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NORWALK, Conn.-Oxford Health Plans Inc.'s latest revision of its medical care delivery, featuring direct access to specialists and care teams, may prompt other HMOs to reorganize their services.
The Norwalk, Conn.-based health maintenance organization isn't providing services that are new to the industry, it is just packaging them more effectively for health care consumers, according to consultants and competitors.
Among other things, the "health and healing" initiative Oxford announced last week will:
Allow its 1.7 million members direct access to specialists.
Create physician "care teams" in nine specialty areas to be responsible for a patient's treatment from the time of diagnosis onward.
These teams could include anyone involved in providing a service to the patient, such as surgeons, anesthesiologists, physical therapists and psychiatric counselors.
Under Oxford's approach, groups of specialists would respond to requests for bids on treating certain conditions, and groups whose bids are accepted would be compensated on a so-called case-rate basis. The team members would decide how to allocate the payment among themselves.
The HMO also will track care team outcomes and turn that information over to enrollees to use in selecting providers.
Assign a dedicated service manager to each member to provide individualized customer attention.
Create a 24-hour toll-free hot line staffed by nurses who ask callers about symptoms and, aided by expert computer systems, direct callers to the appropriate setting for care.
Create a site on the World Wide Web to give members online access to benefits information, a claim's status, or to switch doctors or look up the latest treatments in an extensive medical encyclopedia.
"Consumer sentiment is decidedly in favor of greater choice and less restriction," said Oxford Chairman and Chief Executive Officer Stephen F. Wiggins at a news conference last week in New York.
"Oxford is restructuring its systems to give our physicians and members more freedom to choose from a wider range of treatment options that will get them better and keep them healthy," he said.
But Oxford's moves may not be all that innovative, some observers say.
"There's not quite as much real news there as they're getting credit for," said Dr. Christopher Coulter, executive director and chief medical officer of Ultralink, an HMO network manager based in Costa Mesa, Calif., that also conducts HMO evaluations for employers. "There are a number of health plans already doing this in bits and pieces."
For example, Minneapolis-based United HealthCare Inc. has given its members direct access to specialists since 1974.
"It's a signature product for United Healthcare," said George S. Goldstein, CEO of MetraHealth, United HealthCare's Southern California operation based in Long Beach.
Some other plans, including Blue Shield of California, also have begun marketing these so-called "open access" products (BI, Aug. 5, 1996).
And specialty care teams have been in use for at least a decade, according to Marshall Rozzi, president and CEO of United HealthCare of Illinois Inc. in Chicago. "Everybody's doing case rates for major procedures," he said, particularly cardiac care, cancer and hip replacements.
But even though the changes Oxford announced aren't that groundbreaking by themselves, the approach the company took in assembling them and selling them to the public as a package is new for the managed care industry, observers say.
"Oxford has done the best job of publicizing and packaging this for the public," observed Barry Rosenfeld, a benefit consultant with Apex Management Group Inc. in Princeton, N.J.
And it is likely that other HMOs, if they are not already, will follow Oxford's lead.
"HMOs have to do this if they're going to be able to capture the next segment of the population that so far has resisted managed care," said Armando Baez, principal of Ultralink in Costa Mesa.
"It's clearly what the market has been asking for," agreed MetraHealth's Mr. Goldstein.
"Benefits administrators fear programs that make employees come back to them and say: 'What are you doing? You're putting me into programs that might prevent me from getting access to specialists,'*" said Helen Darling, manager of health care strategy and programs for Xerox Corp. in Stamford, Conn.
"I think this has great potential for reassuring patients," especially those with the misperception that "with managed care, individuals will have trouble or even be denied access to specialists," she said.
Oxford's introduction of specialty teams last week was the latest in a string of announcements that began with the company's creation of an alternative medicine network comprised of about 1,500 acupuncturists, chiropractors, massage therapists, yoga instructors, nutritionists and naturopaths (BI, Feb. 3).
More recently, Oxford said it would begin a program in April using nurses as primary care gatekeepers as part of an agreement with Columbia Presbyterian Medical Center in New York (BI, Feb. 17).
All of the changes have been made in response to consumer demand, explained Oxford's Mr. Wiggins.
And with the case-rate system, which attempts to strike a balance between fee-for-service medicine and capitation, Oxford also is trying to be more responsive to providers, according to Todd Farha, CEO of Oxford's new Specialty Management Division in Norwalk.
"The pendulum may have swung so that HMOs were too focused on cost," making them less responsive to providers, he acknowledged.
This care team approach, which some liken to disease management, already is getting rave reviews from corporate consumers, such as Xerox's Ms. Darling.
The disease management approach "is a terrific idea and very exciting to patients and consumers," she said, adding such an approach will likely prove to be very cost-effective.
"The trick is obviously finding the balance and using good internal medicine specialists and gynecologists and obstetricians to detect problems that may need to be handled aggressively by specialists," Ms. Darling said.
But while Mr. Rosenfeld applauds Oxford's efforts, he expressed concerns that other HMOs that mimic this approach will focus on cost and select only the lowest-bidding providers.
"Such an approach could be dangerous if cost considerations are given precedence over quality," Mr. Rosenfeld warned.
"From Oxford's standpoint, they're always striking a balance between quality issues and cost issues," Mr. Rosenfeld said.
"But as this approach begins to permeate throughout the managed care industry, we're going to have to be watchful," he said.