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Annual Session News

For internists, lessons learned on coping with managed care

From the May 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Deborah Gesensway and Maureen Glabman

SAN DIEGO—From abstract questions of rationing to the nitty-gritty of how to decide if a capitation rate is right for you, this year's Annual Session offered more than a dozen courses on how to cope with managed care.

About a third of all physicians now have some capitated contracts, ranging from 40% in New England and on the West Coast down to about 25% throughout the South. But how much risk these contracts pass on to internists—and for what services—appears to be evolving, according to speakers at a course on capitation and risk assumption.

For instance, Richard E. Dixon, FACP, medical director of the Oakland, Calif.-based National IPA Coalition, explained in a course on capitation that medical groups, HMOs and independent practice associations (IPAs) are giving their primary care physicians fee-for-service payments to encourage them to do more for patients. At the same time, these organizations are trying to control the utilization of high-cost services by capitating their specialists. Dr. Dixon said this strategy works particularly well with physicians like cardiologists, who have considerable discretion when selecting expensive diagnostic and treatment options.

Ethical issues

Meanwhile, managed care has exacerbated ethical issues in medicine, eroding trust between doctors and patients, according to John J. La Puma, FACP. At an all-day pre-Session course, he said that traditional ethical issues such as do-not-resuscitate orders and living wills are joined today by concerns such as incentives to ration treatment and use of resources at the end of life.

Dr. La Puma said that ethical issues are gaining so much attention today because the public is concerned about managed care. He cited studies that have found that the public trusts managed care organizations just slightly more than tobacco companies.

"It's physicians' job to restore that trust," said Dr. La Puma, a Chicago internist and medical ethicist. He emphasized that physicians are still patients' best advocates. "We must solve ethical problems before they become legal ones," he said.

Judging by questions that internists at the session asked, that won't be easy. For example, Diana Koin, ACP Member, chief medical officer for a nursing home in Yountville, Calif., described how HCFA has requested detailed patient information such as the drugs given for psychiatric conditions. Dr. La Puma maintained that turning over such data would represent a breach in confidentiality.

And at this year's annual C. Wesley Eisele lecture, David M. Eddy, MD, PhD, one of the nation's leading experts on quality measurement, explained that the tension in managed care to maintain quality while cutting costs is putting intolerable pressure on physicians. He predicted that this growing clash will inevitably lead to rationing.

To address this growing pressure, Dr. Eddy called for a new code of medical ethics that reflects society's need to control costs and yet spend a certain amount of money on providing top-shelf health care for the population. He said that in the future, practice guidelines must not only be evidence-based, but also "include cost."

Rating physicians

Finally, speakers at the pre-Session meeting said that physicians must also pay attention to the trend among managed care organizations to closely measure and track their physicians' performance.

Several speakers explained that while managed care once focused almost exclusively on cost savings, today the new mantra is value. Most U.S. health plans are using statistical data to choose physician panels for their plans, although the degree varies by region of the country.

Doctors' actions in hospitals, nursing homes and even in many group practices are being monitored. Patient satisfaction surveys are standard in many markets, and physicians are already being compared with other doctors nationally and rated by mandatory report cards. As a result, groups competing for contracts will have to prove that they provide good care with good outcomes at the lowest prices.

"Just as the airline industry has standardized procedures, so too must medicine standardize systems for consistency, with fail-safes, checklists and continuing updates," said Richard L. Doyle, MD, formerly of the consulting firm Milliman & Robertson Inc. in San Diego.

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