The specialist is certainly becoming more special these days, perhaps soon to be included with the spotted owl and plains buffalo as one of our endangered species. A recent Forbes headline put it bluntly: "The Doctor Is Out." The Department of Health and Human Services in 1993 predicted that there would be 165,000 specialists too many by 2020, but that prophesied glut has since dwindled — maybe not so quickly as the federal budget surplus of a few years ago, but fast and steeply nonetheless. Some experts now predict that there will be 150,000 too few specialists by 2020.
"We were wrong," Carl J. Getto, the HHS official who chaired the 1993 panel that foresaw the flood of specialists, tells Forbes, in a statement whose simplicity and humility, in coming from a government official, might mark Getto as something of a rare bird himself.
What you won't find in the Forbes article, published July 21, is a discussion about how HMOs limit access to specialists, and this is one instance where what is not said has more resonance, at least for managed care, than what is.
Specialists and managed care, according to "Back in the Driver's Seat: Specialists Regaining Autonomy," by the Center for Studying Health System Change, are finally getting along.
"Specialists with the most managed care reported a dramatic improvement in their ability to maintain relationships with their patients," says the study. "The proportion of specialists with the highest managed care revenues agreeing that they can maintain relationships increased from 53.9 percent to 71.2 percent between 1997 and 2001. Specialists with the lowest managed care revenues experienced less change (from 66.9 percent to 76.6 percent)."
J. Lee Hargraves, PhD, a sociologist at the center and one of the study's authors, thinks that an increased emphasis on disease management may have helped to give the specialist new prominence.
"Of course, the difficult thing is that for some employers, they don't have enough people with certain diseases to undertake a DM program," says Hargraves. "But it really works well for large companies. Thinking about who the high-cost patients are, and focusing on them — that's certainly something that's going to be seen. To the extent that some of that involves specialty care, they'll be participating."
Still, health plans will probably never shake the fear that specialists will order expensive, and arguably needless, tests.
"They have a demonstrated tendency to be more aggressive in testing, because they don't want to put up with the uncertainty," says Jaan Sidorov, MD, the medical director of care coordination at Geisinger Health Plan. "So they are more likely to get the CAT scan, they are more likely to get the MRI, or more likely to refer the patient to another specialist that they think is better able to assess the patient's symptoms."
Despite this tendency, Geisinger is exploring avenues in which specialists will play more of a role.
"We still have a gatekeeper HMO product, but now we are looking very, very hard at a PPO product," says Sidorov. "We anticipate that the behavior of specialists is such that the PPO product will have to be priced higher. One of the reasons that the product will have to be priced higher is because of the actuarial tendency of specialists to do more testing."
Just how to provide more access to specialists is a problem that Arthur N. Leibowitz, MD, a former chief medical director at Aetna and currently the executive vice president and chief medical officer for a company called Health Advocate, dealt with long ago.
"I actually suggested and did the design for the system Aetna now uses in 1996, before the Aetna-U.S. Healthcare merger, but with the merger, things got put on hold," Leibowitz recalls. "We implemented the program in stages, sort of piecemeal as several events transpired. Point-of-service plans had gained popularity and of course, although these were called HMO plans, they gave members the right to go directly to anyone for care."
Demand for direct access to specialty care really began to manifest itself in the mid-1990s through coverage mandates passed by state legislatures and prudent-layman language for emergency room care.
"Primary care physicians became even less interested in controlling, or even being involved in, the process of specialty referrals," says Leibowitz.
In those days, all the relevant factors seemed to be lining up to open the doors to specialty care in a big way except one — making the technology work to allow the process to happen on the plan's end.
"The main limitation to instituting the program of open access to specialists at Aetna was our computer system that processed HMO payments," recalls Leibowitz. "It was set up to require a referral as the authorization for payment. Y2K made it impossible to do new programming for such changes. All of the computer people were busy working to make the systems Y2K ready, so no one was available and there was no budget for the programming to change the referral/payment system. So we had to find a way to do this without rewriting the underlying computer programs that paid all of the claims.
"We had to trick the computers into thinking there was a referral," he continues. "We found a way to jury-rig the system and started building the program in 1999."
The health plan began by allowing patients direct access to OB/GYN care. "We then had to allow the GYN to refer the patient on for related services. It was just a small step from there to open access to specialists."
UnitedHealth Group's much ballyhooed decision to drop gatekeeper restrictions made it a marketing imperative for Aetna to provide even greater flexibility.
"Now people say, 'See, there is no difference in costs of care between direct access to specialists and referral systems,'" says Leibowitz. "That's not really true. There is no difference in cost between HMO plans as they exist now that require referrals, and open-access HMO plans. But if you go back and examine the cost structure in the more tightly managed HMO plans in the early 1990s and now, there are tremendous cost differences. While one commonly hears that requiring referrals doesn't save money, in fact it does or at least it once did, depending on the model of the plan. But today, there are no pure HMOs to compare to, with mandates for direct access and such."
And, increasingly, the gatekeeper role falls to consumers.
"Today, the prevailing model is to use out-of-pocket costs to drive patients to primary care instead of using the requirement to get the referral to a specialist," says Leibowitz. "So plans have increased premiums for programs with more direct access [the PPO idea] and with more HMO-like plans you see much higher specialist copayments — even tiered copayments for specialty care with a lower copayment for specialty visits like GYN and ophthalmology, and higher ones for other specialties like plastic surgery."
This essentially creates a system where the better-off patients, who can afford the costs associated with direct-nonreferred access to specialists, can get it, and those for whom the costs are a bigger concern go through the primary care process to get referrals.
"This is essentially a two-tiered system; one with referral requirements, and one with direct access to specialty care," Leibowitz observes. "Somewhat ironic isn't it?"
Hargraves, of the Center for Studying Health System Change, expects utilization review and physician profiling to become the cost-containment tools of choice as specialty care becomes more commonplace. "Saying periodically, 'You order X percent more tests than your peers' — I think that's where things are going."
But getting there's a different story, says Sidorov. Specialists playing more of a role in managed care means, in part, that they will have to do more primary care, a transition not without its perils. The saying that an expert is someone who knows more and more about less and less should perhaps be kept in mind.
"One of the reasons why a person who is a physician becomes a specialist is a personality style that has trouble dealing with uncertainty," says Sidorov. "Primary care physicians are willing to use the test of time, willing to use expectant follow-up, willing to ask patients to call us, or lately e-mail us, and let us know how they're doing. That's the take-two-aspirins-and-call-me-in-the-morning approach.
"Primary care physicians are willing to say to patients, 'I don't know what's wrong with you, it's probably nothing serious, let's just see how it's going.'"
Sidorov calls this the game of primary care. "You can't get a CAT scan on every patient with a headache. You can't get an MRI on every patient with a backache."
Specialists have much more trouble with that.
One of the best examples of specialists gaining more prominence in managed care is endocrinologists, who could wind up becoming the primary care doctors for diabetics.
"If a person with diabetes sees an endocrinologist, it's more likely that there will be additional testing and additional referrals of that patient in the course of his medical care," says Sidorov.
This is problematic for the HMO. "The HMO can turn around and say to the consumer, 'You can see a specialist, and let the specialist go ahead and order all kinds of testing on you, both necessary and unnecessary. We, the MCO, can get into the business of deciding medical necessity, but we'd rather not. So, I tell you what, we're going to use market forces instead, and we're going to put some skin in the game from you, by having you copay or set up a medical savings account or deductible, or all those other tools.' Theoretically, the patient says: 'Hey, I know I have a headache and I know you think I need a CAT scan but if I need a CAT scan, I'm going to have to pay this enormous copayment or I'm going to have take this money out of my medical savings account.'"
Sheldon Zinberg, MD, chairman of CareMore Medical Group in Downey, Calif., thinks he's found the solution. Before assuming his current position, Zinberg was a practicing internist and gastroenterologist for 40 years, and has viewed the problem both as a specialist and as someone who manages specialists.
CareMore — a medical group with a wraparound IPA — uses direct referral access, through which a patient suffering from asthma, for example, can see an allergist or pulmonary specialist that same day. But the company goes even further, Zinberg reports. It encourages specialists to behave more like primary care docs, and primary care docs to behave more like specialists, as each case demands.
"To that point, we have regularly scheduled seminars for all our family practitioners on various disease states," says Zinberg. "For example, each year, we have a seminar on asthma and COPD in the early fall because it seems that these patients have the most difficulty in the fall and winter. We review the disease and the treatment. But more importantly, we actually define a program that renders them less fearful."
"Less fearful," as in taking an aggressive approach to treatment. Sometimes PCPs are afraid to use appropriate medications at appropriate times, he says. "For example, they might not use antibiotics because we hear so much about how we're going to create superbugs," says Zinberg. "Well, that's true for treating a cold. But on the other hand, for someone with a definitive diagnosis of asthma or obstructive pulmonary disease, you're better off hitting those people with the correct antibiotics early. And if they're not responding quickly, you're better off treating them with steroids. Early. Not later. You're better off making sure that they're getting their inhalation therapy properly."
To make the program user-friendly, CareMore supplies preprinted prescriptions to doctors for ventilation therapy, antibiotic therapy, or steroid therapy. "All they have to do is check and sign them so that these patients are treated properly and expeditiously," says Zinberg. "We also hold seminars for office staff personnel of these PCPs. We tell them how important it is for them to recognize that they play a role in saving lives. They appreciate this role. Then we send them a hot list of every patient in their office with the diagnosis of asthma or obstructive pulmonary disease that they can keep in front of them from September through March. When those patients call, they're hot lined."
Meet John Doe
So, if John Doe, who has a history of asthma, calls CareMore, the staff is ready. "He tells you he has a sniffle, get him in that day," says Zinberg. "Don't schedule an appointment for two weeks from now. Of course, if you can't get him in that day, I can understand it because you may have a full schedule. Call our member services. We'll get him seen by a pulmonary specialist. Same day. We underscore this service to the office staff of our PCPs.
"The way IPAs often run into money problems," he continues, "is by delaying access to medical care in a timely fashion, or denying access to medical care, as opposed to providing swift access to the appropriate level of service. If you do that, you decrease the rate of hospitalization. You decrease the rate of rehospitalization. You decrease the utilization of expensive resources."
At CareMore, primary care physicians are referred to as gateways, not gatekeepers — terminology that certainly reflects the findings of the study by the Center for Studying Health System Change. It says: "It is increasingly clear that patients and specialists prefer looser managed care. It is less clear, however, that patients, employers, and taxpayers are willing to pay for completely unmanaged health care. Therefore, the current balance among access, specialist autonomy, and costs is likely to shift again."
Paying the price
Leibowitz, the former Aetna official, contends that fulfilling the market's desire is good business as long as the market is willing to pay the price.
"But you have to take a step back and say, 'How long can we tolerate double-digit, year-over-year premium increases?'" he says. "And if someone asks, 'How can we reduce our costs?' — certainly putting in place a process that has a physician writing referrals would certainly be one step in the program."
In other words, by the time we can look at managed care and say "Specialists have arrived," the pendulum may have already begun to swing back.