Managed Care Can Be Made to Work Better

Jane Doe is a middle-aged woman with multiple chronic health problems for which she receives ongoing treatment and medication. Her new employer, a medium-sized firm with about 60 employees, offers health benefits, but neither of its two plans would pay for her to see her longtime doctor.

To ensure that patients like Jane Doe are not forced to change physicians suddenly, the California Managed Health Care Improvement Task Force has recommended that plans be required to provide continuity through a course of treatment when the patients involuntarily change plans or when a provider is terminated for other than cause, up to a maximum of 90 days or until the patient can safely transfer doctors. The task force also recommended that purchasers offer choices of plans to ensure that consumers can choose plans that provide access to their doctors.

Jane Doe must choose a new health plan. She consults friends and relatives for advice. Useful, comparative information about health plans is scarce and difficult to understand. The task force has recommended that health plans be required to list the practitioners who are accepting new patients through that plan and the specialty centers to which a patient would be referred for a serious problem. In addition, the task force has recommended enabling the state agency that regulates health plans to require specific reporting elements so that medical outcomes for particular conditions could be compared.

Eventually, Jane Doe must choose a new primary care physician. To allay her fear that her doctor might be overly influenced by financial incentives, the task force has recommended that health plans, medical groups and individual providers should, upon request, disclose how they are compensated. In addition, the task force recommended that large purchasers in the state begin adjusting payments to health plans and doctors to compensate those that enroll and care for the sickest patients so that health plans no longer have reason to avoid these patients.

Jane Doe chooses Dr. Smith, who belongs to a medical group that contracts with 15 health plans. Dr. Smith reviews Jane’s history, including her medications, and after reviewing her health plan’s policies, prescribes changes in Jane’s medical care.

First, she will have to change medications; hers are not on her plan’s list of approved drugs. One task force recommendation would protect a patient from being forced to change drugs for an ongoing condition. Next, every time Jane Doe needs to see a specialist for her heart problem, she first must see Dr. Smith, who must seek permission for the referral from Jane Doe’s health plan. Another task force recommendation would assure patients standing referrals to specialists for chronic conditions or for a complete course of treatment. Yet another would encourage a shift from requiring doctors to obtain permission in advance of treatment to better up-front screening of physicians for quality practice guidelines and retrospective analysis of the quality and cost of care.

Then, after her health plan denies a treatment that her doctor prescribed, Jane Doe complains. Given the information provided by her plan, she does not understand why her request was denied. The task force recommended consistent mandatory standards for dispute resolution across health plans so that patients receive full explanations for decisions no matter what plan they join. For serious problems, the task force recommended review of complaints by expert, independent third parties.

The task force also recommended creation of a new regulatory agency, devoted to managed care, with the expertise and vision necessary for effective and streamlined regulation.

Given the system that Jane Doe and Dr. Smith experience today, it is not surprising that they are dissatisfied. The recommendations sent to the governor and Legislature by the task force would take a giant step toward better health care for all Californians.