What Managed Care Organizations Look For in a Physician

ARLINGTON, Va--How do managed care organizations (MCOs) choose the physicians for their lists? The MCO’s ideal physician, as sketched by Melinda Privette, MD, JD, director of medical affairs for Blue Cross/Blue Shield of North Carolina:

• Follows a wellness philosophy and works to keep patients out of the hospital.

• Understands the MCOs’ need for credentialing.

• Helps the MCO develop an accurate profile of his or her practice and offers suggestions for improvement.

• Understands what makes managed care plans valuable to the people who buy them.

• Appreciates the managed care contracts that he or she holds.

In addition, Dr. Privette said at the 24th Annual National Meeting of the Association of Community Cancer Centers (ACCC), this medical paragon meets the highest professional standards in training and credentials; practices where large numbers of the MCO’s members live or work; and runs an efficient, friendly, accessible, and well-organized office.

"Your patient is our member," she explained. And MCOs gain members primarily from selling plans to employers, who in turn often employ consultants to advise them on which plan to pick.

Specialists such as oncologists would be wise, then, to regard each of these types of people (MCO officers, employers, and consultants), as their "customers," as well as other providers in a position to refer them patients, she said, because each can influence the size of a physician’s practice. "You are in a service business," she added.

For MCOs to increase their market share, plans need to be affordable while also providing high quality care. Despite a current wave of competitive price-cutting, which is part of the present struggle for market share, Dr. Privette believes that eventually "price will even out" among plans, and MCOs will compete "on benefits, service, and quality." Such factors as waiting time in the offices and ease of getting appointments are important to members, and therefore also are important to MCOs, she said.

Cost pressures are bringing physicians’ management of disease under increasing scrutiny, she added, although, as yet, cancer care has not gotten a great deal of this attention. This will change over time, she predicts. Ideally, she said, physicians, including oncologists, should work closely with MCOs in developing disease management protocols.

With these needs in mind, MCOs choose for their networks doctors who both meet "the highest quality standards" and show willingness to "actively participate with utilization review programs." Because credentialing physicians is very expensive, "we need providers who will participate actively and be a partner" with the MCO, Dr. Privette said.

Physicians’ attitudes toward the requirements for utilization and outcome review, therefore, play an important role in whether they are included.

Beyond a physician’s professional abilities, the management of his or her office also affects relations with the MCO. Skill at documentation, concern for confidentiality, up-to- date equipment, and openness to new patients all figure in the MCO’s decision to accept or retain a physician on their list. MCOs often evaluate these qualities by the simple method of sending someone to sit in the office and watch what goes on.

Earning Relief From Oversight

MCOs must meet the accreditation requirements of the National Commission on Quality Assurance (NCQA), and they depend on their network providers to give them the necessary data. Understanding and complying with NCQA standards can ease relations between physician and MCO, and earn a practice relief from constant supervision.

"When physicians consistently show good utilization," she said, "eventually we turn off the phones." The MCO does much less checking up on such providers because it has established that "they don’t need oversight."

Other keys to getting onto an MCO list, she said, are an accurate description of one’s practice; hospital staff memberships; and relationships with existing patients, as when, for example, a major local employer requests that a certain practice be added because its employees want to remain with it.

To get referrals after one has been listed, she suggested, a provider should "cultivate relationships with case managers, keep them well informed about your practice, and be cost effective."