Tuesday, June 25, 2013

The Real Problem With Managed Care Research

You know the kind of research I am talking about.  The research that shows that managed care is more cost effective and higher quality than fee for service.  This stuff has been out there since the 1990s.  Is there really research like that out there or is it little more than a political exercise?  We have more than a few clues thanks to recent analysis of a Health Affairs article by Kip Sullivan.  The article is titled: "The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality"  Sullivan points out that the title of this article is misleading because it suggests that the managed care intervention here "lowered medical spending and improved quality" in the title, but in the body of the work the authors state:

"Our findings do not imply that overall spending fell for Blue Cross Blue Shield of Massachusetts in 2009-2010."  

and a paragraph later:

"This result makes it likely that total Blue Cross Blue Shield payments to groups in 2010 exceeded medical savings achieved by the group that year."  

Sullivan's analysis here is dead-on, especially the idea that "medical savings" can be parsed from overall savings when there is suddenly a large managed care infrastructure.  From some of the places where I have worked, this means bringing in a raft of middle managers who provide no service and generate no income to "manage' the people who are actually providing the care.  In some settings that could mean a "manager" for every 5 - 10 physicians.   If your goal is to cut reimbursement to the providers by just paying them less or sending them fewer referrals while adding a costly overhead of a number of managers who think they can translate their ideas about business into better clinical care - that seems like a recipe for higher costs, record physician dissatisfaction, and disregard for professional quality based guidelines.  Sullivan points out that this specific problem in managed care research has been around since the 1990's

The "higher quality" issue is as interesting.     I encourage anyone interested to download the paper because it is only free until Sunday June 30.  As you read it, take a look at the table labeled "Exhibit 4".  It is a table of quality care measures across both the control groups and the intervention groups.  Although many of the variables are easily defined a couple of issues appear to be clear.  Many seem to be process variables.  In other words, just keeping track of variables and making sure that you are ticking them off gives you more credit.  This is standard procedure in a managed care environment with more case managers.  They can literally be assigned to remind physicians or ward teams to do tasks on a time frame that gives them credit for the process variable.  More administrative manpower should equate to a larger percentage of process variables.

I note that within the quality variables there are two that apply to psychiatry - Depression: Short Term Rx and Depression: Long Term Rx.  There are no significant differences across that study period at the P<0.05 level.  This is interesting at a couple of levels.  First, if this is actually the number of depressed people treated the change after the managed care intervention is not significant.  Secondly, what measures are used to make this determination.  Are these actually depressed people or are they patients scoring above a certain cutoff on a PHQ-9 rating scale?  Third, is the change in percentage of patients treated a legitimate quality marker?  Aren't we more interested in retention in treatment and actual treatment of individual patients treated into remission rather than a cross sectional look at the percentage of patients treated?

The scientific concerns about this paper are numerous.  Like all research (and I mean all research) there are political implications.  The defined intervention here of the Alternate Quality Contract, is basically a primary care physician as gatekeeper model that consumers rejected over a decade ago.  At that point in time, managed care organizations realized that they would need to compete on the basis of providing direct access to specialty care without primary care referrals.  The adaption of the MCOs was to hire their own specialists and build speciality clinics.  The article describes this as basically the "patient centered medical home" (p 1886).   I wonder if the average consumer realizes that the medical home is really a primary care gatekeeper system from the past?

I can't help stressing the importance of article like this one and all research that purports to save money with larger administrative structures that are there in a large part to supervise physicians rather than create administrative efficiencies.  There is no better example than the non-existent mental health system for what this kind of rationing and administrative excess can create.  Diverting money from the direct provision of clinical care into complicated forms of administrative overhead needs to be measured accurately in all of these studies.

George Dawson, MD, DFAPA

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