Managing Care Through Guidelines

By Peter Nesbitt

In 1991, The Managed Care Alliance (TMCA) began providing medical care to thousands of patients in South Eastern Pennsylvania and over the next ten years it grew to a nationwide program.

TMCA was an experiment. Could a non-adversarial, cooperative partnership between care providers, patients, and payers assure appropriate care for patients, satisfaction for providers, and reduce losses for insurers or employers? The answer was a resounding yes. It managed to reduce medical costs by 40 to 50 percent as measured by the payers.

TMCA rejected the insurance model of healthcare based on an adversarial relationship between care providers and payers. Instead, it sought to meet the needs of both providers and payers. In our view, all healthcare involved three partners whose willing cooperation could achieve the goal of assuring appropriate care for patients and reducing costs.

The TMCA model included building an inclusive medical network of providers who agreed to follow a simple set of guidelines.

1. Treat only based on clinical findings;
2. Be sparing in the use of tests, studies, and specialist referrals unless warranted by clinical findings;
3. Treat at the primary care level unless the clinical findings suggest the need for specialist evaluation;
4. Whenever possible, return the patient to the primary care physician after specialist evaluation.

In return, TMCA paid care providers fairly and promptly. Often, we paid providers more than the insurers would have paid for the same services. We knew that if patients received only appropriate care, this would more than offset the increased fees we paid providers. Needless to say, we had little difficulty signing up tens of thousands of providers – especially since we did not require pre-approval or certification prior to treatment. In our view, the physician was the arbiter of care and so long as they followed our guidelines, they didn’t need our input.

We managed the program with software and a team of registered nurses who maintained contact with providers and patients. I want to stress that the care was managed by medical professionals who were not employed by insurers or payers. No government intervention was needed. TMCA functioned as an intermediary, a partner to the other three participants in care. Because the program goal was to assure appropriate care, the focus was on care, not cost.

The results were astounding. Medical losses for the payers were reduced by an average of more than 40 percent. Patient complaints were reduced and no medical malpractice claims were filed. We could count the number of providers who voluntarily left the system on one hand. Employers who sent their employees to TMCA providers were more than satisfied with employee satisfaction and lower medical costs.

Please note that this was not a single payer system. After TMCA reviewed provider reports and invoices, it submitted them to the payers. The payers were insurers and private self-insured employers. They paid TMCA directly, not the providers. The payers were not allowed to dispute the medical services or bills.

The logic of this healthcare system is overpowering. Primary care physicians control medical care. Their decisions immediately affect healthcare costs. If they willingly treat by the TMCA guidelines, they can assure appropriate care and reduce medical losses dramatically.

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Peter Nesbitt was an Executive for The Managed Care Alliance. He is an Army veteran and entrepreneur, and currently the President and CEO of Quasar Bio-Tech, which designs, manufactures and sells medical grade skin care tools for home-use.