Information is your best weapon
By Jerome H. Carter, FACP
Listening to colleagues discuss the changes we face with the advent of managed care, I could not help but notice their feelings of despair and defenselessness. While I admit things were better in the old days, all is not lost. We simply need to learn to fight fire with fire. In this case, information technology is the fire we need. The good news is the tools we need are widely available. The bad news is that few physicians know how to make use of them.
Because capitated payments force us to choose between spending for our patients and protecting our incomes, we must develop the capability to fight back. But how can we fight managed care companies that threaten us with offers we cannot refuse?
Say a managed care firm comes to you offering "X" dollars per month for a pool of patients--take it or leave it. You decide that the amount offered is not reasonable; however, you are afraid not to take it. Sound familiar? If you are like the average practitioner, you complain that the quality of care will suffer, and of course you have no objective proof.
Imagine how this scenario would differ if you could demonstrate that for any given diagnosis, you provided care that met or exceeded accepted standards of quality, and show in actual dollar amounts the costs incurred in doing so.
You would have a very compelling argument for demanding a higher capitation rate. Capitation has forced physicians into the same business mode in which other enterprises have always had to operate. Ford knows what to charge for an automobile because it knows what it costs the company to make one. Our product is health care, yet how many of us know what it costs to provide quality care? What does it cost you to take care of a patient with coronary artery disease over the course of a year? What about the cost of a single episode of strep throat? This is the kind of information needed to negotiate a reasonable capitation rate, yet few of us have it or have even tried to get it.
Another problem we have as a profession is a lack of concern for some outcomes. Within your practice have you ever attempted to learn which visit patterns of hyperglycemic regimens produce the quickest normalization of blood glucose levels? Have you ever studied why your patients go to emergency rooms? Have you studied the efficacy of ordering urine cultures?
Managed care organizations spend millions of dollars each year for information systems to study these issues. They also pay close attention to your practice habits. U.S. Healthcare is famous for studying Medicare data to get a picture of how a particular doctor practices. How much do you know about your own practice habits? What is your typical length-of-stay for uncomplicated congestive heart failure? Do you order echocardiograms in a timely manner? Do you order more than average?
You don't need an electronic patient record to obtain this information. Many electronic record systems are not even designed to provide this type of analysis. Basic studies can be done with a simple database or spreadsheet. The most important factor in determining one's success in obtaining and using information tools is the simple realization that they are necessary.
We as practitioners are losing the managed care "war" because we are using sticks and stones against those who have planes and tanks. Remember that sinking feeling you had during your negotiations with a managed care company? I am sure the Polish cavalry commanders felt the same way looking across the border in 1939.
What is the lesson here? Never get caught with yesterday's attitude. By looking at what managed care companies consider important, you can protect the interests of your patients and yourself.
Jerome H. Carter is an assistant professor of medicine and health services administration in the division of general internal medicine at the University of Alabama at Birmingham.
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