Journal of Cardiothoracic and Vascular Anesthesia
Volume 23, Issue 2 , Pages 137-139, April 2009

A European View:

Managed Care Health Plans: Better or Cheaper Treatment Strategies?

Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Article Outline

 

IN CARDIOTHORACIC AND VASCULAR surgery, the last decade has witnessed the growing application of new minimally invasive technologies that, in experienced hands, are claimed to result in a reduced complication rate, faster recovery times, earlier discharge from the hospital, and earlier return to routine daily activities.1 Apart from the specific features of these new technologies, the necessity for adapted workplaces (eg, large hybrid rooms with different kinds of multi-image modalities2) may put a large burden on hospitals' financial resources. The implementation of these new technologic advances in daily patient care has indeed been shown to constitute a major factor in the increase of health care costs.3 As cost containment has become one of the major challenges in health care all over the world, the implementation and the financing of such new and expensive technologies are subjects of debate.4

Depending on the organization of the national health care system, these issues may be addressed in different ways. Despite the fact that the European Union now has 27 members that aim at a large political and economic collaboration, the organization of health care largely remains a national issue. The consequence is that health technology assessment and financing systems may vary widely among European countries.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 However, the rapidly increasing costs of health care have prompted an increasing number of these countries to adapt cost-containment strategies. In Europe, the most prominent of these is the adaptation of various forms of managed care. The concept of managed care has been defined as a set of activities that health care plans can undertake to mitigate the propensity for the provision of increasingly expensive services fostered by unmonitored and heavily insured fee-for-service medicine.22 This is usually obtained with the implementation of 3 main strategies. The first is centralization of control over utilization decisions. Contrary to the fee-for-service systems in which physicians and other providers have virtually complete autonomy with regard to care choices, with managed care, health plans may take a significant role in decisions on the implementation of such care choices. For instance, health plans may limit the direct access to specialists by forcing patients to sign up with a particular primary care physician, acting as a gatekeeper, who needs to provide a referral when more specialized advice or services are considered necessary. Second, health plans may impose control on resource utilization by using financial arrangements that put providers at risk for the financial implications of their patient care decisions. A commonly applied plan uses capitation contracts in which physician groups or hospitals are paid a fixed amount per patient and/or per time period for the patient care, thereby forcing them to keep the choices for health technology strategies within the limits of the predefined financial limits. Finally, health plans may define networks of physicians and health care providers with whom they will be working and provide incentives to patients to contact only those providers chosen. Most health plans use one or more of these strategies, but they may vary widely in the combination of approaches used and the emphasis they put on each approach.22

However, the introduction and the growth of managed care have raised fundamental questions about its implications for the implementation of specific new health care strategies in the treatment of patients. It is often argued that such managed care plans put cost cutting in front of concerns about quality of treatment, leaving hospitals and physicians little or no financial room for improvement of health care strategies. This may have important implications for anesthesiology practice. In some managed care systems, anesthesia is considered as an integral part of a surgical procedure; thus, it is not billed or reimbursed separately. The direct consequence of such a system is that extra costs (material or staff related) for surgery will ultimately result in less income for anesthesia. The study by Kottenberg-Assenmacher et al23 underscores this issue by showing how the introduction of a new technology in the presence of a fixed hospital reimbursement system affects anesthesia-related costs. The German diagnosis-related group system links hospital reimbursement for anesthesia to specific surgical procedures, irrespective of case duration. The authors retrospectively compared anesthesia staffing time, costs, and reimbursement for endoscopic cardiac surgery (atrioventricular valve surgery, isolated atrial septal defect repair, and myxoma surgery) with a matched control group undergoing conventional surgery. They observed that endoscopic surgery substantially increased anesthesia staffing time and costs, but that this was not compensated for by the reimbursement system. The conclusion of this study was that the application of the new technology (endoscopic cardiac surgery) consumed more anesthesia resources, leading to an underreimbursement for anesthesia not only as compared with conventional surgery but also relative to the actual costs of the procedure. This means that this specific managed care system did not adequately correct for the increased costs related to the introduction of a new technology. Therefore, this may carry the risk that new, potential beneficial strategies will not be introduced because of their financial implications.

Although this study refers to the specific German situation, it underscores the potential negative implications that might occur when managed care systems are not adapted to changing needs. Managed care systems were initially designed to restrain the waste and inefficiency associated with unmonitored fee-for-service medicine. This search for cost-effectiveness is not necessarily inconsistent with a search for improvements in quality by developing new health technologies. The acceptance of new technologies by the medical profession is a major determinant of their rate of diffusion. This rate of technology spread seems related to the number of specialists in a specific area, partly because specialists receive income and/or prestige from the use of such new technologies and will insist that hospitals invest in facilities to support these technologies.24 Although new technologies mostly represent medical advances, it has been argued that they are prone to overuse and thereby excess cost. A distinct variation seems to exist in the diffusion of new health technologies among countries or different regions within one country.25, 26 Therefore, it has been suggested that the cost problem may not so much be a matter of technology but more of inappropriate technology diffusion.3 The criteria for promoting diffusion of technology are based on 2 major concerns. First, scientific evidence should indicate whether the health benefits of the new technology outweigh its potential harms and whether it provides a substantial improvement on existing technologies. Second, the new technology should be cost-effective with respect to the existing techniques, and it should be clear whether the technology has to be available in all centers or only in specialized centers. Indeed, although novel techniques may benefit patient care, excessively high rates of use of these technologies could represent inappropriate care.27

Theoretically, managed care systems should provide the ideal platform to balance both concerns of health technology assessment. However, the general feeling is that managed care systems tend to overemphasize the financial aspect, thereby impeding the development and introduction of new technologies, a feeling that is also apparent from the study of Kottenberg-Assenmacher et al.23 Such feelings mainly relate to the impression that administrators involved in managed care systems are not familiar with clinical reality and therefore are not able to judge real clinical needs. A more intensive interaction between decision makers and the clinical care givers may help to resolve such division. Ultimately, strategic priorities in health care should rely on fundamental principles that aim to provide an equal provision of optimal health care to every patient. This implies that every patient should be entitled to get the best known treatment when needed.

Back to Article Outline

References 

  1. Kiaii B, Bainbridge D, Fernandes P. Surgical, anesthetic, perfusion-related advances in minimal access surgery. Semin Cardiothorac Vasc Anesth. 2007;11:282–287
  2. Mack MJ. Minimally invasive cardiac surgery. Surg Endosc. 2006;20:S488–S492
  3. Bodenheimer T. High and rising health care costs (Part 2: Technologic innovation). Ann Intern Med. 2005;142:982–987
  4. Bodenheimer T. High and rising health care costs (Part 1: Seeking an explanation). Ann Intern Med. 2005;142:847–854
  5. Wild C. Health technology assessment in Austria. Int J Technol Assess Health Care. 2000;16:303–324
  6. Cleemput I, Kesteloot K. Health technology assessment in Belgium. Int J Technol Assess Health Care. 2000;16:325–346
  7. Jorgensen T, Hvenegaard A, Kristensen FB. Health technology assessment in Danmark. Int J Technol Assess Health Care. 2000;16:347–381
  8. Lauslahti K, Roine R, Semberg V, et al. Health technology assessment in Finland. Int J Technol Assess Health Care. 2000;16:382–399
  9. Fleurette F, Banta D. Health technology assessment in France. Int J Technol Assess Health Care. 2000;16:400–411
  10. Perleth M, Busse R. Health technology assessment in Germany (Status, challenges, and development). Int J Technol Assess Health Care. 2000;16:412–428
  11. Liaropoulos L, Kaitelidou D. Health technology assessment in Greece. Int J Technol Assess Health Care. 2000;16:429–448
  12. Ahern F, O'Doherty N. Health technology assessment in Ireland. Int J Technol Assess Health Care. 2000;16:449–458
  13. France G. Health technology assessment in Italy. Int J Technol Assess Health Care. 2000;16:459–474
  14. Wagener R. Health technology assessment in Luxembourg. Int J Technol Assess Health Care. 2000;16:475–484
  15. Bos M. Health technology assessment in The Netherlands. Int J Technol Assess Health Care. 2000;16:485–519
  16. Pinto MM, Ramos F, Pereira J. Health technology assessment in Portugal. Int J Technol Assess Health Care. 2000;16:520–531
  17. Granados A, Sampietro-Colon L, Asua J, et al. Health technology assessment in Spain. Int J Technol Assess Health Care. 2000;16:532–559
  18. Carlsson P, Jonsson E, Werkö L, et al. Health technology assessment in Sweden. Int J Technol Assess Health Care. 2000;16:560–575
  19. Cranovsky R, Schilling J, Faisst K, et al. Health technology assessment in Switzerland. Int J Technol Assess Health Care. 2000;16:576–590
  20. Woolf SH, Henshall C. Health technology assessment in the United Kingdom. Int J Technol Assess Health Care. 2000;16:591–625
  21. Banta D, Oortwijn W. Health technology assessment and health care in the European Union. Int J Technol Assess Health Care. 2000;16:626–635
  22. Baker LC. Managed care spillover effects. Annu Rev Public Health. 2003;24:435–456
  23. Kottenberg-Assenmacher E, Merguet P, Kamler M, et al: Minimally invasive—Minimally reimbursed? Anesthesia for endoscopic cardiac surgery is not reflected adequately in the German-DRG system. J Cardiothorac Vasc Anesth
  24. Gelijns A, Rosenberg N. The dynamics of technological change in medicine. Health Aff (Milwood). 1994;13:28–46
  25. Fisher ES, Wennberg DE, Stukel DA, et al. The implications of regional variations in Medicare spending (Part 1: the content, quality, and accessibility of care). Ann Intern Med. 2003;138:273–287
  26. Fisher ES, Wennberg DE, Stukel DA, et al. The implications of regional variations in Medicare spending (Part 2: health outcomes and satisfaction with care). Ann Intern Med. 2003;138:288–298
  27. Bodenheimer T, Fernandez A. High and rising health care costs (Part 4: Can costs be controlled while preserving quality?). Ann Intern Med. 2005;143:26–31

PII: S1053-0770(08)00376-5

doi:10.1053/j.jvca.2008.12.011

Journal of Cardiothoracic and Vascular Anesthesia
Volume 23, Issue 2 , Pages 137-139, April 2009

Article Tools