Recently, another health care payor decided to outsource its medical management functions. This is just another example of health-related businesses failing to recognize their companies’ actual product. Insurance companies think they are generating covered lives, premiums, and claims management structures when their real product is population health that decreases the cost of health care.
These companies do need efficient operational capacity, but they will not avoid unnecessary emergency room visits or revolving-door hospitalizations without experienced clinician-executives. The companies need medical directors with significant experience in direct-patient care, practice management, provider and member education. These executives can implement risk-stratification strategies and interventions that lead to positive health outcomes, as well as time- and cost-effective management. I believe these physician resources must be local.
Companies must tailor new policy and substantive evaluation of existing programs to their specific corporate environment and the culture and resources of the communities in which their members reside. It is also much easier for an onsite medical management team to form productive partnerships with providers, encouraging the behavior changes that make population management possible. In-house clinician executives can also engage local public health professionals and social resource networks that are essential in crafting relevant care management and member education programs.
Yes, we physicians are expensive and all of that education and experience may not be necessary to review pre-authorization requests or manage colds, urinary tract infections, and stable diabetes (I’m not really sure about that. Advance practice professionals train for “what is” while we train for “what is” and “what if.” Often, you don’t know which circumstance you’re dealing with until you put your foot in it). However, to effect the kind of health system changes that will improve health and decrease cost, docs have to be active members of the team. It’s about more than dollars and cents.
Dr. Woodson is a clinician-executive, consultant and author. Contact her at www.drcherylwoodson.com and like her on Facebook.