Improving Medical Resident Perceptions of Health Plan Decision Making

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The American Journal of Managed Care, September 2005, Volume 11, Issue 9

Objective: To determine the effect on medical residents' perceptionsresulting from attending a medical policy meeting.

Study Design: Pre- and postsurveys administered to residentsattending BlueCross BlueShield of Tennessee's (BCBST) MedicalPolicy Subcommittee meeting. This group is a subcommittee of theMedical Policy Review Committee (MPRC), which is responsiblefor the final approval of medical policies at BCBST.

Methods: Residents were invited to attend BCBST's MedicalPolicy Subcommittee meeting to determine what impact observingthis process would have on their attitudes toward health insurers'use of scientific evidence. This subcommittee, which consists ofboth BCBST medical directors and network physicians, plays a keyrole in determining whether new medical technologies or new usesof established technologies are medically necessary, cosmetic, notmedically necessary, or investigational. Residents were given apre- and postsurvey to assess their attitudes regarding the methodsinsurance companies use to make coverage decisions.

Results: Medical residents rated BCBST's use of scientific evidencehigher after attending the subcommittee meeting. Only 4 ofthe 10 residents surveyed prior to the subcommittee meetingagreed with the statement, "Insurance companies base their coveragedecisions for medical treatment on scientific evidence." In thepostsurvey, all 10 residents indicated that they agreed with thestatement. Other questions showed similar positive changes in residents'opinions of the health plans' decision making.

Conclusions: Many medical residents likely have negative perceptionsof health insurers and may be prone to believe that medicalpolicy decisions are based predominantly on financial impact.Such attitudes can easily persist as they move into private practice.Although drawing firm conclusions from this small study is difficult,exposing residents to actual decision-making processes withininsurance companies may be one means of improving theiropinions of how such decisions are made.

(Am J Manag Care. 2005;11:573-575)

The public often has a negative opinion of insurancecompanies, particularly of managed careorganizations.1 Such negative opinions are alsoheld by some practicing physicians. These physiciansbelieve that insurance companies are concerned mainlywith finances and are not interested in scientific evidencewhen important coverage determinations mustbe made.2

People working within the medical policy decisionprocess at health plans know that scientific evidence iscarefully considered when determining what servicesare reimbursable for members. Evidence-based medicine,defined as the "conscientious, explicit, and judicioususe of current best evidence in making decisionsabout the care of individual patients" is a tool used bymany insurance companies.3 The BlueCross BlueShieldAssociation's Technology Evaluation Center, for example,uses the results of scientific studies to assess newand established technologies. Many health insuranceplans use such sources to assess medical technologies.BlueCross BlueShield of Tennessee (BCBST) and otherhealth plans often balance the assessments publishedby these organizations with practitioner experience.

Medical policies at BCBST are developed by a staff oftrained researchers and reviewed through a 2-step committeeapproval process. The first step involves a presentationof a drafted policy and supporting evidence toour Medical Technology Assessment Subcommittee(MTAS), the voting members of which are BCBST staffphysicians and community physicians. These physiciansconsider medical policies from a scientific andclinical standpoint. Two of the community physiciansare also affiliated with the University of TennesseeCollege of Medicine, Erlanger Unit. The second step ofthe process is consideration by the Medical PolicyReview Committee. This committee consists of bothadministrative and medical staff and is charged withfinal approval of medical policy proposals. This committeegenerally accepts the policy proposals approvedby MTAS.

The goal of the small study presented in this articlewas to determine whether allowing residents from theUniversity of Tennessee College of Medicine, ErlangerUnit, to attend MTAS meetings would positively impacttheir views of health insurance decision making.Influencing physicians early in their careers can positivelyimpact their long-term perceptions of insurancecompanies. Clearly, skepticism and negativity are barriers to a productive dialogue among the stakeholders inthe healthcare system. Time wasted dealing with falseimpressions could be better spent focusing on providingthe best care for members.

Crossing the Quality

Chasm.

Encouraging services based on the best available scientificknowledge and discouraging services that areunlikely to benefit patients was 1 aim of the Institute ofMedicine's influential book, 4 The report encouraged all of the constituentsinvolved in healthcare, including providers and payers,to work together to achieve this goal. The first step inachieving this goal is for health insurers and cliniciansto achieve a greater understanding of how each groupapproaches decision making about clinical care. Thisstudy offers one way in which such understanding canbe achieved.

METHODS

Residents were invited to attend an MTAS meetingby 1 of the subcommittee members who was a facultymember at the University of Tennessee College ofMedicine, Erlanger Unit. The faculty member typicallybrought 1 resident with him per month; MTAS meetingsoccur on a bimonthly basis. During the course of 15months, 10 residents attended. Each meeting typicallylasted 60 to 90 minutes. Drafted medical policy addressingnew medical technologies and new uses of establishedtechnologies were reviewed and discussed ateach meeting. Examples of medical policies consideredinclude plasmapheresis/plasma exchange and genetictesting for colorectal cancer.

Residents were given the same brief questionnairebefore and after the meeting. The questionnaire consistedof questions in an agree/disagree/don't know format(Table 1).

RESULTS

All 10 medical residents attending MTAS meetingscompleted the pre-and post-MTAS questionnaires.Table 2 lists the results of the questionnaire with thestrongly agree/agree and strongly disagree/disagreeanswers combined into 2 categories. The pre-MTASquestionnaire shows a marked negativity toward insurancecompany decision making with respect to newtechnologies. Only 4 of the 10 residents surveyedthought that insurance companies considered scientificevidence when making coverage decisions about medicaltreatment. Only 2 of the 10 responded that insurancecompanies valued clinical/practitioner expertisewhen making coverage determinations. Most thoughtthat insurance companies were primarily concernedwith cost containment in making coverage decisionsabout medical technologies, and only 4 thought thatinsurance companies considered patients' needs whenmaking determinations.

The post-MTAS questionnaire results were significantlydifferent. All 10 of the respondents agreed thatcoverage decisions were based on scientific evidence.Nine of the 10 responded that insurance companies valuedclinical expertise in making such decisions. Only 3responded that coverage decisions were based primarilyon cost, and 7 responded that coverage decisionswere based on patients' needs.

DISCUSSION

Managed care organizations and practicing physiciansboth strive to practice evidence-based medicine.Managed care organizations want members to receiveproven treatments that may improve health. Physiciansalso want to use treatments proven to be effective inimproving health. Unfortunately, differencesof opinion often arise between the2 groups as each becomes suspicious ofthe other. For physicians, this suspicioncan manifest itself as skepticism aboutthe intents of health insurers and theopinion that health insurers are concernedprimarily with containing costs.5,6

Missing from this dialogue is theview that health insurers often serve asdefault stewards of health insuranceresources. As with any resource, healthinsurance is not limited, but ratherfinite. Health insurance plans need tobe able to price their product to appealto employers and individuals. Theyneed to minimize healthcare spendingon unproven and potentially harmfultechnologies, which drive up the cost ofcare, because spiraling costs for healthinsurance makes it more difficult for employers andindividuals to purchase healthcare coverage.7,8

Evidence-based medicine is one tool that can beused to stem the tide of increased costs due tounproven or unnecessary care. Because evidencebasedmedicine is also an important part of the practiceof medicine, it is an area of common ground betweenhealth insurance plans and healthcare practitioners.9,10If physicians see health insurance plans basing theirdecisions on scientific evidence, then their views ofhealth plans might be less negative and skeptical. Thiscould foster an atmosphere of collaboration betweenthese 2 groups. One way to cultivate this partnership isto allow physicians to see how health plans make decisionsabout new medical technologies. Encouragingresidents to attend medical policy meetings at healthinsurance plans can promote an important alliancebetween plans and physicians.

Results of this admittedly small study have shownthat attendance of physicians at such meetings might bean important tool in improving their perceptions ofmanaged care. At best, the results of this study are preliminaryand further studies are needed to confirm thefindings. The number of survey respondents was notlarge enough to calculate statistical significance.Additionally, the fact that residents attended with a facultymember may have introduced bias into the resultsas far as influencing the willingness of some residents toattend the meeting and their responses to the survey.The administration of the survey by BCBST staff mayhave been a source of potential conflict of interest.Finally, there is a question of whether attending 1 meetingallowed the residents enough exposure to formulateinformed opinions. Future studies of this ongoing endeavorwill help address such issues.

We are hopeful that the results from this small studywill encourage similar efforts and studies by other plans.

From BlueCross BlueShield of Tennessee, Chattanooga, Tenn.

Address correspondence to Richard S. Mathis, PhD, Senior Manager, Medical PolicyResearch and Development, BlueCross BlueShield of Tennessee, 801 Pine Street, 2E,Chattanooga, TN 37402-2555. E-mail: richard_mathis@bcbst.com.

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