MANAGED HEALTH CARE HASN'T ARRIVED HERE; DOCTORS' GROUP ADMINISTRATORS SAY FURTHER EDUCATION NEEDED

The growth of managed care has provided a much needed education for physicians, Jerry Nicholson said.

But before true managed care gains a foothold in the Cape Girardeau region, more education will be needed for physicians, employers and workers, say Nicholson, the administrator of Orthopaedic Associates, and Gregg Thomas, administrator of Physician Associates.

Local physicians have contracted to provided services under several health-care plans, Nicholson said, including HealthNet Blue, HealthLink, GHP, Ethics and GenCare.

"In Cape Girardeau there are no managed care plans," he said. "There are contracts for reduced fee for services plans."

In true managed care, he said, large employers funnel all their workers to one or two providers and pay fixed sums each month to cover health-care needs.

Any employee who seeks health care outside the network must pay the full bill out of his or her own pocket.

"In Cape Girardeau it doesn't work that way," Nicholson said. "There are no large employers that can funnel business to a small, select group of providers."

Traditionally, true managed care offers its clients a closed panel of providers with no freedom of choice, Thomas said. "In Cape, where the consumer has the choice of going to whatever physician they want, that's a hard sell."

Managed care has become a hot topic since a trade magazine published a report that MedAmerica HealthNet, a physician hospital organization made up of five area hospitals and their medical staffs, was under investigation for antitrust violations by the U.S. Department of Justice and the Missouri attorney general's office.

Both agencies have refused to comment on any investigation that might be ongoing.

The trade magazine cited unidentified sources who complained that employers who want full managed care options are paying higher prices for services and premiums.

But managed care creates a number of concerns for health-care providers, Thomas said.

"One of the things that providers are really concerned about is the quality versus financial-issues question," he said. "A lot of providers feel third-party carriers have nothing but financial interests on their minds" and so they limit the care options available to consumers in order to contain costs.

Some insurance companies may limit the number of investigative procedures or lab tests that they will pay for, Thomas said.

But that limitation on coverage does not relieve the physician of any legal liability he or she may face for not ordering a procedure to identify an ailment, he said.

Money is an issue for providers as well. Contracts for services usually pay 80 percent of the cost for a particular service, which means providers are taking a 20 percent cut. That, coupled with increased administrative costs to keep up with managed care's "phenomenal paperwork," adds up to lost revenue, Nicholson said. But that's not the biggest concern.

Managed care forces competition between providers, he said, a situation that is hard for physicians to get used to.

"It's a new concept for doctors to be competitive," Nicholson said. "They're used to being collegial. Managed care represents competition. That's very uncomfortable for doctors. It's not the cost issue at all."

Managed care also forces physicians to choose between hospitals and requires patients to choose from a small pool of providers.

A medical office building now under construction at St. Francis Medical Center has prompted some concerns that physicians might choose that hospital exclusively.

"That's not the intention at all on the physicians' side," Thomas said.

With managed care, there is also the question of who makes the final decision regarding the treatment the patient receives. Under many managed care plans, the insurance company decides what tests can be ordered, which specialists can be consulted and whether a patient is admitted to a particular hospital.

"We're expected to call some high school student in Chicago or St. Louis to get permission for a procedure," Nicholson said. That's a very grating requirement for physicians, he said.

HealthNet Blue and other PHOs, which were organized by providers rather than insurance companies, give the clout to physicians, not the insurance companies, Nicholson said.

Thomas and Nicholson differ on when and if true managed care will gain a foothold in the region.

Thomas thinks managed care will arrive "to some extent," and points out that MedAmerica and Humana are both working on products.

Nicholson, though, says there aren't enough consumers -- known as "covered lives" in the insurance industry -- to make managed care effective. A HMO can operate with 20,000 people, he said, but to be really effective it needs 40,000.

What managed care has done is force everyone involved -- providers, employers, consumers and insurance companies -- to reexamine health care and how to control its cost, Nicholson and Thomas said.

"A lot of the issues come down to whose responsibility it is to control the cost of health care," Nicholson said.

A prime example is educating employers about ways to reduce the cost of workers' compensation claims by bringing recovering workers back to the office for light duty assignments, he said.

Managed care also has forced doctors to become more aware of the cost of the procedures they order and to be more selective in what they ask for.

The changes wrought by managed care also force consumers to become more responsible for their own health care.

"Most health-care executives will tell you there will be no more 100 percent, first-dollar coverage, if there is any left now," Thomas said. "If you have 100 percent, first-dollar coverage, you'll go to the emergency room for a hang nail. Why not? It's all paid for.

"But the flip side of that is, then you're missing something that could turn into something more expensive."

The key to managed care is balancing cost control with good health care, Nicholson and Thomas said.

A good health-care plan should include a fully covered annual checkup to find things like skin cancer or other conditions before they become serious, Nicholson said.

"If you include that and the office visit co-pay, that pretty much covers it," he said.

When managed care was introduced, Thomas said, "you had no preventive medicine. There had been too many uterine cancers because they didn't have pap smears and so on that could have been caught at an earlier point. That could have saved costs, and of course, patients' health."