The Managed Care Transition: Touching All the Bases
As his multispecialty group ushered in change, the author found that life imitates baseball.
Fam Pract Manag. 1998 May;5(5):48-58.
“The future ain't what it used to be.” — Yogi Berra
The above statement fittingly describes the development of our health care system. Think back 10 years: Did you see yourself practicing in today's health care environment? I certainly didn't. I never dreamed that I would move from independent private practice to a multispecialty group. I never dreamed that I would go from not being able to spell HMO to becoming a medical director. And I certainly never dreamed that I would be called upon to be an agent of change for my partners and colleagues.
Although we see research advances and pharmaceutical breakthroughs almost daily, most of us more readily attribute the changes in our professional lives to managed care. I'm no exception. I am among the physician leaders of a productivity-driven multispecialty group that has seen its percentage of income from capitation increase from zero to over 50 percent in just four short years. Navigating this change has exacted its toll of anguish, frustration and anxiety, but our group has survived and even thrived under managed care.
I'd like to share some things I've learned during our group's transition that might make yours a little easier. Along the way, I'll explain some insights I've gained as a student of baseball that have helped me understand and adapt to the changes that managed care brings. (As one of my Little League coaches drilled into our heads, “Baseball is like life, boys. I'm just not sure how or why.”)
An old baseball anecdote known as “The Parable of Yo La Tengo” offers a cautionary tale for succeeding in today's health care environment. The story begins in the Polo Grounds of New York City during the inaugural season of the New York Mets, a team that distinguished itself by losing 120 games that year — still the worst losing record in baseball history. The only player of any repute was the center fielder, Richie Ashburn. Ashburn was flanked in right field by Elio Chacon and in left field by Frank Thomas. Whenever he and Chacon were going after the same fly ball, Ashburn would yell, “I've got it,” only to have Chacon barrel into him, creating a spectacular collision and causing the ball to fall in for a hit. Ashburn discussed the problem with his inimitable coach, Casey Stengel, who told the fielder to learn three words, “Yo la tengo.” That's Spanish for “I've got it.” The next time a looping fly ball came into the outfield, all three fielders converged on the ball. Ashburn saw Chacon closing in, yelled, “Yo la tengo,” and Chacon stopped in his tracks. Then, just as Ashburn was about to make the play, from out of nowhere came Thomas, who careened into Ashburn, causing the ball to fall in and allowing the opposition to score the game-winning run.
The parable illustrates two simple points about the health care market: Not all the players speak the same language, and that can get us all in trouble. More important, you need to pay attention to what's going on around you or you'll drop the ball. For years, we physicians have been looking over one shoulder thinking our destiny was in the hands of federal health care reformers. Many of us paid too little attention to what was over our other shoulder and, consequently, were blindsided by managed care.
An even more important lesson to keep in mind as you make the transition to managed care is one that many aspiring ballplayers learn the hard way: You can't score if you don't touch all the bases. Adapting successfully to managed care requires two trips around the bases — one to face the reality of change and another to make changes in your practice.
“Change is inevitable, except from vending machines.” — Anonymous
To reach first base, we must recognize the inevitability and irreversibility of change. Change is an immutable law of nature. No matter how far we dig in our heels or how tightly we hold on to the status quo, change will result. Not that it's easy to recognize inevitable changes when we see them or to distinguish them from fads, follies and passing fancies; that requires wisdom that we all wish we had more of. The point to take with you from first base is just that you can't reverse change or wish it away. In our birth-to-death practices, we see that all the time. While the easiest route home from first base may seem to be running right back down the first baseline, that's not an option. Turn your eyes ahead; as sure as fate, that's where you're going.
“The less things change, the more they remain the same.” — Sicilian proverb
Getting to second base requires the understanding that with change come growth and pain. Your adolescent patients illustrate this point well. Over the four years in which our clinic's revenue stream went from zero to 50 percent capitation, my partner's 11-year-old son went from a diminutive preadolescent to a muscular, athletic teenager. Neither process was without its painful moments, but neither was avoidable. What it takes to round second base is the realization that a certain amount of pain is to be expected.
“Who will change old lamps for new?” — The Arabian Nights
In pursuit of third base, we must realize that we are agents of change. We care for our patients as they progress from birth to death. We encourage our patients to change their unhealthy lifestyles into more productive ones. We try to change blood pressures, blood sugars and blood counts. Our professional lives are devoted to helping others make changes.
Having touched all three cognitive bases, we arrive back at home plate, which should always be the patient — the reason we are all here. Because if we don't recognize what's going on around us, and if we don't think about where we need to go from here, accept the pain that's coming to us and move on, we're not going to be able to serve the patient well.
True, none of this is new, and maybe none of it is very surprising. Still, given how much of our time is devoted to helping our patients manage change, I'm sometimes a little surprised that we're not better at recognizing the need for a little change management in our own lives —including our professional lives.
Managing managed care
“You can observe a lot by watching.” — Yogi Berra
Being athletically challenged during my childhood years, I spent a lot of time on the bench, an activity baseball players refer to as “riding the pine.” There I learned a great deal about the intricacies and nuances of the game by observing the action and listening to the coaches talk. This technique served our clinic well as we prepared for managed care.
Our clinic management team organized a field trip that took key physicians to the West Coast to see firsthand the impact of managed care on a large multispecialty clinic. We talked with physicians, patients and office staff about their perceptions. We saw that their reimbursement rates for patients in Medicare and commercial managed care plans exceeded their reimbursement rates for traditional Medicare and indemnity plans. However, we had to be convinced that patient satisfaction and physician satisfaction were good. After an extensive two-day visit, we returned home and were able to report back to our clinic members our positive experiences.
Since most change management fails due to inattention to the people dimension, it is imperative to involve people from all levels of the organization at the outset of any major transition in the research and due diligence. Our field trip and the organization and presentation of the data would allow our clinic to make an educated decision about managed care, and provided us with necessary background material and data to support our transition.
Management organizations change for one of three reasons: internal crisis, external crisis or leadership vision. Our clinic recognized that crisis factors were not a satisfactory basis for inducing change, and we chose the route of leadership vision. Our clinic leaders brought managed care to the organization based on a vision of the future, not with any sense of immediate or impending crisis. We saw, rather than felt, the inevitability of the changes coming. We had reached first base.
To get to second base, we had to gain the commitment of the entire clinic. Our research, particularly what we learned from our field trip, convinced us that the cost of maintaining the status quo exceeded the cost of making changes — and would ultimately fail. We were able to convince the other members of the clinic to commit to change on this basis. One of the key factors in the commitment process was attaining the buy-in of both the specialists and the primary care physicians. We did this primarily by making sure that all incentives, financial and otherwise, were aligned. We could all see the painful adjustments ahead, but at least we could all see that they were necessary.
Third is the most difficult base to reach in baseball and in the change process. It represents communication. The management literature tells us that organizational change occurs one person at a time. In order to effect change and to overcome individuals' inherent distrust of it, effective communication must be made a priority.
We knew that as leaders bent on managing change, we couldn't afford to focus on some future state of the clinic to the exclusion of the transition state. We had to have a vision of both and share that vision with other members of our clinic. We accomplished this in our clinic by providing conferences and educational opportunities to apprise physicians of changes in their practice patterns that are necessary to be successful in managed care. For example, we had to convince them that in some instances in which they would tend to admit a patient, hospitalization is not the most appropriate level of care — that skilled nursing facility care or even home health care for intravenous antibiotics can be appropriate and acceptable. We also provide our physicians a forum for voicing concerns and discussing their feelings about the change process. As medical director, I've always encouraged them to communicate openly about their concerns, and I've made it clear that I will support them if they have their patients' best interests in mind.
We regularly meet with physicians to provide feedback. We attach performance measures to their reimbursement. We make an effort to ensure that the criteria by which they are judged are more objective than subjective, can be measured and defended, and are clearly communicated.
“If you don't know where you're going, any road will get you there.” — Anonymous
Now we're making the turn toward home, the patient. As physicians, we have to reinforce our role as patient advocates and not just advocates of the dollar or the guideline. The surest way to disaster is to flag charts or categorize patients as “HMO patients,” “IPA patients” or “paying patients.” As patient advocates, we have to treat them all with the same diligence and respect regardless of their payment status. We are doing our best to keep our entire clinic focused on meeting the needs of the patient in the changing environment.
As I said before, we physicians are agents of change, not just for our patients but for our colleagues and our practices. Duty requires that we make sure our patients understand the health care delivery and reimbursement systems, and to do that, we need to understand, too. We need to make it abundantly clear to our patients that through partnership, we can make managed care work for them — and we need to learn how to make it work in fact.
So, how do we face change? How do we stay on the leading edge and avoid the bleeding edge? We cover all the bases and become positive agents of change for ourselves, our colleagues, our patients and our profession.
Copyright © 1998 by the American Academy of Family Physicians.
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