The health care constellation - managing the complicated health care options of the '90s - Integrating Managed Care - editorial

Business & Health,  Annual, 1991  by Robert McCarthy

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Health care, in the '90s, has become a study in complication. There are the nightmarish costs insatiably devouring ever-larger portions of our GNP. There are the numerous health care providers. Not simply the proliferating medical/dental/pharmaceutical specialists with their armories of new technologies and chemical entities, but also the health care provider combines. Those HMOs, and PPOs, and EPOs, and group practices, and specialty networks for dental, vision, substance abuse, etc., etc. Adding to the potential for confusion are the service providers; those who watchdog and/or streamline the actual providers of medical care; viz., utilization reviewers, who make sure lengths of hospital stay are consistent with treatment needs; case managers, who oversee the health care needs of patients with complicated conditions; workers' comp specialists; data management specialists; elder care experts; etc.

Choosing confusion

Now picture the average employer, wanting to provide health care coverage for his employees and their dependents, and maybe even hoping for some cost-containment. Picture him faced with this bewildering array of providers, entities, combines, service bureaus, all throwing their hands in the air and shouting, Choose me!

And so the employer, of necessity, does, picking one vendor from column A, two from column B, three from . . . Until a wilderness of contracts ensues. Snarled lines of communication better at tripping up than connecting. Turf fights over areas of competence. Data incompletely gathered and maintained, so that no single provider or manager knows everything there is to be known about a patient or his course of treatment.

Where there should be bridges among the services, there are breakdowns. Where people should be talking--both for the good of the patient and for the cost-effective implementation of care--there is no communication.

Systems integrator

Failures to communicate can have tragic consequences. Especially in medicine, such failures can result in patients who don't get better, and program costs that spiral upward yet don't produce commensurate gains in patient health.

What's needed more than ever in health care, experts tell us, is some means of guaranteeing communication, of ensuring continuity of care; some umbrella organization to untangle lines of communication, a system integrator, someone to traggic patient care all the way from gatekeeper to outcome.

All of the pieces must be made to work together. If a patient comes to his employee assistance program with a substance abuse problem, psychmanagement must be kept abreast, and the drug benefit people should be alerted, and utilization review should probably get involved as well.

Maybe what's needed is some kind of synergy, a popular concept a few years back, the idea of parts working together to produce effects greater than the sum of the parts working separately. Except that, in today's health care delivery world, it's not a fusion of UR with workers' comp that we want, or a dominance of mental health services under the EAP banner. For it's important each component retain its distinctiveness, if only to act as a check and balance upon the other components.

Syzygy

No, what's needed is the coordination of the parts, not their fusion; their more perfect alignment, not their blending together into something amorphous. What's needed is a coordination of the effects and properties of UR, workers' comp, case management, EAP, mental health/substance abuse, etc., so that they all work together for the best possible outcome.

Not synergy then, but syzygy: "the conjunction or alignment of heavenly bodies." Syzygy--which implies a voking together of pairs of things for maximum effect. UR and workers' comp, case management with organ transplant networks, elder care with prescription drug utilization review, and with all the reins in the hands of a single driver, who knows which way to pull the team, when to give UR its head, when to urge on case management.

The future of health care delivery may well rely precisely upon this sort of total coordination of care, yielding a total continuity of care, yielding the best of all possible care.

Wholism

Medically, such an idea makes sense. While an illness may be concentrated in only one part of the body, its consequences involve the whole person; even more, that person's family, fellow workers, and employer. And though it's true that a quantum of independent caregivers can come together and administer to a patient's varying needs, it's also true that these caregivers can get in each other's way, that all may believe their service should take precedence, and that the patient's rights and even chances for recovery can be damaged in ensuing squabbles. It thus makes a kind of intuitive sense to call for a provider who can adjudicate among the jostling parts, who can rank their importance and application--both from the point of view of patient health and of payer cost.