Friday, November 05, 1999

HMO to re-empower MDs

Paperwork was costlier than care

The Cincinnati Enquirer

        United HealthCare Corp., one of the nation's largest health plans, plans to announce next week that it will stop par ticipating in one of the most unpopular aspects of managed care: second-guessing the decisions of doctors.

        Ken Hoverman, chief executive of United HealthCare of Ohio, gave a brief preview Thursday of the company's internal reorganization to Leadership Cincinnati, an annual class sponsored by the Greater Cincinnati Chamber of Commerce that invites community and business leaders to study big issues facing the Tristate.

        “Expect to hear a lot more about this in about a week,” Mr. Hoverman said. “I call it an end to the "Mother may I' approach to health care.”

        United HealthCare covers more than 19 million people nationwide and claims to be the nation's largest publicly traded health insurer. Locally, United covers more than 80,000 people.

        Mr. Hoverman offered few details about the new plan, but talked extensively about several internal, bureaucratic processes that will stop as a result. Most important, Mr. Hoverman said practices such as requiring pre-authorization for hospital stays and diagnostic tests will cease.

        The company studied itself and found out it was spending more on the people and paperwork involved in denying allegedly unnecessary care than it was saving by refusing to pay for services.

        For example, United HealthCare calculated that it avoided paying about $38 million one year by refusing to cover services it considered unnecessary given the patient's diagnosis. But to “save” that money, it spent $128 million on the paperwork involved, Mr. Hoverman said.

        Locally, United staff members recently challenged 100 orders for colonoscopies be cause the insurer felt the doctor failed to provide a good reason for the diagnostic test. After going through time-consuming arguments with doctors and formal appeals from patients, United ultimately paid for all but one of the tests.

        In months to come, United will “put the doctors in charge,” Mr. Hoverman said. The health plan sees its future as more of an information resource on best practices for doctors and health education for patients.

        “A managed care company should not make medical necessity decisions,” Mr. Hoverman said.

        United plans to offer new products that tailor benefits more closely linked to a person's life-stage, Mr. Hoverman said. Meanwhile, the company will continue peppering doctors with “report cards” that compare their practices to other physicians. It also plans a stepped-up role in teaching patients how to take care of themselves after they leave the hospital and where to go for the best care.

        Like any health plan, United gathers vast amounts of data on patient illnesses and what gets done about them. The information puts the company in a position to identify many of the best surgical methods, diagnostic tools, medications and services.

        It plans to use that information more aggressively to persuade doctors to change wasteful ways — but not by denying care to patients.

        Much of United's changes are a response to the skyrocketing growth of Internet-based commerce and the vast amounts of health data already available to consumers with computer savvy.

        Within three years, Mr. Hoverman predicted that consumers will be able to gain direct access to some of the report card data now available only to health plans, large employers and health care providers.


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