NEW CONCEPT BEING UNVEILED FOR PROVIDING HEALTH SERVICES

A group of Southeast Missouri business leaders believe they have come upon a way to curb rising health insurance costs by linking businesses with medical providers and insurance carriers.

The Southeast Missouri Business Group on Health is unveiling a new health insurance program based on quality care and cooperation, said Mary Dunn, executive director of the group.

"This is a cutting edge, quality care program," Dunn said. "We are coming together to purchase health insurance, but our main focus is not just to reduce costs but to ensure quality care. In order to do this, we need a partnership established in this community."

The proposal hinges on commitment from three entities: an insurance carrier, medical providers and employers.

The group is in the middle of a feasibility study in Cape Girardeau that will determine whether the proposal can work here.

The concept is so new it has not begun to operate anywhere yet. In Minnesota, a group of small businesses representing 50,000 employees will put this program into effect Jan. 1, 1993.

Area medical providers are being notified by letter about the proposal and about an upcoming meeting.

An Aug. 18 meeting is planned to discuss the idea with members of the medical community and with business and industry representatives.

"We are asking them to join us in partnership to continually enhance quality care," said Jeffrey Fox, associate with William M. Mercer, Inc., the world's largest actuarial and employee benefits consulting firm. Mercer is working with the local business group in developing this plan.

Dunn said the business group is also in the process of securing an insurance provider to administer the plan. If all goes well, the plan could go into effect April 1, 1993.

Greg Kuhn, a principle with Mercer, said, "The focus, simply put, is delivery of high-quality health care to the Southeast Missouri area.

"We are not necessarily looking to slash costs, but to make services high-quality, appropriate and with attention to outcomes," Kuhn said.

"The last 10 years haven't been very fruitful," Kuhn said. "Everybody is pointing fingers and the price keeps going up."

Fox said businesses have seen 15 percent to 25 percent increases in health insurance costs annually.

"We know what hasn't worked. Maybe if we do this on a cooperative basis and a local basis it will work," Kuhn said. "What do we have to lose?"

Fox said, "What we've determined is that quality medical care is cost-effective medical care. If we can enhance the quality and continually improve the care, we will eliminate unnecessary care and inappropriate care. Eventually we will get to the point that only the best care is being delivered."

The Southeast Missouri Business Group on Health was formed in 1991 by a group of businesses looking for ways to curtail rising insurance costs while still providing coverage for employees.

Now the group includes 28 businesses from Perryville to New Madrid representing over 7,000 employees. Membership is open to other businesses and industries that may want to join this process at the beginning, Dunn said.

Bob Cranmer, president of the Southeast Missouri Business Group on Health and employee relations manager at Procter and Gamble, said, "This brings together the medical community, businesses and insurance. In my book that's the only way to go, to bring those three groups together in a partnering kind of way to attack this whole problem. We have got to have everyone working together.

"It's a natural thing," he said. "It's what you do in business anyway, develop partnerships.

"What we hoped, when we formed two years ago, was to come up with new, creative, innovative ways to solve the health care problem. I think this is a way," Cranmer said.

The quality-based health care program being proposed is a departure from other health insurance plans.

Fox said, "The traditional managed care focus has been to go to a hospital or doctor or other medical provider and say here's the price. Agree to get reimbursed this price and agree to be in our network and we will direct business your way.

"Big companies cut special deals based on price and people outside the system get cost-shifted to," Fox said. "PPOs are going to say they have quality criteria, but the main criteria for joining the network is not quality; it's price.

"Trust and communication are crucial aspects to making this work," Fox said.

Under this proposal, medical providers, doctors and hospital administrators, would develop the guidelines, Fox explained.

"We don't come down with practice guidelines," Fox said. "We want the doctors in Cape Girardeau to tell us how to treat patients, with the sole focus being on quality, not what costs less.

"Since you're the clinicians, tell us how you go about providing service and what is the highest quality care," Fox said.

Kuhn said, "Doctors have had to practice very defensively. We propose putting control back with the doctors. They can develop guidelines, not some outside force."

Fox said, "We should not be telling them how to practice medicine, they should tell us how they practice medicine. Then we track what they tell us and ask questions when they are not practicing the way they said. There may be very good reasons for that."

Kuhn said studies show as much as 30 to 40 percent of care is unnecessary or inappropriate.

"If the service is necessary, it doesn't matter what it costs," Fox said. "If you do that in the long run, total medical costs will be much lower.

"As we all know, many doctors have different approaches, but we hope they can sit down and agree on the best approach. We would start with the most common and frequent conditions."

He added that the guidelines will change. It's an evolutionary process.

The idea is new, but officials with the consulting firm and the business group believe it is workable.

"What's our choice?" Fox said. "It seems clear that if the private sector cannot find a way to solve this problem in the next 5 to 10 years, maybe even sooner, the federal government will have a heavy hand, if not total control, of health care. Personally I dread that day.

"We think it offers great hope to what many consider a crisis. And it keeps the government from solving it for us. Many of us think the private sector can far more effectively deal with the problem, if we can cooperate with each other," said Fox.