Managed care was created to centralize patient care within a single network or provider system. The goal, traditionally, was better health outcomes while controlling costs. While the intention may have been good, it didn’t pan out exactly as planned.
The main outcome of traditional managed care was more control. Primary care providers were forced into gatekeeper roles to control a patient’s access to care. When a patient needed to see a specialist, they had to see their primary care provider to get a workup and referral to an in-network specialist, regardless of cost or quality.
Moreover, they were punished financially for trying to sidestep the system’s process for getting care outside their network, whether it was a wide PPO or narrow HMO. This type of constraint, however, doesn’t automatically translate to better health outcomes.
This type of constraint doesn’t automatically translate to better health outcomes.
This is especially true in today’s reactive sick care system where no one gives a patient a plan that will help them live better or overcome their health issues, much less guide them through that plan.
Traditional managed care’s primary weaknesses
Essentially, the primary weakness of traditional managed care starts with primary care reimbursement.
Healthcare is a business designed to make money, and the fact that the system has failed patients suggests that it’s working — at least for some.
Managed care, historically, was intended to treat symptoms for less money. The idea was to reduce waste through an environment of fee-for-service. However, there was, and has been, a financial incentive for everything. “Everything” might include services and care that aren’t in the best interest of the patient.
In the traditional managed care model, insurance companies wouldn’t reimburse primary care providers for the treatment they were trained to do and had already been successfully performing for years.
Primary care providers were forced to refer patients to specialists as dictated by the network, regardless of cost or quality. Because there was no incentive for primary care, patients would stay under the supervision of the specialist until another issue came to surface that required a primary care provider to dole out another referral. The whole process would start all over again.
The result was more gaps in care. Specialists are trained to treat one specific organ, system, or aspect of medicine rather than the whole person, like primary care care providers are trained to do.
Because specialist care is much more expensive than primary care, having specialists provide treatment that primary care providers are already trained to handle results in wasteful spending.
Managed care, when done right, can be effective
While traditional managed care never worked as intended, the foundation of the traditional model was right — to manage patient care proactively.
Financial incentives and reimbursement issues aside, it sought to provide care coordination for patients and help guide them throughout their care journey.
When it’s done right, with primary care at the center, managed care can be effective. Primary care providers are ultimately responsible for the care of every single one of their patients — even in cases where specialists are needed. Primary care providers (and the entire clinical support team) act as coordinators, guiding their patients along on their health journey.
There’s less waste and fewer gaps because primary care is intentional about building rapport and relationships with patients, planning and guiding their health plan, coordinating their care, and following up.
So specialists only see prequalified patients, and because the primary care provider has already done preliminary tests, it takes less time for the specialist to assess a qualified patient’s health issues. Likewise, specialists spend less time weeding out issues that can be resolved with primary care.
Managed care of the future: A platform for advanced primary care
Advanced primary care is the future of healthcare. It involves a primary care team that’s empowered by information technology, data, and analytics to deliver the right kind of care to improve health outcomes across a specific patient population.
The entire advanced primary care model is effective because it’s driven by data to determine, plan, and resource a primary care team (even a whole care center) to meet the actual needs of the population they’re serving.
When it’s built on the platform of managed care (primary care-driven coordination), a patient has a better and more convenient care experience because providers are equipped and operating at the top of their medical licenses and can provide a higher level of services right there on site.