for a national or state society's annual meeting to obtain new information and updates.
The World Wide Web is emerging as a powerful, speedy tool to address this need. Most Web users have discovered how to find clinical information using any of several search engines. But finding practice management and administrative information has been more frustrating. Whether negotiating a contract, developing network marketing strategies, or preparing a capitated bid, it's essential to know as much as possible about the payors, patients, and competition. So let's look at some interesting and important Web resources which I'll loosely group in the following six categories: demographics/regional variations, healthplans, employer coalitions, competition, quality assurance and credentialing, and legal.
Demographics/Regional Variations Understanding population demographics and regional variations is key to success in any managed care contracting. Factors such as age, ethnicity, family size, regional pricing variations, etc. all play powerfully on utilization and costs, and on the network size and provider mix required to service a particular population. Payors are often unable or unwilling to share such information, but if you know where to look the Web gives access to volumes of useful data for vision and eyecare.
HCFA's site should be the first stop (http://www.hcfa.gov). Here you can find a wealth of demographic data with special sections devoted to Managed Medicare and Medicaid. For example, if you're keeping current with the action in Medicare HMOs and want to know what's happening in any state, it is a simple task to download the current list of HCFA-approved plans. Another file gives you the current Adjusted Average Per Capita Costs (AAPCC) for every county in the nation plus Puerto Rico. Before submitting a capitated bid it's very useful to know what HCFA pays HMOs. (Special note: See the premier issue of this newsletter for an update on Medicare Choice and 1998--1999 funding.)
The National Institute of Health (http://www.nih.gov) is another rich website with valuable information on specific populations. For example, let's say you were in Arizona and considering a capitated agreement with the Indian Health Services to care for the Pima Indians. On the NIH site you can find a report (Diabetes in Native Americans and Alaska Natives, NIH Guide, Vol. 21, No. 34, Sept. 25, 1992). That report notes the rate of non-insulin dependent Diabetes Mellitus is two to five times higher among Native Americans than the general population, and 19 times higher among the Pimas compared to Caucasians.
Certainly you might already know that Native Americans are predisposed to Diabetes and its complications. But if you were bidding capitation or retina sub-capitation on this population it would be disastrous not knowing that you were facing significantly higher risk than you'd even imagined. Additional information on Native American populations is available at the Indian Health Services website (http://www.ihs.gov) which also contains a sub-page on optometric services within the IHS.
Another interesting and demographics-rich site for managed vision and eyecare is the CDC sub-site under the Department of Health and Human Services (http://www.cdc.gov/nchswww). Among the many recently posted resources available there is a 15 page report on Glaucoma utilization (Office Visits for Glaucoma: United States, 1991-92, Advance Data, Number 262, March 30, 1995).
The General Accounting Office's searchable report database (http://www.gpo.ucop.edu) has an abundance of useful reports including one essential for any eyecare group or network considering Medicare HMO contracting (HCFA Should Release Data to Aid Consumers, Prompt Better HMO Performance, GAO/HEHS-97-23, October, 1996). This GAO report blasted HCFA for not providing seniors with necessary information on the performance of Medicare HMOs. The report contains a wealth of information including some startling statistics on disenrollment rates. High levels of patient dissatisfaction is a red flag.
Another startling report on the same site (Medicare: Many HMOs Experience High Rates of Beneficiary Disenrollment, GAO/HEHS-98-142, April 1998) reveals that in 1996 the highest disenrollment rate in Portland (7.4%) was less than the lowest disenrollment rate in Miami (10.1%). The lesson: Wining a capitated contact for patients who then disenroll in droves is a losing proposition.
Healthplans If you are a provider for a particular healthplan (or hoping to become one), wouldn't it be nice to know what the patients are being told about the eyecare services you provide? Most HMO websites include a wealth of patient and provider oriented information. Doctors and administrators will find this useful, particularly when seeking insight to a payor's contractual or marketing "hot buttons." One site to check is Aetna/US Healthcare (http://www.aetnaushc.com).
Here you'll find a section with patient information on many topics including cataract, glaucoma, contact lenses, and diabetic eyecare. These are examples of specific areas in ophthalmic care that Aetna will want to see emphasized in any current or potential provider's quality assurance and/or utilization management programs. Other HMOs provide similar clues on their websites. Such opportunities should not be missed.
Managed care is like Chess... Know the rules, plan ahead, prepare for the unexpected.
The Cigna website (http://www.cigna.com) is an example of a national HMO linking its various local plans through a central access point. By going to the national Cigna site you can access any of 44 local Cigna HMO and POS plans. And by accessing any local plan you can find key contacts and phone numbers in important departments such as provider relations, members services, etc. These contacts are typical of those so important to any individual, group, or network seeking access to decision-makers.
Other HMO sites provide very specific insight into diseases or conditions which the payors have identified as key to managing their costs and improving patient satisfaction. Thus, providers and administrators are presented with golden opportunities to develop focused programs and systems which will dove-tail into a healthplan's. Kaiser Permanente's website offers an excellent example.
KP's site is another that has linked all its local plans to a central point (http://www.kaiserpermanente.org). Even if there is not a KP plan in your area, each is worth a look for ideas you can adapt and adopt.
For example, within the area called "Press Room" Kaiser Permanente Hawaii announced it has initiated a program to identify those at high risk for diabetes. All new patients fill out a questionnaire with family history and health habits. Based on the results, in one year KP Hawaii diabetic eye screenings increased from 48% to 72% of the identified population. This is gold.
That an HMO has taken such steps is significant, for it says very clearly to the provider community that the plan is interested in raising its HEDIS report card scores. This is useful information not only for the practitioners who will likely see more patients as a result, but also for any network administrator who might be asked to submit a capitated bid on a healthplan's membership. If the plan is going to initiate a push to increase eye exams for diabetics, that push will mandate (and justify) an appropriate adjustment in the capitated bid to account for this plan-induced utilization spike.
Finally, many healthplans provide administrative support for managed care through their websites. Oxford Healthplan's site is an example (http://www.oxhp.com). Here office staff can access the most current information on patient eligibility and benefits. In addition, current information on claims status is available. Accessing this or similar information on-line is much faster and far less costly than inquiry by phone with its constant frustrations of busy signals and being left "on hold."
Administrative services such as these can make an individual practitioner's office run a bit more efficiently, particularly if the office sees a lot of the plan's members. And for groups or networks seeking a "carve-out," being able to piggy-back onto the plan's systems can save up-front dollars invested in hardware and software -- major considerations for those just getting operational.
Employer Coalitions In many markets large employer coalitions wield enormous power over healthcare purchasing choices at both the macro (healthplan) and micro (benefits) levels. Without information on the decision-makers and without knowing what's important to them, vision and eyecare networks may find that they are locked-out from significant blocks of patients directed to closed delivery systems.
What kind of managed care information can one find on such sites? One easy to find but critical bit of information is the coalition membership -- whose employees and dependents are represented? See The Greater Detroit Area Health Council (http://www.gdahc.org) as an example. With a click of the mouse button you can instantaneously access a complete list of all Detroit-area participants. These companies have banded together to leverage their collective strength (in much the same way and for the same reasons that eyecare professionals form networks).
And, as part of market research, wouldn't it be useful to know if an employer coalition had a relationship with any vision and/or eyecare groups? Some sites provide this information. As an example, check the site sponsored by The Georgia Business Forum On Health (http://www.gbfh.org). Note that it promotes the "20/20 Vision Plan" through Peach State Eyecare.
And wouldn't it be useful to know what purchasing coalitions say to their members and to the employees and dependents about HMOs and quality of care? One of the most informative sites is sponsored by the Pacific Business Group On Health (http://www.healthscope.org).
This site provides disenrollment rates on every Medicare HMO in California, and then discusses the significance of these rates. A mouse click farther into the site and the reader gets specific information on preventive care performance for California HMOs. Another mouse click and you find educational information about diabetic retinal exams. Throughout, the reader learns the significance of all this for making a choice among HMOs. This, too, is gold.
Now, while the information on each coalition site will differ, all are worth a look, even if you don't reside in that state. Pull information from an out of state site and show it to your regional coalition(s). Ask if they have local data you can access. If not, maybe they'll help develop the data for their members and for the local provider community.
Competition There are many powerful and well capitalized vision and eyecare networks competing for managed care contracts, and many have informative websites. While these sites are obviously self-serving, each is worth a look.
Vision Service Plan is the nation's largest provider of insured visioncare. At a minimum, VSP's site (http://www.vsp.com) merits your interest to review their interesting on-line claims submission, benefits, and eligibility verification systems. Since VSP will promote these on-line systems to payors, patients, and providers, it's important that other groups and networks think of this as a public benchmark, and develop systems no less efficient or user- friendly.
Davis Vision, a Pennsylvania Blue Shield subsidiary, has a large site (http://www.davisvision.com). As expected, you won't find any secrets, but there is insight here into an aggressive player that is now the nation's second largest provider of insured visioncare products. You'll find information typical of that which Davis Vision provides to payors when bidding on managed care business. In addition, check the website for Davis' parent company, Clarity Vision (Blue Cross). It's one of the net's better sites (http://www.clarityvision.com).
Another information-rich, webpage is Superior Vision (http://www.superiorvision.com). Be sure to note the user-friendly ways in which purchasers, patients, and providers are each targeted. For example, Superior offers providers on-line access to change the data in their provider directory profiles.
Other, less developed sites include Omega's EHN-Eye Health Network (http://www.omegahealth.com), Eye Care Plan of America (http://www.ecpa.com), and Opticare (http://www.opticare.com).
Quality Assurance and Credentialing As HMOs respond to employers and regulators they are demanding more of their providers in the areas of quality assurance and credentialing. The Web has many sites which provide important information to any eyecare network building or refining its systems. Let's look at two.
The National Committee for Quality Assurance (NCQA) is one of the most influential organizations in managed care. It sets the rules and standards for healthplan accreditation. It also established the HEDIS report card measurement tools by which healthplans are rated and which many employers use for their purchasing decisions. This site is a must-visit (http:www.ncqa.org).
For example, the numerous downloadable files include HEDIS testing and reporting set measures, clinical practice guideline standards, and scope and content of clinical quality improvement activities standards. In addition, the site has specific information on physician and ancillary provider credentialing standards (in case you want to do it yourself) and on select CVOs -- credentialing verification organizations -- which have been accredited by NCQA to perform the services for others.
Another sight worth a look is the Joint Commission on Accreditation of Healthcare Organizations (http://www.jcaho.org). JCAHO provides many of the same services as NCQA but is focused more on hospitals and networks than on healthplans. Still, information obtained from this site will add to any provider or administrator's understanding of managed care quality assurance and credentialing.
Legal Visiting the sites described next will not in any way reduce a provider or network's need for qualified, experienced managed care counsel. However, these sites will give the reader considerable insight into the myriad legal and regulatory issues which flow over and under the surface of this volatile healthcare delivery environment.
Everyone building or joining a network to pursue managed care contracts must eventually address the issue of antitrust. Some measure of self-education is necessary, and two sites are must-visits. The Federal Trade Commission (http://www.ftc.gov) has an antitrust/competition sub-site with two useful managed care links (Statements of Antitrust Enforcement Policy in Healthcare, and FTC Antitrust Actions In Healthcare Services). The other useful site is that of the Department of Justice, Antitrust Division (http://www.usdoj.gov/atr/index.html).
Another increasingly complex managed care issue is whether networks will be allowed to accept at-risk contracts (capitation) without first securing an insurance license. Contracting directly with employers would allow provider-owned entities to bypass the healthplan middlemen, thereby directing a higher percentage of premium dollars to patient care. Each state sets its own standards, and information is available from State Departments of Insurance.
Recently, however, the National Association of Insurance Commissioners began an intense effort on behalf of its insurance company clients to change state laws and preclude provider-direct contracting without costly insurance licensure. Ophthalmic networks want to avoid this if possible, so dialogue with your Department of Insurance is important. Fortunately, NAIC (http://www.naic.org) makes this easy for most states. Click their link labeled Insurance Regulators.
OMIC (http://www.omic.com) is another information-rich site. For example, with reimbursements falling many practices are reallocating staff resources to lower practice costs. But that carries with it potential complications. See the Closed Claim Study, volume 7, number 1, Winter 1997 for a valuable piece titled Telephone Triaging By Nursing Staff Imposes Corporate Vicarious Liability.
These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.
The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.
Copyright © 1997, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author's prior written authorization.
