J Oral Maxillofac Surg 53:639, 1995

Profiting From Managed Care Although managed care is not a new concept, its

use has increased dramatically in recent years. Enroll- ment in HMOs grew more than 10% in 1993, and now 18% of the US population are covered by such health care delivery systems. Insurance carriers have also gradually introduced their own modifications in order to control the escalating costs of health care. A major consequence of all these changes has been the signifi- cant shift of health plans from a fee-for-service basis to one involving managed care. Whereas participation in such plans may not be an ideal situation for either the practitioner or the patient, and one could provide very plausible arguments to support this position, we need to realize that in one form or another managed care is here to stay. As so aptly stated in the AAOMS Forum last year, " . . . the issue is not one of advocat- ing or opposing a managed care system, but rather it is the realization that oral and maxillofacial surgeons need to be positioned advantageously in whatever ne- gotiations they may pursue." A recent AAOMS survey indicated that almost three quarters of the membership already participate in one or more managed care plans.

The basic philosophy behind managed health care is obviously to provide the best possible service to the patient at the most reasonable cost. Ideally, this should be accomplished by increasing efficiency and effec- tiveness and by eliminating unnecessary treatment or services. Unfortunately, at the present time, more em- phasis is being placed on reducing cost than on main- taining quality, and managed care is merely becoming a euphemistic term for rationed care. Therefore, one needs to consider who really benefits from the cost savings that occur.

It is obviously not the patient. Patients now face deductibles, copayments, as well as additional costs if they wish to take advantage of the point-of-service option that would give them some freedom of provider choice under a managed care plan. This differs from past plans when appropriate medical expenses were generally completely reimbursed. The reduction in length of hospital stay and the emphasis on more home care have also shifted this burden of cost to the patient. Unfortunately, it is unlikely that the money saved by employers as a result of their paying reduced health care insurance premiums will result in wage increases for their employees, or that cost savings by insurance carriers will result in lower premiums or an expanded set of covered services.

If the patients don't benefit from managed care pro- grams, then w h o does? An obvious choice is the in- surer. While benefits to patients continue to decline, costs of insurance continue to escalate. There has been no tendency to liberalize underwriting polices or to ease restrictions on preexisting conditions in order to helP provide broader coverage. Instead, the reverse is occurring. The goal appears to be to decrease the scope of service, reduce the length of hospital stay, and find whatever reasons possible to deny or reduce the pay- ment of benefits.

Another beneficiary of the managed care dollars is the HMO. In 1994, the liquid assets of the HMOs increased more than 15%. However, these profits were not used to benefit patients. Instead, they were used for such activities as acquiffng other firms, making investments, and paying dividends to shareholders.

Clearly, managed care has turned what was a profes- sion into a business and it is the "business compo- nents," the insurers and managed care organizations, and not the patients or the practitioners who appear to be reaping the benefits. On the other hand, managed care is a reality and we must learn to live with it. How we incorporate such plans into our practices is still a matter of individual choice.

There may be some oral and maxillofacial surgeons who wish to continue on a fee-for-service basis, and who can remain successful under these circumstances. They will still be able to attract patients who value the traditional doctor-patient relationship, who want freedom of choice, and who are dissatisfied with man- aged care. However, as indicated by the AAOMS sur- vey, most have chosen to participate in managed care in one way or another. The question i s - to what degree should this be done? Some authorities believe that par- ticipation should be limited so that one does not be- come completely dependent on managed care plans. This provides the option of caring for all patients who desire our services. They also caution that careful con- sideration be given to which organizations we join, and to select only those that reflect the proper concern for quality of care.

The financial benefits of practice will certainly be affected by managed care. However, we still profit from being professionals, and appropriate treatment of patients is still the bottom line. In the end, the most pleasurable and lasting rewards are the respect and gratitude of patients well served.

DANIEL M. LASKIN

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