The Next Generation of Medical Management

Abstract

The traditional delivery model of managed care, based on the theory of cost cutting, is being replaced by a broader focus on the overall health of covered members. This new era of "managed health" features novel ways of operating and competing as a health plan. The shift to a new medical management paradigm results not only in better outcomes but also in increased provider and member satisfaction. Key to this model is the integration of partnerships and technology. In order to move to the next generation of medical management, Foundation Health, a Florida Health Plan, had to reallocate resources and think beyond the traditional assignment of responsibilities. This concept of medical management obligates the organization to shift its thinking from managing by hospital or doctor to managing by diagnosis, which can more effectively influence care outcomes and expenditures. Traditionally, health plans controlled costs by implementing barriers to treatment, such as preauthorizations and second opinions. However, it has become apparent that this strategy does not reduce, but rather delays, overall healthcare expenditures. Likewise, it has generated significant patient dissatisfaction. A better alternative is to manage expensive diagnoses through a series of proactive, data-based case management interventions delivered through a coordinated healthcare system.