Center for Studying Health System Change

rovider respondents report that attempts to influence clinical practice and the delivery of care -- practice guidelines, case management, physician profiling, disease management programs, prevention and screening programs -- are common among health plans and, to a lesser extent, among PHOs that accept global capitation from plans. However, two market factors have limited the prevalence and effectiveness of these practices.

First, physician alignment with plans is loose, with the exception of physicians in Cigna’s staff-model HMO option and the Thomas Davis Medical Centers’ historically close connection with Intergroup. It is relatively common for physicians to have a dozen or more plan and PHO affiliations, which minimizes any one plan’s ability to influence an individual physician’s practice.

Second, there is no coordinated purchaser pressure on health plans to make specific changes in care delivery. Lacking such pressure, health plans and PHOs have pursued various initiatives to influence physician practice, but little evidence is available concerning their effectiveness.

A few health plan respondents spoke of their plans’ increased emphasis on prevention and health promotion activities. For example, HealthPartners is entering into a joint community health education effort with the Maricopa County Health Department. More broadly, the local association of HMOs participated in a statewide initiative with the county medical society, the state hospital association and the state Department of Health to improve the delivery and reporting of childhood immunizations.

Some health plans, medical groups and mature PHOs report using practice guidelines to help physicians address specific conditions. Case management and disease management programs also are relatively common among health plans. Disease management programs typically focus on asthma, heart disease and diabetes. Cigna reports that 28 formal disease management programs are available for its enrollees and describes 18 as very successful. Some health plans use case management programs developed by contracting hospitals. FHP, for example, has tapped John C. Lincoln Hospital for help in managing care for enrollees with chronic lung disease. In addition, FHP is shifting staff from traditional utilization review activities to case management functions.

The potential of these initiatives to influence care delivery is a matter of debate among Phoenix providers. There are few data concerning their effectiveness. Some providers said they believe that health plans have increased accountability for care delivery and that has improved the quality of care. Others were skeptical, however, saying that these practices are more likely to hinder physicians’ efforts to provide good care. These opinions reflect conflicting views concerning the primary motive behind these efforts: cost control or quality improvement.