Secrets To Making Managed Care Profitable

As the healthcare landscape continues to change, it can be a challenge to survive in a managed care environment, let alone thrive. This author provides pearls for streamlining office management and offers insights on carve outs and selling OTC products in the office.

   Over the past 12 years of working in private practice, I have had the unique opportunity to work in a practice that includes managed care patients. There have been many changes in the makeup of these health maintenance organizations (HMOs) since I started in practice and we have made many adjustments to the office management of these patients.

   In 1996, there were more than 10 different independent practice associations (IPAs) managing more than 200,000 HMO patients in our region of southern California. Since that time, many of these IPAs have consolidated or gone out of business. There are now only four different IPAs in the region. This does not include Kaiser Permanente (a closed managed care organization).

   This consolidation has occurred for many reasons, which include a desire to cut costs, improve patient outcomes and become more efficient. It is interesting that the IPAs that have been successful and have survived over the past decade are not the ones that cut corners with reimbursing physicians or approving authorizations. Rather, the survivors are those that have strived for a higher quality of care.

   Typically these organizations are performing internal reviews of the doctor’s quality of care, patient outcomes and patient satisfaction with the use of numerous surveys and data reports. Organizations share these reports with the physicians in an effort to create awareness of patient perception and satisfaction with the care provided.

   As physicians and surgeons, we do not always realize what a patient sees or perceives about the care we provide. However, we can learn from our mistakes and continue to improve as a private practice. Sometimes a patient has a great outcome from surgery but is disappointed with the way a staff member interacted with him or her or with the manner in which a billing service spoke to the patient. These reports and surveys have helped us improve.

Insights On Streamlining Office Management

   The greatest challenge for a busy practice is how to include HMO patients but not let the practice be overwhelmed by the additional paperwork and increased patient volume. The use of authorization request forms will help improve communication between the doctor and the staff. This will eliminate wasted time looking for diagnosis or procedure codes, and assist the staff in expediting the authorization.

   The IPAs in our community are able to authorize all requests via the computer. Unlike with most PPOs and workers’ compensation patients, obtaining authorizations in the IPA setting does not require numerous phone calls or waiting on the phone for 15 or more minutes. Office staff do not need to be redirected to a supervisor or leave messages for a claims adjuster. Computerized authorizations are much more efficient and we are able to obtain authorizations within 24 to 48 hours.

   One of the keys to treating a large volume of HMO patients in one’s practice is to resolve the clinical problem as quickly as possible and resolve it permanently. This may require a change in treatment protocols for the foot and ankle specialist.

   For example, many doctors prefer to perform a partial nail avulsion for a new ingrown toenail. In our experience, most ingrown toenails, particularly those in children, recur more than 50 percent of the time. It is our preference to perform a partial nail matrixectomy on the initial visit to help resolve the problem permanently and prevent the need for numerous follow-ups in the future.

   Another example may include the management of heel pain syndrome (plantar fasciitis). Many doctors will initially treat the patient with oral anti-inflammatory medications, stretching, ice and over-the-counter (OTC) orthotics. If a patient is limping, we will typically give a corticosteroid injection and may begin the use of a night splint on the initial visit. This will help resolve the patient’s symptoms as soon as possible.

   In a busy practice, it is important to control the number of new patients that one sees each day. Unfortunately, this may affect how quickly one will see the patient if the schedule is already full. One helpful approach for our offices has been the creation of a waiting list for our HMO patients who are unable to get an appointment within a two-week period. We typically call patients early in the week to confirm their appointments. If a patient cancels, then we simply fill the schedule with the use of the waiting list or may move up an appointment to an earlier date. This has greatly improved our patient satisfaction, even prior to the patients’ first visit.

What You Should Know About ‘Carve Outs’

   Several years ago, we noticed a trend in patient dissatisfaction with respect to durable medical equipment (DME). Initially, when we started providing HMO care, a large, nationally recognized prosthetic company provided all DME. This included ankle braces, Cam Walkers, diabetic shoes, custom orthoses and functional ankle foot orthoses.

   We felt the pedorthists providing the care were very nice but did not have the same training as podiatrists with respect to biomechanics or orthotics. Patients would need to wait for additional appointments with the prosthetic company and this would delay their care for several weeks. In addition, co-pays seemed very high for these items and many patients were unable to afford the co-pay, and would not purchase the needed ankle brace or orthotic. After several years of patient complaints and increased co-pays, we decided to investigate a “carve out” for durable medical equipment with the IPA.

   We discovered during these discussions that the prior contract with the prosthetics company had significantly higher rates than podiatrists receive with Medicare or Blue Cross.

   We came to an agreement for a contract for all DME products. This contract has evolved over the past three years. Patients who have a fracture or an ankle sprain can now receive a DME item immediately and do not have to wait several days for an item that is medically necessary. When a patient needs a custom orthotic, we can do the casting and perform a biomechanical evaluation as we have advanced training in this arena.

   Patient satisfaction has greatly improved. This has been a win-win situation for everyone. The IPA is happy because it is saving money by contracting directly with the podiatrists and the patients are happy with the improved quality of care.

   Other carve outs that one may consider would be for X-rays or wound care. Most HMOs do not cover an X-ray cost unless it is performed at a designated facility at a hospital or radiographic facility. If a patient has a fracture or is a post-op patient, he or she must go to an outside facility for the X-ray. This requires additional office visits, co-pays and additional time for the patient. When a patient is in pain and requires the use of crutches or a wheelchair, it is very difficult for him or her to drive around town to get an X-ray. Some HMOs allow for a carve out per X-ray in these urgent situations.

   Diabetic foot and ischemic foot ulcerations are very complicated problems that often result in infection, hospitalization and sometimes amputation. Most hospital-based wound centers are excellent in treating pressure or burn wounds, but foot ulcerations are more challenging.

   Some podiatrists specialize in offloading techniques such as total contact casting and custom orthotics. In addition, podiatric surgical management is sometimes necessary to help prevent an amputation or recurrent infection. There are some podiatrists who have created carve outs for the management of foot ulcerations. This has helped the HMOs save money by significantly reducing the number of hospitalizations and amputations.

A Helpful Primer On OTC Products In The Office

   Every patient that walks through the office door, regardless of the type of insurance he or she has, may benefit from an over-the-counter office product. Most pharmacies and shoe stores sell a variety of OTC products. These may include pads, OTC orthotics, shower covers, antifungal creams or sprays, and anti-inflammatory gels or ointments.

   Unfortunately, many of the products sold in these stores are not effective or are sold in a diluted form. In addition, some patients may spend hours shopping for a specific product until they find it. This may be frustrating for the patient and time consuming.

   Over the past 10 years, we have tried a variety of different OTC products and have found some to be better than others. We currently stock our favorite products in the office and sell them at a reasonable price. Patients are very happy with the convenience and appreciate the quality of some of the products we recommend.

   One very effective product that we recommend is AmeriGel wound gel (AmerX Health Care), which we use for postoperative care for nail matrixectomies. There are several advantages to this product. These advantages include auto-debridement, antimicrobial activity, the need for only once-a-day dressing changes, and the product’s ability to absorb the drainage and neutralize the phenol we use.

   This is more convenient for patients and obviates the need for daily soaking. Teenagers, adolescents and busy professionals often do not have time for soaking. They do have time to apply the AmeriGel wound gel daily with a piece of gauze and a Band-Aid or tape. This product has reduced our healing times by at least one week for each procedure and minimizes the chance of infection.

   Another product that is very popular in our offices and often effective is Cryoderm anti-inflammatory gel. It is an herbal anti-inflammatory with its key ingredients including Arnica, Ilex, botswellia, menthol and peppermint oil. We have tried several other topical anti-inflammatories over the years including Biofreeze (Performance Health) and Traumeel (Heel). We have seen better results with the Cryoderm and our patients purchase more of the product.

   We use Cryoderm for different types of tendonitis including Achilles, peroneal, posterior tibial and extensor tendonitis or myositis. Patients should use it two to four times a day as needed. We have also had success with using it to alleviate neuropathic pain. It will not eliminate neuritic pain but will often alleviate some of the acute pain often felt at night. We also recommend that patients use the product with phonophoresis at physical therapy. Patients will take the Cryoderm with them to physical therapy and use it as a substitute for dexamethasone.

   Silicone gel pads and reusable gel pads are very helpful for patients. These are non-medicated pads that alleviate pressure over bony prominences. The pads are very difficult to find in stores. Patients find these very helpful for calcaneal apophysitis, hammertoes, metatarsalgia and neuromas.

   Another product that is very popular is Tineacide cream and spray (Blaine Labs). It is an antifungal topical agent used for onychomycosis. Most topical antifungals do not work despite the claims by the companies that sell them. This product is cost effective and is sometimes very helpful. At the very least, it will soften the nails and prevent the spread of the mycosis. The product is sold in a diluted form over the counter. However, it comes in a physician strength that is 30 percent more concentrated. Patients only need to use the spray two to three times a week in a common shoe. It helps resolve the mycosis and aids in preventing recurrence.

   We do not carry OTC orthotics in our office by choice. We have found that insoles are difficult to stock and too costly for the practice. We prefer to carry products that are effective and difficult for patients to find. Some unique products we stock in our office include the XeroSox shower cover (XeroSox), and sprays/roll-ons for hyperhidrosis or foot odor.

   Over the counter products are essential in any podiatric practice. They will improve patient satisfaction and add additional revenue to your practice. Although the profit margin is minimal, you will provide a needed service to your patients and help them find the best product of its kind. Stock a product only if you believe in it and only if it is popular in your practice and cost-effective.

What Is The Future Of Managed Care?

   California is often the place where many innovative healthcare programs originate. I wrote a letter to our American Podiatric Medical Association president 15 years ago, explaining the concerns I had with managed care and how it was affecting the foot and ankle specialist in California. He wrote back and noted that he did not think this would affect the rest of the country, and that it is an isolated problem in California. After 15 years, we have seen the spread and evolution of HMOs, and the challenges this has created for the doctors who provide this type of care.

   I believe we will see a higher level of oversight in our patient outcomes, practice patterns and patient satisfaction. This can be helpful to the practitioner if he or she is open-minded, and uses the information to help improve patient care. It is impossible to achieve a “perfect” outcome for each patient and it is impossible to keep every patient happy. However, we can continue to strive toward this goal. The increased use of electronic medical records, HMO data reports and the ability to accumulate statistics on a national and regional level on patient care for specific pathologies will change the way we practice in the future.

   We have seen many HMO plans begin to increase their co-pays for office visits to a specialist. This is one way to keep the annual premiums for the consumer at a reasonable price. Unfortunately, it discourages patients from asking to see a specialist, especially in this difficult economy. In addition, patients are discouraged from making a follow-up appointment due to the cost of the co-pay, particularly if they are doing well.

   Our practice encourages patients to utilize our Web site to contact us by e-mail if they are doing well, which helps save them an unnecessary follow-up visit and co-pay. This has actually increased our patient volume by developing greater patient satisfaction.

   Many of these patients will often refer their friends or family members because they realize that we are sympathetic to the economic challenges they face, but sincerely want to help alleviate their foot and ankle pain.

Dr. Feit is a Fellow of the American College of Foot and Ankle Surgeons, and practices privately in San Pedro and Torrance, Calif. He is the Past President of the Los Angeles chapter of the American Diabetes Association.
For further reading, see “Inside Secrets For Maximizing Efficiency” in the March 2005 issue of Podiatry Today or “Current Concepts And Controversies With In-Office Dispensing” in the November 2008 issue.