Can Managed Care Be Successful Without Primary Care?

Managed care was, traditionally, designed to be a solution to control costs by shepherding a patient’s care along their health journey.

The intention was right, but the systems put in place didn't deliver on managing the patient’s medical care, and frequently failed to control costs.

Early iterations of managed care created more waste of both time and money, but managed care can work— it just requires a strong  basis in primary care.

The problem of traditional managed care

Part of the problem has been the limitations on reimbursement for care providers like doctors and nurse practitioners.

Insurance companies wouldn't reimburse primary care providers for treatment they were trained for and experienced in if those treatments were designated for specialists. As a result, primary care became nothing more than a gatekeeper rather than the hub of all patient care.

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Within the traditional managed care model, primary care providers were forced to refer patients to specialists as dictated by the network, regardless of the cost or the quality of care. Because there was little incentive to return to primary care, patients would wait until another issue surfaced that required a primary care provider to refer them to the correct specialists.

There are glaring problems with this approach. Firstly, specialists are trained to treat one specific organ or system, not the whole person like primary care providers are. Also, specialist care is much more costly than primary care, making this system more profitable for some at the expense of patients.

When primary care is at the center . . .

Unless primary care is the center of a managed care model, the model doesn’t work. It costs too much money and wastes too much time. It causes a great deal of frustration for patients who don’t have someone actively looking after their health, and healthcare journey, from a holistic perspective.

However, when primary care is the center of the healthcare model, all decisions and planning take place within the context of a patient's holistic health.

Patients may be referred to a specialist, but only when the treatment required is outside the capabilities of the doctor or care center. Primary care providers (and the entire clinical support team) become guides, working closely with patients along their health journeys.

The result is less waste and fewer gaps. When primary care is doing its job right and building relationships, planning and guiding their health plan, coordinating their care, and following up, there’s suddenly little or no need for:

• Urgent care visits
• Preventable trips to the ER
• Specialists charging more for things primary care providers are trained for

Instead, specialists receive qualified patients from primary care providers who have narrowed down the diagnosis and treatment options. When the primary care provider has already done the preliminary tests, the specialist needs less time to assess the patient’s health issues, and the patient gets the care they need more quickly.

Most importantly, the patient has a better and more convenient care experience, whether they need a specialist or not. 

For employers, centralized primary care means less spending on healthcare that isn’t necessary or appropriate. It improves employee health more quickly with less chance of important symptoms, drug interactions, and other details falling through the cracks.

Advanced primary care, using managed care as a platform

When allowed to do its job, primary care is already more effective, but imagine what happens when it is fortified with claims and patient data from the population it's serving. That's advanced primary care, and we believe it's the future of the healthcare industry.

Advanced primary care requires a care team that’s empowered by information technology to deliver the right kind of attention to improve health outcomes for individual patients and across a specific patient population.

The advanced primary care model is valuable because of its ability to determine, plan, and resource a primary care team (even a whole care center) to meet the needs of the exact patient population.

It’s built on the platform of managed care—the primary care providers and care teams are responsible for the health of every patient, rather than being forced to pass them on to specialists. It means less waste and fewer gaps, and the patient has a better and more convenient care experience. With advanced primary care, providers are operating at the top of their medical licenses and delivering a higher level of care, including services that most people think require the expertise of a specialist.

If you're interested in learning more, download our FREE white paper, Delivering Managed Care The Way It Was Intended.