Is Quality Medical Care Dead or Just Buried Alive?

Independent physician associations (IPAs) were thought to be one of the saviors of physicians during healthcare reform in the 1990s. These organizations formed to give physicians a greater say in the delivery of healthcare, including protecting the patients' interests and improving quality of care, while still implementing cost-effective strategies. In the year 2000, however, most IPAs are under severe economic pressure or becoming insolvent. How has this occurred, and how will this effect where we, as neuroradiologists, will be going in the future?

The 1980s brought increased pressure from healthcare buyers and consumers to decrease cost because of the perceived uncontrolled escalation in healthcare cost. Insurance companies quickly realized in the late 1980s that they could not shift this cost escalation to the consumers, and began to devise strategies to shift the risk and increased cost to hospitals and physicians. At this time, physicians perceived that they were losing control over patient-care decisions to insurers and hospitals, and were experiencing a continual decrease in reimbursement. Thus, both physicians and insurers supported the concept of forming physician organizations that could contract with hospitals and insurers, accepting some of the economic risk and gaining potential reward from the insurers. These new IPAs would contract with insurers, and if the IPAs were financially successful, physicians would benefit from increased reimbursement. The insurers saw an opportunity to shift financial and medical decision-making risk to the physicians by making the physician the “gatekeeper.”

These IPAs initially used Kaiser Permanente as a model. In the late 1980s and early 1990s, for-profit health maintenance organizations (HMOs) formed or evolved from nonprofit companies because of the potential for large economic gain to the owners. This conversion, along with the development of for-profit companies to manage IPAs, created the environment of changing “managed care” into “managed competition.”

In reality, this conversion led to the current problems with managed healthcare. First, HMOs usually marketed the same group of physicians and services to the consumers. Thus, the only opportunity to compete between the HMOs was on price. Second, a goal of “for-profit” HMOs was to maximize shareholder return. An HMO that broke even, but delivered excellent care, was considered a failure. Third, insurers and some physicians saw an opportunity to capitalize economically on the growing conflict between primary care and specialty medicine. This occurred by pitting the two groups against each other, fighting over a declining dollar. Fourth, these changes were occurring when the public financial market, many entrepreneurs, and physicians believed that healthcare companies were the “new darlings of Wall Street.” The stock price and value of these start-up companies (management companies and for-profit HMOs) were overvalued by standard evaluation methods.

The driving force in managed care and IPAs became cost containment, not cost effectiveness and quality of care improvement. The issue of quality care took a back seat to the market value of these companies. Primary care–controlled IPAs were the “hot” new way to control excessive specialty spending. Many primary care physicians were convinced that the road to economic parity was to become a manager of healthcare, not a deliverer. The rise in healthcare costs declined in the mid-1990s, and the publicly traded physician management companies boomed on Wall Street. The initial success of many of these IPAs was achieved through controlling Medicare hospitalization. Most IPAs assumed this could easily translate to the commercially insured business. Unfortunately, the “great savings” from controlling overhospitalization was not present in the commercial market. Additionally, most management companies did not have the technical ability to manage a large patient population and multiple physicians. Most HMOs, management companies, and IPAs fell into the trap of trying to pit the primary care physicians against the specialists as the major mechanism of lowering cost.

The main mechanism for increasing physician reimbursement was for IPAs to accept the risk of managing healthcare. Physicians assumed that they could better manage the economic risk of delivering healthcare than could the insurers. This was not based on past data, experience, or any factual information. Unfortunately, the insurers knew better and encouraged physicians to become the economic advocate and not the patient advocate. This new healthcare delivery system of for-profit HMOs, economically driven IPAs and publicly traded physician management companies, took only 5 years to implode. Consequently, many IPAs are facing bankruptcy. There is great consumer dissatisfaction with HMOs. Many consumers are wondering who is the patient advocate. These past 5 years have shown that the following assumptions are inadequate for quality patient care:

• Primary care physicians can manage costs by delaying or preventing referrals to specialists.

• IPAs can better manage risk than insurers.

• Specialty overuse is the primary cause of IPA failure.

• The correct treatment for good or excellent healthcare is known. It is difficult to determine the correct treatment because technology is evolving so rapidly (eg, positron emission tomography scanning, functional imaging, and diffusion imaging for the diagnosis of stroke). These rapid changes retarded the ability to determine how to deliver the best care for the lowest cost. Thus, insurers and consumers reverted back to the goal of simply lowering cost. Unfortunately, physicians contributed to this process because they were reluctant to support the evidence-based algorithmic approach to medicine unless they developed the algorithm.

• IPAs should develop patient care algorithms and, thus, lower cost and remain the patient advocate.

The basic question of how to deliver cost-effective medicine (good healthcare at the lowest price) still has not been adequately addressed. Quality is like pornography, everyone knows it when they see it, but few can define it. What does the future hold for radiology, particularly neuroradiology, in this healthcare environment? If the past is any indication, it will not be long before there are rising healthcare costs again and, eventually, the industry and consumers will demand change. If there are no indicators by which to measure quality care, or a process to deliver “better, cost-effective care,” then the cycle will recur with the insurers and industry demanding and finding ways to decrease costs by decreasing reimbursement and withholding care. There will be few other choices. Thus, we are at a crossroads.

During the next several years there is an opportunity in this fee-for-service environment to develop vehicles to demonstrate quality care and cost-effectiveness. The American Society of Neuroradiology has an opportunity to be a leader in this endeavor. There are several issues we should address to enhance what we are doing. First, we should continue to evaluate new equipment with the emphasis on its cost-effectiveness for improved patient outcome, not just by whether its use will be reimbursable. Second, we should continue to develop imaging algorithms for diseases (eg, acute stroke, degenerative brain disease, carotid artery disease), and work with other specialties and insurers to determine what studies should be reimbursed and on what type of equipment. Third, we should work with other specialties to enhance patient care and shorten hospitalization time (for patients with spinal cord and head injuries, back disorders, or dementia, for example).

By being proactive and defining quality care and cost-effectiveness, we hopefully will not be driven back into the cycle of having patient care withheld, physician reimbursement decreased, or both to manage the cost of healthcare.