Jul 30 2007
Managed Care: Does It Really Have To Be a Nightmare?
For years, I have heard people refer to managed care. I don’t think I really understood what the problem was, until now.
In Washington State, many of the people who’d previously been on Medicaid, have now been moved to one of the managed care programs through the state of Washington (healthy options or basic health).
While the programs are based on Medicaid, and the reimbursement to providers is no different than if the person was strictly on Medicaid, the requirements and what is allowed on each program are very different. Two areas that have me very frustrated are medications and making referrals to specialists.
Medications: One of the managed care plans not have a separate formulary for their healthy options patients, instead when I talk with them they tell me to use their regular formulary for their commercially insured. However what I have found, is that just doesn’t work. It becomes a real pain, when you have to stop what you’re doing and go back and try and find a medication that is covered. It angers me, that with the proper information, I would have ordered the covered medication to begin with. (I use the formularies into Popper teased extensively).
If I need a prior authorization on a medication, it often takes a lot of time and effort to find the documentation from say a previous provider to substantiate why this person needs a different medication. They often want documentation on what has been tried in the past, the dates of those trials, and the patients reaction. If it’s a new patient to my practice…well, it’s a mess.
Referrals: We further run into problems in trying to find a provider who will accept their insurance. An example of this is trying to find a nephrologists for a person who has impaired renal function and is a diabetic. The closest person I can find right now, who will accept this insurance, is located 1 1/2 hours away. Many of our patients find that drive just too costly (in terms of gas).
All of these “hoops” results in a higher cost in my practice in terms of staff time to complete these various tasks. One of the things that we’re doing rightis tracking the amount of time we spend doing these tasks. I’ll then take the data and figure out what is costs us to actually see these patients, and compare the cost to us to see each patients with the average revenue we receive per patients. Our preliminary data shows that I might be better off closing my panel to one of these managed-care plans.
As nurses and nurse practitioners, we almost always good about for the “underdog”. While I would really hate to have to close my panel, to patients that are not being served and other practices, one truly needs to watch one’s bottom line. If you don’t do so you may just find yourself out of practice.
A practice cannot stay open on a negative cash flow, nor can you as the nurse practitioner, work as hard as you do, for little or no salary. This became glaringly evident in these last two weeks. A NP owned practice located at the far reaches of this county (in a very rural area) called and told me she was closing her practice. Even after gaining RHC status (and thus higher reimbursement for Medicare and Medicaid, it just wasn’t enough to keep her open.
Health care, regardless of our social and ethical feelings, is still a business. And sometimes our decisions have to based on sound business practices. Unless you have structured your business model to provide free care, and have the funding to support your overhead, you can not see patients for free.
Tag: Practice Mgmt
