Asking for opinions on a term that probably never actually meant anything in the first place has obvious difficulties. Nevertheless, there continue to be no shortage of commentators willing to debate what UK `managed care’ is or – perhaps more appropriately – was. During the first half of the 1980s, managed care became a buzzword in the health insurance market. Spokesmen from large group PMI insurers at times seemed incapable of putting a sentence together without referring to it. And the distinction of having been the first company to introduce the concept into the UK was fiercely contested.
Third party administrators claimed responsibility for planting the very first seeds – Hogg Robinson Healthcare when managing the healthcare needs of two Blue Chip clients in 1985 and Medisure when launching a similar service the same year. PPP healthcare felt that no proper managed care programme in the UK was launched until 1989 when it began on-site case management work with Pilkington. Cigna Healthcare, on the other hand, pointed out that it became the first company to actually take managed care to the marketplace two years later.
Such arguments were certainly not helped by the lack of anything approaching a universally held definition.
Originally, the term started being used in the US to refer primarily to cost and quality controls involving the insurer and the care provider. In the UK, however, its meaning has never been directly comparable because it has often been used to refer exclusively to services aimed at benefiting the client at the claims stage.
Modern UK definitions still vary widely and managed care has been used to refer to virtually every method used by PMI insurers to control costs without jeopardising the quality of healthcare provided. It has even been used to dress up the provision of features which are as standard as pre-authorisation help-lines.
But by the late 1990s most insurers had realised that they were in danger of killing the goose that laid the golden egg and that the term managed care was resulting in more confusion than new business. All except Cigna Healthcare, therefore, claim to have either stopped using it or “virtually stopped using it” for marketing purposes during the last three years.
QBE International Insurance, another smallish player which has gained a good reputation for cost-effective quality care since entering the UK PMI marketplace in April 1999, is widely understood to offer ,a similar managed care service to that offered by Cigna Healthcare, but it never actually uses the term.
This trend to abstain has only increased the confusion. Different but sometimes similar-sounding terms, such as `care management’, are used as direct substitutes by insurers to describe the implementation of controls which are clearly straight out of the Cigna Healthcare mould.
Bupa’s announcement last August of controversial new rules to prevent unnecessary hysterectomies represents an obvious example. The company, alarmed by surveys suggesting that up to a quarter of the hysterectomies carried out in Britain each year could be unnecessary, now requires very detailed clinical information from consultant gynaecologists about why an operation is necessary. And it ensures that patients are properly informed about the available alternatives.
Little clarification of the situation is available from intermediaries, many of whom still commonly refer to many services under the managed care label for the purposes of simplicity – even though the insurers concerned do not.
Employee benefit consultants William M Mercer’s senior consultant Mark Burley says: “Different insurers approach managed care in different ways and some have probably been guilty of dressing things up although this may be getting better as a result of managed care principles being brought into every day practices. It’s a term which has been used by many companies as a spoiling tactic to purport to offer something similar to the likes of Cigna or QBE.
“Among larger players, like Bupa and PPP healthcare, nurses are involved more in checking that claims are valid and that protocols are being followed as opposed to providing personal support. With Cigna, on the other hand, when you claim, you speak to a nurse.”
Debate about managed care tends to be at its fiercest when it concerns its potency as a cost cutting tool. Once again, the lack of a clear definition often means that arguments are taking place at cross-purposes.
Cigna Healthcare is in no doubt that it can provide an effective method of slashing costs. It reports that the annual medical inflation on its managed care business runs at six per cent less than on its book of non-managed care business. Nevertheless, such claims are met with no shortage of scepticism from insurers and intermediaries alike.
Benefit consultants Watson Wyatt Partners’ head of risk consulting John Gillman says: “I am cynical about any promise that says managed care automatically means cost saving. However, I do believe that where it is delivered well it benefits patients in improved quality and may possibly also deliver longer term cost savings.”
WPA director of communications David Ashdown demonstrates a far higher degree of cynicism but probably hits the nail right on the head.
He says: “There has never been any concrete evidence to suggest that so-called managed care can be any more successful in keeping costs down than any other methods of cost-cutting. This is hardly surprising because managed care basically equates to all other methods combined.”