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AAHP OFFERS GUIDANCE ON DOCTORS' ROLES IN NETWORKS

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WASHINGTON-The nation's leading association of managed care plans hopes that new guidelines calling for more physician involvement in health plan decisions will stem recent criticism of managed care decision-making.

The Washington-based American Assn. of Health Plans, in several quality-improvement directives to its membership of more than 1,000 health maintenance organizations and other managed care companies, said that the new policies are a model for physician involvement based on what many networks already are doing.

"This is a real clear, straightforward responsibility to codify what is going on in the health care world," said Karen Ignagni, AAHP president and chief executive officer. "We're raising the bar here, and we're very excited about that."

The directives, which she said will be ratified by the association's board at its national conference in Seattle next month, are:

Managed care plans should allow physicians to direct quality assessment and improvement programs and to be involved in their design and implementation.

Physician committees consisting of plan doctors and other medical experts should write practice guidelines and change them as needed based on new scientific evidence.

Utilization management should involve plan physicians and be directed by a doctor, and decisions should be based on medical evidence. An appeals process, in cases when a doctor disagrees with the decision of the health plan, should be directed by an experienced physician.

Drug formularies should be reviewed and developed by plan doctors; appeals should be overseen by a physician.

The new policies guarantee that patients will have access to doctor-controlled "safety valves," or appeals mechanisms, at various stages in the health care delivery process, Ms. Ignagni said.

During the past year, as managed care has come under increasing scrutiny of the media, public interest groups and state and federal lawmakers, AAHP has issued a series of policy statements intended to set minimal acceptable standards of professionalism for its members. These latest rules were prompted by many Americans' belief that managed health care decisions are made "by folks with green eye shades" and not with objectivity and professional knowledge, Ms. Ignagni said.

Benefit managers have expressed a wish to see these kinds of standards published, she said.

One benefit executive, Helen Darling, manager of international compensation and benefits at Stamford, Conn.-based Xerox Corp., said it is important for the managed care industry to create a floor of expectations below which no network would drop.

A greater role for network physicians in decision-making is appropriate, she said, because only doctors and medical researchers are qualified to bring HMOs up to speed in the adoption of new and emerging medical technology.

Industry self-policing is much preferable to enforcement of similar priorities by government, said Ms. Darling. More than 85% of Xerox's employees are in managed care plans.

The association's newest policies may help alleviate some of the well-known friction that has existed between plan doctors and managed care networks in the past by giving doctors a louder voice in important care decisions, said Robert Doherty, vp of government affairs and public policy of the Washington-based Society of Internal Medicine.

Plan sponsors, he said, can use the AAHP guidelines to judge whether doctors have an adequate role within their network.

"This provides a template that employee benefit managers, physicians, patients and others can use to view a plan," Mr. Doherty said. "Those that are meeting the standards should be rewarded in the system, and those who aren't should be taken a look at."

The Society of Internal Medicine will educate its physician members about the AAHP's new policies and tell them to report HMOs that continue to discount physician input, he said. "If they're not living up to the letter and spirit, we want them to let us know."

AAHP was able to persuade the internal medicine group to support its initiative because the new policies mandate participation of plan physicians in key decisions, not simply the input of doctors employed by the plan itself, he said.

"Certainly, it's important to have physicians on staff," he said. "But that's not adequate from our point of view."