01/31/2009
Dallas Morning News – Online
Do managed care plans really contain costs? Not according to the following article posted in the Dallas Morning News – Online. Whether the intention of managed care is to contain costs or to manage the care of patients, one thing is for certain, health care costs among physicians and other providers continue to rise.
New research by a UT Southwestern Medical Center physician calls into question whether health insurers are adequately performing one of their main functions: containing costs.
Dr. Ethan Halm, chief of internal medicine at UT Southwestern, found that private managed-care plans for Medicare do no better job of steering patients away from unnecessary surgeries than the traditional fee-for-service system, where the patient goes to any provider and the doctor or hospital bills Medicare directly.
Local insurers didn’t dispute Halm’s findings but said it would not be practical to always implement the level of cost-saving scrutiny Halm’s report suggests.
While working at Mount Sinai School of Medicine in New York last year, Halm examined differences in care for 11,400 Medicare patients who received a carotid endarterectomy a surgery to restore blood flow by removing fatty plaque from neck arteries over a 10-year period.
Halm said he chose patients undergoing that surgery because it’s common, costly and mostly an elective procedure. He said he also chose carotid endarterectomy because it’s a surgery for which managed care plans routinely require pre-certification to weed out patients who don’t need it. ‘This is a procedure for whom the vast majority of care is appropriate and necessary; however, about 9 percent is being done unnecessarily,’ said Halm, whose research was published in the December issue of the American Journal of Medical Quality.
In Halm’s opinion, insurance companies bare some blame in escalated health care costs for not using their resources, pre-approval protocols, and existing published guidelines to prevent overuse of unnecessary and costly procedures. ‘Trying to reduce costly but unnecessary care is the low-hanging fruit when trying to control the costs of health care,’ he said. Halm said there is growing evidence that the federal government is wasting money in Medicare cases by paying managed care companies much more than fee-for-service plans with the hope of containing costs or improving quality.
John Goodman, president of the National Center for Policy Analysis, a Dallas-based think tank, has long felt managed care companies are ill-equipped to contain costs. ‘It’s incredibly hard for them to do so,’ Goodman said. ‘The whole concept is the buyer of a product is going to tell the seller and producer how to produce. Can you think of any other market that works that way?’ Goodman said true cost savings in health care must come from doctors and hospitals, not insurance companies.
North Texas’ largest insurers supported their actions.
Dr. Allan Chernov, medical director for Blue Cross and Blue Shield of Texas, the region’s largest insurer, said his company is not in the business of ‘micromanagement of every health care interaction.’ That’s because physicians, patients and legislators have strongly opposed such moves in the past, Chernov said. ‘Although some large companies, and consultants, often seem to expect care micromanagement from a conceptual standpoint, they generally don’t support it in the face of employee/consumer reaction,’ he said. Aetna health insurance spokeswoman Anjanette Coplin said the insurer focuses more on preventive and wellness strategies.
As a way of containing costs, its Web site lists price ranges of common surgeries for all local hospitals and doctors in their network.
Dr. Sam Ho, executive vice president and chief medical officer of UnitedHealthcare, the largest Medicare HMO in North Texas, said there is little medical evidence to justify spending extra money to pre-approve patients for a carotid endarterectomy.
UnitedHealthcare does require patients to meet prequalification guidelines for other costly procedures, such as back surgery and knee replacement surgery, he said. ‘We have to balance out the hassle factor to physicians and the cost to manage this program,’ Ho said.