HOW WILL MANAGED CARE AFFECT  MT. WASHINGTON VALLEY?

By  David M. Baughan, M.D.

Presently about 5-10% of residents of  Carroll County and nearby Maine have health insurance through a managed care organization, such as HealthSource, Matthew Thornton, Blue Choice, and a few others.  This is a much lower percentage than many parts of the country, and is likely to change fairly rapidly in the next several years.  Many people are unfamiliar with how managed care organizations (MCOs) work.  Since I have worked with several types of managed care plans in my practices in Seattle, North Carolina, and San Diego, I would like to offer my perspective on what we might expect here.  Hopefully, by anticipating some changes, we can make a smooth transition for patients and doctors.

The driving force for managed care plans replacing traditional health insurance has been cost.  As the cost of health care has increased, it has become increasingly difficult for employers to afford (or even to anticipate and budget accurately) health care benefits for their employees.  Managed  care has provided a market response to lower and make predictable the cost to an employer.  MCOs have been able to grow as they have by marketing primarily to employers; once they are fairly successful, then they may offer health coverage to individuals or families.  So the first result we can anticipate is that employers may be able to continue to provide health benefits to their employees.  A few employers may be able to afford benefits when they could not before, and a few individuals may be able to obtain health care coverage when they could not previously afford to do so.  This is an important issue in our community, where 33% of our neighbors have no health care insurance. Managed care will have an even bigger impact if the state and federal government offer or adopt managed care models for Medicare and/or Medicaid.

How will this affect choice of doctors?  For primary care doctors (family physicians, internists, and pediatricians), probably not much.  Due to our rural location, there are only likely to be a few companies that will compete for managed care patients here, and most, if not all the primary care doctors will contract with those several companies.  Therefore, we will avoid one of the most obnoxious features of medical practice with managed care that I experienced in San Diego.  Each year approximately 25% of people in San Diego had to change doctors because their employers changed insurance plans which contracted with different doctors.  This was miserable for doctors and patients alike.

There may be some change in access to specialists.  One way managed care reduces costs is by encouraging (or requiring) that most visits to specialists occur after evaluation and referral by a primary care doctor.  This is because today’s primary care doctors are trained to handle 95% of the problems that require a doctor’s visit, and they have been shown to do so less expensively (for those 95% “common” problems) than specialists.  So if you prefer to see an ear specialist for an earache and a dermatologist for acne or a rash, you may be frustrated in a managed care plan.  But since we do not have that many specialists living full-time in the Valley, I have experienced less of this attitude than in large urban areas.  Where it might be more of an issue is when the personal physician wants to refer to a specialist.  The patient may prefer to go to Portland or Boston, but their plan may have contracts with specialists at Dartmouth (or any such combination).  I have been satisfied with limitations in my choice of consultants in different plans as long as I found that the consultants gave high quality care; patients and primary care doctors will have to remain vigilant that quality as well as cost determine which specialists a plan will include.

Convenience of care is an area of frequent tension in managed care plans.  Most care given through emergency rooms or walk-in clinics is more expensive than care (for similar problems) given in doctors’ offices.  Therefore, most MCOs try to limit or discourage use of such facilities when the problem could have been taken care of in an office.  This is frustrating to patients, though, if they feel such limitations do not fit their lifestyle or are not appropriate to their health problem.  MCOs want patients to be satisfied, though, so they usually will encourage physicians to offer more convenient hours, urgent appointments, or coordination and cost-sharing with walk-in centers.  In general, managed care prompts (or pressures) physicians to interact, communicate and plan with each other;  when this is done in consideration of the needs of the patient and community, then everybody wins.

Let me mention one additional common tension when people first experience managed care.  Most MCOs require little out-of-pocket expense by a patient for a given problem.  Some people trust certain tests or treatments more than they trust their doctors. When there is no financial barrier to the patient, I have found managed care patients more likely to say, “I want a CT scan for my headache even if you don’t think I need it,” or “I want an antibiotic anyway,” when I was confident the infection was viral.  This tension has always existed in the doctor-patient relationship, but it can become more difficult if the patient suspects my recommendations are colored by my desire (or financial incentives) to limit costs.  It will be more and more important for doctors and patients to openly discuss their suspicions, levels of trust, and health care beliefs if managed care systems are to provide high quality of care in a cost-effective way.  Building trust is always a difficult task, but one I have always felt is necessary to have healthy relationships in a community.

There are many other aspects of managed care that may affect us in the coming years, but these I have found to be some of the most common trouble points as patients, doctors, employers, and others struggle with planning ahead for how to care best for their community.