5 Priorities for Managed Care

When I began my career in managed healthcare in the mid-1980s, I worked at a large nonprofit hospital. Employers were frustrated about rising healthcare costs and were willing to push employees into preferred provider organizations and HMOs through financial incentives. Our primitive attempts at managing healthcare costs included tracking all hospitalized patients using a chalkboard and working to get them out of the hospital while also enforcing precertification for new hospitalizations.

Managed care was a developing industry and not particularly effective at doing anything but riling up providers and members. Costs continued to escalate.

Fast forward four decades. We are still an evolving industry. We’ve gone beyond a simple focus on cost management to improving healthcare outcomes and access to care. Are we actually doing it? The jury is out. But we are still riling up providers and members.

So where should we focus if we are to meaningfully impact healthcare in a positive way going forward? With the benefit of hindsight, there are five areas that I believe offer the best prospect for the future of managed healthcare and that emerging leaders should embrace.

Improve coordination of healthcare resources.Healthcare has become many times more complicated in the past 40 years. Members with chronic conditions are often bounced around between a myriad of providers, some in network and some out. Overworked health plan staff often struggle to stay on top of all the issues facing members with cancer, diabetes, heart disease and a host of other scary problems. Nurses, social workers and other care coordinators could make a huge difference — if there were enough of them.

Take on the challenges of long-term care. Coordinating long-term care, respite and hospice services must become part of our industry’s future competencies. Our rapidly aging population, increasing incidence of debilitating conditions and insufficient supporting resources are a formula for a crisis in this country. Coordinating services for this population with a focus on keeping people in their homes or other noninstitutional settings has demonstrated success in outcomes and costs.

Incorporate behavioral and dental healthcare. Untreated behavioral health conditions and lack of dental care have a significant impact on health outcomes and costs. Coordinating access to these services for members should be a critical part of addressing members’ needs. Unfortunately, these services are often the most difficult to access, particularly for those on Medicaid or Medicare.

Address social determinants of health. Where you live, what you do for a living and your socioeconomic status have a huge bearing on every aspect of your health. Assessing each member’s status relative to social determinants of health should be part of the coordination of services that will impact outcomes and costs.

Ensure women have access to reproductive health services. Sadly, the Supreme Court has interjected conservative legal opinion into an area that begs more, not less, resources. The maternal death rate in the U.S. rivals many third-world countries in large part due to lack of access to prenatal care and other reproductive health services. It will continue be a difficult issue for plans to deal with given the state of the country.

If there is one overriding theme of how to best address producing better outcomes and cost management in our industry, it’s addressing the astounding lack of coordination. Managed care organizations should fill that void in our system.

After 40 years , it’s now or never.

Don Hall, M.P.H., is the principal of DeltaSigma, LLC and a member of the Managed Healthcare Executive® editorial advisory board.