Utah: IHC Health Plans dropping specialist referrals and surgery approvals

[NRSKarenRN, BSN, RN]

IHC to cut 'hoops, loops' hassles

It's easing its rules on referrals and surgery approvals

By Lois M. Collins

Deseret News staff writer

Thursday, August 02, 2001

http://deseretnews.com/dn/view/0,1249,295015088,00.html?

IHC Health Plans, the largest managed-care plan in Utah, said Thursday its members will not need referrals from primary-care doctors to see a specialist beginning next year. And doctors will not need advance approval to perform surgeries covered under the plans.

The changes, to be effective Jan. 1, seem to be a trend both nationally and locally, a break away from the traditional "managed care" model of health insurance. And it's particularly significant in Utah because Intermountain Health Care's managed-care plan has more than 480,000 members, according to Daron Cowley, IHC spokesman.

"The care is still being managed, but the physician is going to have the final say in care decisions. Obviously, it's more convenient for patients. But we think it will also be so for physicians," he said.

"The most important thing of all is the reduction of what I believe the consumer and provider have felt the last few years, that it's almost a hassle of hoops and loops to get through before care is provided," said Sid Paulson, chief operating officer of IHC Health Plans. "We've always believed care should be managed by the physician, but I don't think it's always felt that way to the consumer. We think it will change the ability to access care in a more efficient way. We've been working on this for a long time."

IHC is not the first to make such a change. Another major insurer, United HealthCare, did so more than a year ago. A few others, like Aetna, have announced they will offer "plans without gatekeepers" in their menu of plans, said Lorraine Mayne, a consulting actuary at Milliman USA.

"This is a trend nationally, especially among major carriers," she said, adding that the old system had both pluses and minuses. To the extent that having a referral eliminated unnecessary care, it held down cost. But there was an administrative cost, including the cost of the office visit to get the referral. "The plans that have gone with a more open model feel like the consumer satisfaction element is worth it to them."

Customer satisfaction is becoming a bit of an anthem in health care nationally, as seen with recent debate on a "patients' bill of rights" and the recently passed patient medical privacy protection rules.

Mayne said it's hard to predict if other insurers will follow suit. "Will other local plans feel the pressure to follow? That turns on how the market reacts to this change. If the purchasers of plans see this as something they want to demand from other carriers, (those insurers) will have to respond."

"I don't know that what we do or what others do will inspire changes," Paulson said. "I believe we each have our own reasons and data to go by, and the larger you are, the more ability you have to believe that data."

"I think it will probably open the door at other companies," said Merwin U. Stewart, Utah's insurance commissioner. "If carriers feel comfortable that the physicians have incentives to control the costs, that's all they're concerned about. They're willing to rely on the judgment and wisdom of their physicians."

IHC Health Plans expects the change to be cost-neutral as far as the premiums. There will be administrative savings, and the clinical nurses that used to preauthorize procedures will be redeployed. As part of the change, the plan is asking for notification before surgery so that appropriate education can be provided to patients and follow-up services can be arranged. Studies have shown that good education and follow-up lead to better outcomes and thus savings, Paulson said.

IHC has also realized savings by focusing on "best practices," identifying the best treatments for certain illnesses and then standardizing care to a much larger degree throughout the IHC health network, he said.

"There will be administrative savings, and the clinical nurses that used to preauthorize procedures will be redeployed."

Bottom Line: They will save on RN employee expensive, administrative AND cost of a doctors visit related only to surgery and specialists visits. Expect to see them continue to require homecare prior authorizations. Karen

[Mijourney]

Hi NRSKaren. Another good topic. I worked in insurance precert for a short while. I think what we need to be aware of is that insurance companies in returning more power to physicians will probably beef up both their customer service and claims oversight. It will be particularly important for health insurance policyholders, members, their practitioners, and customer service staff of insurance companies to work closely together. More and more, employers are dropping or adjusting downward what they will pay in benefits. Before we go for a nonemergency health or medical service, it will be critical that we pay attention to what we will be liable for in terms of cost and if it is covered or not. Costs are increasingly being shifted to the patient, so just because something will not require precert does not necessarily mean that insurance will pay for it in the end.

Physician office staff and nurses will need to increase our advocacy role for the patient. I'm going to assume that more and more nurses will be shifted to the case manager role for this purpose.

[fiestynurse]

"If carriers feel comfortable that the physicians have incentives to control the costs, that's all they're concerned about. They're willing to rely on the judgment and wisdom of their physicians."

What sort of "incentives" are we talking about here? CASH bonuses for holding costs down? This has me concerned.