"Gently" managed care (America's Health Insurance Plans annual meeting)

Knowing that they don't inspire trust, but that physicians do, insurers want to make physicians messengers for health plans, improving members' health to save money. But they also want to prompt doctors to change their own behavior for even more savings to the plan.

"Health plans are realizing they have to work with the trusted brand of the physician," said Dennis Schmuland, MD, a family physician who is the health plans industry solutions director for the U.S. Health and Life Sciences Group at Microsoft.

The difference between care and care management, proponents say, lies in enhancing the role of the physician -- at worst in a superficial sense, and at best in a way that allows the physician to make good decisions without interference.

At the annual meeting of America's Health Insurance Plans, held in San Diego in June, some of the flashiest, biggest booths -- one offering martinis, another offering California wine -- were hosted by firms vying to sell health plans the perfect care-management tool.

All promised a means to gently, effectively use physicians to change patient behavior in a way that doesn't alienate either the patient or physician, and results in savings for the insurer.

Some vendors, such as Emeryville, Calif.-based MedeAnalytics, offer software packages for hospitals and health plans. Other firms have integrated care-management prompts into existing products. Boston-based American Well, for instance, has integrated prompts into its portal for online medical visits.

"What we see in the market is a proper evolution: You have to keep the doctor in the center," said American Well President and Chief Executive Officer Roy Schoenberg, MD. "Patients viscerally say, 'I need to see a doctor.' "

In many cases, care-management systems can be integrated into a health plan's Web page and are automated. So when staff at the front desk run an eligibility check, the system produces reminders and suggestions, such as, "This patient's record shows some signs that she has a history of depression. Consider giving her a depression questionnaire as part of this visit," or, "This patient is due for a mammogram. Please schedule an appointment soon." Those messages could show up in an e-mail, a text message or a window on a doctor's handheld computer.

"It's kind of catching the patient at the moment of truth," said Ted Ryan, vice president of sales for ZeOmega, a Frisco, Texas-based care-management system company. "You've got the data and got the patient in front of you. Before, it would have been a letter after the fact, or the ability to extract that data and push it back into clinic just wasn't there -- that was a daylong project."

Doctor skepticism

But physicians may not be easily convinced that health plans are interested in "care management" for the right reasons, or that health plans can improve the system.

"I think it's a waste of money and not helpful," said Joseph W. Stubbs, MD, an internist from Albany, Ga., who is president of the American College of Physicians.

"So many times, their information is erroneous and irrelevant, because they don't have access to the clinical record," he said. "I can't tell you how many pieces of paper I have that say have you considered this or that."

It would make more sense, he said, to pay doctors directly to manage care rather than hiring a third company to deliver messages from the health plan to the patient.

Short of that, he said, for any health plan communication to be effective, it should be initiated by the physician, completed electronically and linked to a clinical record, not just claims data.

Health plans and vendors of care-management systems said they know the problems. Doctors are overwhelmed with information, most of which comes at the wrong time, the wrong way or both.

Rather than simply using a preapproval requirement, "when a physician does make a request for advanced imaging or prescription, why not deliver the evidence-based guidelines side by side with the approval?" Dr. Schmuland asked.

There is also the credibility problem. Doctors don't always trust clinical information handed to them by health plans, so the health plans need a third party to provide objective clinical evidence that will sway doctors to do the right things. That's where the care-management companies say they come in.

They try to stress to doctors that they're not all about money. Instead, they pitch how their systems focus on quality measurement based on established standards. Some also use systems that integrate the practice record. For example, MEDecision, a subsidiary of nonprofit Blues plan holder Health Care Service Corp., uses electronic health records as touch points for advising physicians, hospitals, health plans and patients. It identifies "gaps in care" and passes that information on to doctors in a nonintrusive way.

Scott Storrer, president and chief operating officer for MEDecision, said many physicians in focus groups hosted by the company said they would pay for the system themselves because they found it so useful.

Care-management companies also say they could solve one of health insurers' big quandaries: how to use the vast amount of information they hold -- claims data about members' hospital stays, visits to the doctor, prescription drugs -- to cut costs and improve care.

Over the past five years, some health plans have tried sending the information and tools they own straight to members. The idea is that motivated patients spending their own money will search for value, educate themselves and act in their own best interests while driving quality and efficiency.

It's still in play, but it hasn't worked out as quickly or as well as some had hoped. Consumers have proven difficult to reach, they don't have the information they want, and, despite sometimes having good information, they still don't always make the best choices.

"I think there's less belief that it really is just a health-plan-to-consumer interaction that's going to make the difference," Dr. Schmuland said. "There's recognition across the industry that health care is a collaborative team process, and that to really have the long-term impact in reducing chronic disease and improve health, that requires more than just giving information to the consumer."

Not insignificantly, care-management companies say health plans are willing to pay doctors for their time and attention, either under a capitated payment system or a fee-for-service arrangement as part of pay-for-performance programs.

Proponents say that under a health plan's care-management system integrated into its existing portal, doctors would be prompted at the time of care to follow pay-for-performance guidelines. Tracking success would be simpler, and the clinical rationale for the pay-for-performance incentives would be delivered to the doctor at the time of care. "As annoying as pay-for-performance can be, physicians know it's coming, so the more opportunity they can have to get access to data [that supports payments], the better," said Terry Fouts, MD, chief medical officer for MedeAnalytics.

Beyond paying for doctors to follow health plans' advice, those in the field said health plans also are figuring out that much of their success depends on the tone of their communications.

The key to getting doctor buy-in is in how the message is framed, said Matthew Zubiller, business leader for advanced diagnostics management for McKesson, which owns InterQual, one of the oldest care-management tools. "Physicians don't mind being asked questions, but not stupid questions," he said. "This is about engaging the health care provider in a different way."