Why physicians get deselected

By Rebecca Anwar, Ph.D. & Judy Capko

Not so long ago, physicians in Pennsylvania hesitated to get involved in managed care. They were reluctant to sign contracts that cut their reimbursement. But these attitudes have changed now that employers are encouraging their workers to enroll in managed care plans and employees are taking the bait, even if it means changing to a “panel physician.” Fearing patient abandonment and a loss of referrals, physicians have signed on with the major insurance plans in the area. This massive physician enrollment gives the plans power to attract employers with a large physician panel and, inevitably, tie up the market.

Insurance companies and health systems have been strategic in their approach to capturing market share with expansive physician panels that attract employers and employees. Once a plan has a fair piece of the managed care pie, they begin to scrutinize the performance of each physician on the panel. The end result is to have a tight panel of providers that meets managed care’s objective of quality care and cost containment. The first step in accomplishing this objective is to shrink the panel, based on various factors. This process is commonly called “deselecting.” Here are some of the deselection components:

• Shifting the requirement from board eligibility to board certification.

• Specific specialty needs, based on reduced utilization.

• Physician performance factors, utilization and access.

• Patient satisfaction.

• Prevention and patient education programs.

Managed care organization (MCOs) and insurance plans will retain physicians with the highest level of clinical expertise. For this reason it has been common to require board eligibility for all contracting providers. When the MCO or plan takes steps to maintain control and contain costs, while ensuring patient care and service is not compromised, they will begin to shrink the physician panel. Here are some of the ways this occurs.

Board Certification

One of the first steps that sweeps a panel is the shift to requiring board certification in your specialty, instead of simply being board eligible. Physicians that are board eligible, but not board certified, will be deselected by cancellation of the contract, denying a contract renewal or given a time frame in which to obtain board certification.

In some cases, board certification may subtly begin to infringe on patient care. For example, recently a physician in the northeast who provided capitated specialty services for several years received a call from the MCO that held the contract. He was told that one of the plans (we’ll call it Best Plan) was tightening up it’s requirements. Even though this physician had the exclusive capitated contract with the MCO, he would be required to engage the services of a board certified specialist to care for his patients that were enrolled with Best Plan.

Utilization Management

Your cost for care will be monitored against your peers and your case management will be assessed. High cost physicians with the same result achieved by lower utilizers will be examined in the deselection process. It begins with a review of the services provided in your practice—professional fees and ancillary services. Beyond this, your utilization patterns outside your practice will be evaluated. These aggregate costs will include ancillary services, number of hospitalizations and length of stay (LOS), specialty referrals and the quantity of services provided per enrollee compared to community peers in the same specialty.

A second component of utilization management involves the assurance that patients are not being denied access to care. For radiologists, this means offering timely patient appointments, prompt response to clinical phone calls, appropriate and timely referrals to subspecialists, as well as prompt and accurate reporting of diagnostic and therapeutic services to both the referring physicians and the managed care organizations (MCOs). These are essential components to examining quality case management.

Patient Satisfaction

MCOs conduct random surveys on patients enrolled in the plans. Your future value to the MCO will be influenced by the marks you receive. Collect your own marks by conducting patient satisfaction surveys and repeating them periodically to ensure you are making any necessary improvements.

Many physicians are adapting their survey instruments to match the guidelines MCOs use to obtain the National Committee for Quality Assurance (NCQA) accreditation. This accreditation is quickly becoming the gold standard for selecting health plans. With increased competition and demands for quality, value and service, NCQA is gaining the attention of plans and MCOs nationwide.

Supplement this with random new patient post-encounter telephone interviews. It is important to have a valid survey instrument to measure your results. In addition, conduct employee in-services that focus on consumer satisfaction, phone skills and effective communication. If you do this, you will have a winning combination.

A five-physician orthopedic group in the Midwest was concerned about the keen competition in their community. They also knew the increasing penetration of managed care would affect specialty referrals. So, when they conducted a patient survey and received impressive marks they touted their results to the largest MCO in their area and landed an exclusive contract. They also seized the day by examining areas where they felt they could improve service and made some important changes such as expanding their geographic coverage by merging with another orthopedic group.

Preventive Health Programs

Partner with your patients, your colleagues and the MCO to provide patient education programs regarding prevention, early intervention and proper treatment and diet for chronic illnesses. Also provide support materials such as a video library, newsletters and participation in community support groups. This type of involvement will gain the attention of MCOs, referring physicians and patients. You will outshine the competition and be positioned for success with managed care.

MCOs will expect you to develop mechanisms in your office to ensure patients obtain appropriate preventive screenings such as mammograms. Follow-up care is also important. This means having an effective recall system in place for post-treatment of conditions that need medical follow-up and reminders for repeat prevention screenings.

Supporting Managed Care

MCOs want team players and top performers. Getting on the managed care bandwagon is not a matter of signing up with every plan in town without scrutinizing the contracts. It’s a matter of understanding managed care’s objectives and buying into the concept. Know what managed care wants from you and be prepared to deliver it without compromising the quality of patient care. You can show your support by serving on committees and giving your input on clinical issues and administrative protocols regarding patient care.

Participate in preventive health programs the MCO or insurance plan have in place. In addition, work with your referring and specialty physicians to develop preventive health programs and support early detection. Combine this with patient satisfaction, appropriate utilization, quality care, cost containment and a team approach to medical care and you will have fewer reasons to be concerned about deselection.

Rebecca Anwar, Ph.D., is based in Philadelphia, PA and Judy Capko is based in Newbury Park, CA. They are senior consultants with The Sage Group, Inc., a national consulting firm specializing in managed care assessments, integrated practice formation, strategic planning and practice management, quality improvement and marketing for health care providers.