Physicians gain final say

January 1, 2000

Pharmaceutical Representative

In a move that could signal a trend in managed care, UnitedHealthcare, a subsidiary of Minneapolis-based UnitedHealth Group, announced that it is doing away with doctor preauthorization for many inpatient hospital procedures.

In a move that could signal a trend in managed care, UnitedHealthcare, a subsidiary of Minneapolis-based UnitedHealth Group, announced that it is doing away with doctor preauthorization for many inpatient hospital procedures.

The new program, called Care Coordination, is part of an effort to simplify patient care for enrollees and doctors. "Care Coordination is part of our continuing vision to facilitate a better, more positive health care experience for consumers and physicians," said William McGuire, UnitedHealth Group chairman and chief executive officer. "After a decade of focused interaction between providers of care and third parties, we believe it is appropriate to expand on the critical needs of patient education and advocacy, physician support and assistance, complex care coordination, availability of specialized resources and simplification of the health care system."

The care coordination initiative was begun in 1998 and tested in six markets. Results from those markets, which showed that the program was able to improve health care without added cost for employer or member, led United to implement the program on a national level.

"Millions of dollars are spent every year on reviewing the treatment decisions made by physicians," said Archelle Georgiou, chief medical officer for UnitedHealthcare. "Over the last decade we have seen the value to patients and employers of these efforts diminish as runaway health costs have been slowed and services expanded. The vast majority of reviews support the clinical decision, so it makes sense to focus on other programs and efforts."

The move to place decisions regarding patient care in the hands of physicians was met with support from the medical community.

"This action is historic and represents a long overdue victory for America's patients and the care they receive," said Thomas Reardon, president of the American Medical Association. "Patient care cannot and should not be determined by third parties outside the exam room. Physicians are eminently qualified to make the decisions affecting their patients' care. They should not have to battle insurance companies to do what is best for their patients."

An emerging trend?

According to the American Association of Health Plans, giving doctors the final say on patient care may become a new trend in the managed care industry. "What United has done is definitely on the leading edge of change," said Karen Pisano, a spokesperson for the association. "There is a move now away from the procedure by procedure review, toward looking at a physician's overall pattern of practice and working with physicians on that basis. You still see prior authorization, but you see it focused on a narrower group of activities, the kinds of procedures that continue to be misused or overused."

Pisano attributes the change to several factors. First, health plans have been successful in reducing variation with respect to many procedures and are already approving virtually all the procedures that doctors recommend. Second, technology has allowed health plans to prepare a profile of a physician's overall pattern of practice. And finally, physicians and patients have said quite clearly that they want the health insurance process to move more smoothly.

The American Medical Association is encouraging other health plans to adopt policies similar to United's. "We urge other health care insurers to follow UnitedHealth Group's lead and halt their unwarranted intrusions into the patient-physician relationship," said Reardon. "We agree with United's conclusion that efficiency and cost-savings within the managed care system can be achieved without compromising the trust and integrity that must exist between a patient and their physician." PR