As the medical director for one of the nation’s managed care organizations, Dr. Lawrence jack discusses continuous quality improvement in managed care
Just what is managed care looking for? You’re a member of your local, state and national associations. You care for your patients in a professional and responsible manner. You certainly don’t think you over-utilize services. You go to post graduate continuing education classes for license renewal.
You graduated from a great chiropractic college, and yet the chiropractor down the street got into the network and you didn’t.
Sound familiar? I can tell you there are no magic bullets or miracle remedies for getting “on the list” of a managed care organization (MCO). I also don’t believe that it always goes to the most qualified chiropractor in town. Politics, who you know, luck, and occasional clinical skill goes into the selection process. I believe that there are some steps that you can take that will benefit you and your marketability to managed care. Managed care parameters are becoming more and more stringent, not only for the chiropractic community but for the medical community as well. Hospital length of stays are cut to the bare bones. Procedures you do in your office heretofore identified as necessary are now termed medically unnecessary. What’s going on?
As I lecture to our colleagues I am amazed at the frustration level, as well as the horror stories I hear about the parameters of care imposed on our profession. The “Swinging 70’s” gave rise to the “Me” generation of the 80’s, which has fostered the “Austerity Budget” of the 90’s. The practice behaviors and patterns that were developed in the 70’s and the 80’s don’t work anymore in the 90’s. Those of us that have been immune to the ravages of managed care are now face-to-face with drastically reduced incomes and possible extinction. Patient loyalty, in which we prided ourselves, no longer exists. Long-standing patients will move to the chiropractor down the street due to a $5 or $10 co-pay, because he or she is “on the list.” HMO’s and PPO’s are more like HM-No’s and PP-No’s. As I asked earlier, “What is it that managed care wants?” In a nutshell, they are looking for a way to decrease costs and increase quality by homogenizing the delivery of care as much as possible (refer to Graphs One and Two on the following page).
The ‘Me’ generation 80’s had the mentality that more care is better care. If the patient didn’t respond, we were taught to increase the number and frequency of visits. Technology of all kinds is increasing. As an example, there are more MRI units in Atlanta, Georgia than there are in all of Canada. Is the population in Atlanta sicker than the population in Canada? We pride ourselves in being the biggest and the best in this country, but bigger is not necessarily better. Realizing that the insurance health care dollar is not a bottomless pit, and with pressure from employers and government, the medical component of the Consumer Price Index had to be slowed down. As a result, every phase of the health care delivery system is being questioned.
One of the questions that I ask my audiences is, “How many of you know the top five diagnoses that your office sees over the course of a year?”
I am always amazed at how few people actually know these statistics. The top five diagnoses are an excellent indicator of:
- What you are good at.
- What the community that you practice in thinks you are good at.
- Where your biggest book of business (income) comes from.
- What your insurance company profile is all about.
I then ask my audience to assume that their #1 diagnoses is an 847.2 lumbar sprain/strain. Next, I ask them if they know what resources they bring to bear to resolve that patient’s problem (refer to Example One).
FBy this I mean how many examinations over the course of a year on average does it take to resolve one 847.2 presentation? In addition, how many sets of x-ray studies does it take to resolve this condition? How many adjustments/manipulations does it take on average to resolve this condition? And finally, how many physical therapy modalities/procedures does it take to resolve this condition? If, for example you count up all your 847.2 diagnoses for the year of 1996, how many x-ray studies were associated with that diagnosis? How many examination procedures were associated with that diagnosis? How many adjustments/manipulations were associated with that diagnosis? How many physical therapy modalities were associated with that diagnosis? Then divide those numbers by the number of patients that had that diagnosis (see Example Two).
You will come up with a very interesting and useful picture as to how others (the insurance companies and managed care organizations) see you. Say, as in our above example, it takes you three examination procedures (initial exam and two re-exams), two x-ray studies, 24 adjustments/manipulations, and 96 (3 per visit) physical therapy modalities to resolve the “average” lumbar sprain/ strain injury. Some of you may be familiar with this concept, which is known as managing by statistics, but taken to another level.
The question I posed earlier, the same question managed care is asking is, “How do I increase my quality and decrease my costs?” Another way of looking at this is, “How do I maintain the same level of patient satisfaction/ outcomes with less resources (exams, x-rays, adjustments, therapies). Can I attempt to resolve an 847.2 in less than two examination procedures, one x-ray study, 20 chiropractic adjustments/manipulations and 47 physical therapy modality services (two per visit) and still maintain the high success that I enjoyed with the old numbers?” You may say that that would be an impossible task because, “I never recommend more visits than I should,” or “I don’t do maintenance care,” or “My technique demands certain parameters be followed,” etc., etc., etc. If you had to perform quicker, cheaper and better, could you?
I offer my own experience as an example. When I graduated from NYCC in 1978, the main technique that I used in my practice was SOT. I was pretty darn good at it, and when I first opened up my office, I had enough time to spend with my patients using SOT. I certainly in no way intend to denigrate SOT. In fact, when I practiced and got “stuck” resolving a patient’s problem, I would resort to my SOT skills, and invariably they would help me resolve the problem. I soon learned, however, that my osseous adjusting skills, separate from my SOT skills, could largely get me the same or similar results that the patient and I were looking for to resolve their presenting symptoms. Without even knowing it, I decreased my costs, and increased my quality (or I was able to achieve the same results with less resources). I was able to see more people during the course of the day with the same or similar results. It is this type of quality improvement that will be required of us by managed care organizations. This concept may not be not a direct challenge, but a subtle imposition by way of capitation (X dollars per member, per month). Well, it doesn’t take a rocket scientist to do the math. If you are making $13 per office visit as a result of capitation plus a $10 co-pay and you see the patient 24 times, then the math is ($23 X 24 = $552). If, however, you can decrease your costs and increase your quality (see the patient fewer times with the same or similar outcome), you can take that $13 office fee and increase it by $2, $3, $4, or $5 dollars (by getting the same outcome in less visits or less resources, your capitation dollar increases). This may make the difference between the successful practitioner, the marginal practitioner, or a practice that has to go out of business because of managed care. My point is that if we stay locked into doing business as usual, with the mentality of the 80’s, or that we maintain a false adherence to a philosophy or a technique, we may lose our practice to the detriment of our patients and the community we serve.
Assume you are the best Gonstead practitioner in town and that it takes you on average 24 visits to resolve a lumbar strain/sprain injury. Someone in your area uses a different technique, and is able to resolve the same lumbar strain/sprain injury in 20 visits. If you were the managed care company, who would you choose, all other things being equal? Here’s the plan: I suggest that you start looking at your statistics.
- Identify what your top five diagnoses are first.
- What resources do you bring to bear to resolve those diagnoses (refer to Examples One and Two on previous page).
- Resolve to do it quicker, better, and cheaper, without it having to affect patient outcome.
If you find that your numbers don’t compare favorably with your colleagues, please take the steps to make your numbers as good or better than theirs. I can’t promise you that a particular managed care company will select you, but at least you will understand what they are looking for, the rules of the game, and you will know that you have clinical excellence by way of continuous quality improvement (CQI) to guide you.
Obviously, there is a bottom line to all this. Believe it or not, managed care companies are not trying to put everyone out of business and just collect premiums. The medical community is faced with these same dilemmas as we are, as evidenced by the recent 24 hour maternity stay controversy. There was a tremendous push from the patient and physician community which has caused most managed care plans to have a 48-96 hour maternity stay (it is interesting to note that there is nothing in the literature to support 48 or 96 hours, but that length of stay seems to be a common practice, therefore it is an accepted, not scientific norm). I expect more of the pendulum to swing back in favor of the consumer in some areas in the very near future. Already there is evidence that cost is not the only issue MCOs are concerned about. There is strong evidence to suggest that the next stage of managed care indicates that quality is becoming another major issue MCOs are looking at. I suppose this only makes sense, because quality eventually translates to a bottom line issue.
If the quality of care rendered to their subscribers is substandard, the subscriber will not subscribe again the next year. Therefore, poor or substandard quality turns into a loss for the MCO. So, quality becomes important because it becomes a bottom line issue. The health care community has never been asked the questions, “How much (time, frequency, & duration) is enough?” or “How little is enough?” or “When is enough, enough?” Obvious-ly, there is an end point where quality equals quantity. We have never asked ourselves the question, “Is three times a week for four weeks, twice a week for four weeks, once a week for four weeks written in stone somewhere?” yet most of us have been taught that this is a traditional treatment pattern when seeing a typical chiropractic patient. We have never asked ourselves the question, “Who said that and why and for what problem?” For example, “Should a cervicalgia and a sciatic radiculitis both require three times a week for four weeks, twice a week for four weeks or once a week for four weeks?” Logic dictates otherwise. The best thing that can be said is that the past does not equal the future. Let’s question even the best methods for delivering chiropractic care, so that we can turn over to our children a healthy, viable profession to take us into the next hundred years. MCOs are not trying to have us bid in a “Name That Tune” fashion of I can resolve that problem in 10 visits, …9 visits, …8 visits etc. We need to find where that end point is. And what else can be done (by way of active care measures (ACM) or coordinating our care with other health care providers) to continuously improve our results and have greater patient satisfaction.
Dr. Lawrence M. Jack, of Atlanta, Georgia, is distinguished as receiving national recognition for his work with the insurance industry. He has won praise as a lecturer, educator and consultant to the chiropractic profession, as well as national organizations and associations. In addition, Dr. Jack has conducted a successful clinical practice for almost 14 years in the Atlanta area. He has undergraduate degrees from the University of New York and Hofstra University, and is a 1978 graduate of New York Chiropractic College. Dr. Jack served as the Associate Medical Director of Chiropractic Services for the Travelers Insurance Companies, as well as for Conservco, a utilization management company. Dr. Jack also served as the Medical Director for MetraHealth, the largest health care carrier in the country (formerly Travelers and Metropolitan Life Insurance Companies) and has since assumed the role as Medical Director of Chiropractic Services for United HealthCare, which purchased MetraHealth, and is one of the nation’s largest managed care organizations.