Managed Care Forces Growth

By Kate McGahan CSW

The absence of a national health policy seems to have created a black hole that has been filled with profit driven managed-care programs. While states such as California have been adapting to the managed-care concept for a number of years, New York is just beginning to feel the effects. Syracuse is a good example of community agencies working together to rise to the changes in demographics and in the industry.

The cost of running Medicare and Medicaid programs has been growing at nine percent per year. Experts say that, by the year 2030, Social Security, Medicare and Federal pensioner programs will exceed the federal government's revenues. The seemingly insurmountable task of trimming the budget seems to have come down to trimming the payments to the care providers. Massive state and federal cutbacks have severely affected hospital and health programs and the way they do business.

What does this mean to us? The managed care shift has had the tendency to refocus the healthcare industry toward business development and marketing efforts rather than customer service and patient care. The game has become "SURVIVAL". In the hierarchy of needs, physicians, hospitals, home care agencies, and other programs which rely on insurance to keep them alive have had to find a way to put food on their proverbial tables. This is a challenging task and makes it difficult to meet the more advanced qualitative needs of perfecting patient care.

Aggressive insurance procedures now affect providers on a multitude of levels. Insurance companies reward hospitals for treating patients with higher clinical needs. Medicare pays a certain rate for the treatment of a specific illness and the insurance companies follow suit. The more severe the illness, the higher the reimbursement. They also can refuse to pay for days a patient spends in the hospital on which a significant intervention did not take place. Subsequently, providers now find they need to perform surgery and diagnostic testing on weekends and after hours to promote reimbursement. This means paying additional staff for hard-to-fill time slots. It also includes paying additional staff to process the multitude of paperwork required for patient billing and reimbursement.

The "system" encourages the prompt discharge of less acute patients and begins a ripple effect that forces all parts of the healthcare delivery system to push a patient quickly toward the least restrictive, most cost-effective setting. This ripple effect causes nursing homes, rehab centers, home care agencies and others to need to be available off-hours and on weekends to do intake assessments, admissions, and crisis intervention. This new system presents an arena of discharge planning and case management considerations.

Because nursing home and rehab facilities are reimbursed for patients with higher needs, they also are eager to discharge residents who are more able to manage in a less-restrictive setting. People who one would have been permanent residents in nursing homes are now being encouraged to return home with services or to go to assisted living programs and special care facilities. The system has been forced to be creatively revised in the face of these new regulations. New residential and home care programs have arisen to compensate for the greater number of nursing home and hospital discharges. Some skilled facilities have developed subacute and short term rehabilitative services to capitalize on higher reimbursement levels. More and more independent living programs are offering a concierge of services.

Alzheimer's Disease is tragically one of the lowest reimbursable illnesses. It is one of the most common, of the longest duration, the most time consuming, and exhibits some of the most frequent repeated use of services in the system. The system does not financially reward providers for caring for people with such disorders.

How we cling to the status quo! Peter G. Peterson, in his book Gray Dawn, gives us a reality check: By 2015, most developed countries will have more elders as a share of their population than the state of Florida today. Caring successfully for older adults in the face of managed care will take a community-wide effort. The population is aging and managed care is here to stay.

Healthcare providers need to develop a positive attitude despite the lack of perfection in the system. This means making a shift from a sickness mentality to a wellness mentality; to prevention vs. cure. It's about having vision and defining a contributing role within a system that thrives on networking. It's about being proactive rather than being swept along with the tide of managed care; to begin to create and enhance programs, products and services and to become leaders in a system specialty.

Many US hospitals are forming partnerships with residential and rehab programs, home-care agencies, and primary care providers. Residential facilities are developing day programs and menus of services to expand their markets. Doctors are joining forces to meet the comprehensive needs of their patients.

There are many ways to partner - formally and informally- to meet the needs within the senior healthcare system. Formal alliances allow partners to share operating costs and collectively to meet the needs of the community. Clinical, financial, social, private, and public programs need to be available, accessible, and mutually beneficial to the older population. We need to learn how best to utilize one another to support the needs of those who need us.

Learn to see this as a challenge rather than as a problem. Exciting innovations are already occurring within the Central New York system. Follow the leaders of the community in developing unique programs to offset the negative consequences of managed care.

Loretto and St. Joseph's Hospital have partnered to meet specific needs which make programs like PACE/Independent Living Services- a program designed to prevent/reduce institutionalization and subsequent costs possible. Crouse Hospital and Community General Hospital together created The Alliance, which proposes to merge with VNA Systems to streamline the continuum of care for their patients. SUNY Health Science Center recently announced participation in WebMD - a full-service Web site for doctors and their patients --made possible by the combined efforts and funding or organizations such as DuPont, Microsoft, and CNN.

Competition is a driving force of the new system. Once we re-establish our equilibrium, we can allow competition to do what it does best: improve quality, reduce costs, and encourage providers to be creative in the marketing and delivery of their services. We must also work collectively to keep the continuum of care smooth and as user-friendly as possible.

The possibilities are endless. Growth doesn't just "happen" without people making a conscious change. If we don't promote change on our own, life will inevitably do it for us. It has pushed us to grow in challenging, sometimes frustrating and very exciting ways.

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