'Mother May I?'
The changes at United are packaged under the name "care coordination," a program that redefines how physicians interact with the insurer, and creates new opportunities for the plan to interact with individual members.
Previously, physicians had to obtain pre-authorization for a myriad of medical procedures in order to be reimbursed. Under the new guidelines, physicians no longer need permission to provide care that is clearly covered, and they only need to notify the insurer about hospitalizations and certain procedures, such as cosmetic surgeries.
United officials say that effectively gets them out of the business of medical decision-making, a dramatic departure for a managed care company.
"The conceptual change that we made is huge," said Michael Hawkins, MD, medical director for United's health plan in Austin, Tex. The plan no longer approves or denies any care based on "medical necessity," he said, and physicians only need notify the plan about certain procedures that administrators want to monitor for quality purposes.
Second-guessing physicians has become a risky practice for health plans, anyway. In February, the Texas Board of Medical Examiners proposed sanctions against a United medical director, David Ellis, MD, for denying private duty nursing care in 1998 for a patient who needed home ventilator services. United has filed a lawsuit to block that action, arguing that the decision was based on benefits coverage and not on medical necessity.
Even under United's new guidelines, physicians still may need to contact the health plan to determine individual patients' benefit coverage. But overall, the volume of phone calls from physicians to United nationwide has dropped 21 percent since last fall, according to Archelle Georgiou, MD, United's chief medical officer. That translates into a million calls a year, she added.
But at both the national and regional levels, officials say some physicians still are calling for unnecessary authorizations. "They have trouble believing that what we have done is real," said Dr. Hawkins.
Medscape Neurology. 2000;1(1) © 2000 Medscape
Cite this: United's New Approach: Good PR or Better Patient Care? - Medscape - May 22, 2000.