DOOR OPENS FOR MANAGED HEALTH CARE

Managed health care, a staple of medical practices throughout the country, took a foothold in Southeast Missouri over the past year.

The area's first physician hospital organization was formed, and several companies announced plans to market managed-care health-insurance packages.

While managed care, health maintenance organizations and preferred provider organizations -- commonly known as HMOs and PPOs, respectively -- have been around for years, the ideas are new to Southeast Missouri. Two-thirds of insured workers nationwide have some type of managed care.

Mary Dunn of the Southeast Missouri Business Group on Health said the influx of managed care is great for businesses. The organization brings together business and industry leaders in a search for quality health care at affordable costs.

Managed care adds another party to the health-care team, one that reviews doctor and hospital recommendations before an insurance company pays for services.

"Where we see managed-care companies coming in, we see competition," she said. "And competition breeds pretty good stuff."

Dunn said competition drives health-care prices down and managed care should improve medical outcomes.

Last June saw the formation of the region's first physician hospital organization. Known as a PHO, it includes five hospitals and more than 200 doctors.

Called MedAmerica HealthNet Inc., the PHO links the staff and services of both Cape Girardeau hospitals with Missouri Delta Medical Center at Sikeston, Perry County Memorial Hospital at Perryville and Dexter Memorial Hospital at Dexter. Health-care providers in the network agree to provide services for discounted fees to keep patients from leaving the area for treatment.

In December, officials of the PHO and Alliance Blue Cross Blue Shield announced a new insurance package. Available to all companies with three or more employees, the package is called HealthNet Blue. Promoters say the plan will offer higher benefits when using MedAmerica providers, but members still may choose a doctor or hospital outside the network.

Humana, one of the nation's largest managed-care insurers, is working to expand its health-care products into Southeast Missouri. Initially, Humana is coming to the region as a provider of health insurance to between 2,000 and 3,000 state government employees.

Humana will sell a preferred-provider option, also called a PPO, which allows covered employees to choose from a list of doctors and hospitals. Patients pay an initial deductible amount in cash, beyond which the insurance company pays a set amount; for example, 80 percent of all charges.

Later, Humana intends to set up a HMO. This is the most restrictive, least expensive arrangement for managed health care. Under a HMO, employees choose a primary-care physician from an approved list. That doctor meets routine needs and serves as a sort of gatekeeper who has the authority to refer patients to specialists in various fields. The role of the gatekeeper is to hold down costs by avoiding unnecessary medical treatment. Deductible payments usually aren't required; instead, patients pay a modest charge each time they visit their primary-care doctor. The insurance plan pays the rest. The idea is that HMOs trade lack of choice for low cost.

Representatives of HealthLink, a managed-care company with customers primarily in Missouri and Illinois, met in December with Cape Girardeau's two hospital administrators, employers and insurance agents to express an interest in serving Cape Girardeau customers. At the meeting, several insurance agents said their customers are already members of HealthLink and would like to see Cape Girardeau's hospitals participate with that company.

GenCare Health Systems received approval from the state to market HMO health-benefit services in Butler, Carter, Dunklin, Madison, New Madrid, Pemiscot, Ripley, Stoddard and Wayne counties. The company signed contracts with Lucy Lee Hospital at Poplar Bluff in November 1993, Twin Rivers Hospital at Kennett in January 1994, and Madison Memorial Hospital at Fredericktown in April 1994. GenCare is also interested in expanding into the Cape Girardeau area.

Dunn said the more options businesses have, the better medical benefits employees will receive.

"We think it's positive," she said. "It's our time. It's here all around us, and our companies are asking for it. All of us have to do a better job of managing our care."