Striving for Optimum Transitions of Care

John Marcille

It’s a fact that the nature of managed care as it has evolved, with the HMO or some other insurance (or sometimes just administrative) company in the position of paying for everything but often not having the last word on what’s being done in the clinics, has frustration built into it. Why do these folks not pay more attention to expert guidelines? What about those conflicts of interest between being a surgeon and owning part of a specialty hospital devoted to surgery? And on and on.

And yet these plans have had a positive effect on restraining costs and improving care. As we know, the two often go together.

One of the big cost drains, we have recently come to recognize, is a consequence of the fragmented nature of our delivery system: the imperfect transition from one care status to another, and you know I’m talking mostly about hospital admissions and discharges. Insufficient information accompanies the patient; tests are duplicated; the patient’s overall drug picture isn’t monitored; and so on. All too often, the result is a hospital readmission that might have been avoided.

Managing editor Frank Diamond goes into all these in detail in our cover story, but the most interesting part is what insurers are doing to smooth and improve transitions of care — Geisinger Health Plan, UnitedHealthcare, the Regence Group, and elsewhere.

Health plans, which know a lot about case management and have enormous data sets, are in the forefront of improving these transitions.

And let me point out that our Q&A subject this month, Peter J. Pronovost MD, PhD, has a lot to say about what happens within the hospital. His systems for reducing errors and the spread of disease have had a profound positive effect on the care that patients receive. Fewer diseases and errors, less cost.

MANAGED CARE April 2011. ©MediMedia USA

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