Primary Care Sports Medicine in the Managed Care Environment: Coping in Today's Culture
Michael Henehan, DO; Robert Jones, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 6 - JUNE 97
In Brief: Managed care is giving rise to changes in the practice of medicine. These changes can be problematic for physicians who care for athletes on sports teams if team physicians and athletes are not in the same insurance plan. Also, insurance carriers are sometimes unaware of the special needs of athletes. Physicians can function more efficiently in the managed care environment with coping strategies such as joining multiple insurance plans, cultivating referral options, negotiating directly with insurance companies, designating a staff referral specialist, developing sports medicine programs, and allying with other sports medicine physicians.
Managed care, as defined by Iglehart (1), is "a system that, in varying degrees, integrates the financing and delivery of medical care through contracts with selected physicians and hospitals that provide comprehensive healthcare services to enrolled members for a predetermined monthly premium." This shift from the traditional indemnity insurance model—in which insured patients are reimbursed after carriers review and process filed claims—has profoundly and probably permanently changed the way physicians practice medicine.
With the emergence of managed care, increasing numbers of physicians face the impact of changes in continuity of care, patterns of referral, reimbursements for medical services, and access to specialized testing (1-5). These changes pose unique challenges to the sports medicine physician.
Players and Roles
The primary care physician (PCP) may interact with athletes as a team physician, a primary care provider, or both. The PCP, chosen by the patient in some insurance plans and assigned to the patient by the insurance company in other plans, provides basic medical care and coordinates specialty care within the plan's guidelines. With a PCP-based managed care system, all aspects of the athlete's care must be coordinated through the PCP. The PCP may or may not have training in sports medicine.
Specialists or PCPs may function as team physicians. A team physician is formally affiliated with a sports team and is designated to coordinate the team's medical care. In this article, the term "team physician" will refer to a primary care sports medicine physician rather than a specialist. The team physician may or may not be the PCP for individual athletes on a team.
PCPs or sports medicine physicians who provide or coordinate medical care for all the athletes on a team have an especially difficult task in a managed care environment, since team physicians and athletes may not be in the same insurance plan or the insurance carrier may not be sensitive to the special needs of the athlete. Medical care can become fragmented or delayed, and desired services may even be denied by the patient's insurance company.
Negotiating the labyrinth of managed care is increasingly part of the primary care sports medicine physician's job description, especially if he or she is a team physician. Physicians need to understand the various types of managed care plans and how these plans affect the practice of sports medicine. With an understanding of the fundamentals of managed care, a sports medicine physician can develop an effective strategy for coping with changes in healthcare coverage.
The Managed Care Environment
Each managed care plan has its own reimbursement schedule, provider panel, and referral mechanism (2). Some plans are capitated, paying an annual fee to a physician or group of physicians for each participant in the plan; some are discounted fee-for-service, offering services to patients for predetermined negotiated rates; and a few remain with the traditional indemnity insurance model. Many of the plans have restricted physician provider panels and specific contracts for ancillary services such as physical therapy, radiology, and pharmacy (3,4). Preauthorization for services and utilization reviews—which determine how a physician's usage of treatments and referrals compares with that of peers—by the managed care organization or a third-party administrator are almost universal.
Thus, in its present form, managed care creates healthcare "islands." A given healthcare plan provides care to a pool of patients who are collectively referred to as "covered lives." The plan specifies physician panels, labs, hospitals, and ancillary service providers. Within this integrated system, sports medicine care can often be provided efficiently (6). But when the patient and the physician or other provider are not in the same system, problems arise.
For example, it may be difficult to get insurance company authorization for desired diagnostic tests, physical therapy services, or referrals. The team physician might not be reimbursed for services. This can be a dilemma, especially when the physician is expected to provide care to all of the athletes on a team.
The net effect for patients is limited availability of medical care providers, limitations on referrals to specialists, restrictions on ancillary services such as physical therapy, and restrictions on specialized testing such as magnetic resonance imaging (MRI) scans.
The extent of a team physician's involvement with managed care can vary greatly depending on the percentage of patients enrolled in managed care plans within a given healthcare market, the number of managed care plans in the physician's community, and the level of managed care in the physician's practice. Even the physician who has no intention of becoming involved with a managed care program often must do so if he or she is to function as a team physician. The more managed care patients and the greater the number of managed care plans in a given community, the more likely it is that the sports physician will need to care for athletes who are covered by a managed care plan.
PCPs can be involved in a spectrum of managed care scenarios. These range from working with a large mix of insurance and managed care programs to working completely within a single managed care system such as a large health maintenance organization (HMO) or a university student health system.
Likewise, the type of insurance coverage athletes have varies widely. Adult recreational athletes and people who exercise for health or fitness generally have the same levels and types of coverage as the general population. High school athletes generally participate in their parents' insurance programs. Secondary supplemental insurance carried by a school and covering all of a school's athletes is rare. Some high school athletes have no insurance. College athletes generally have some form of health insurance coverage: At some colleges all of the intercollegiate athletes are covered by the same insurance plan, and in other collegiate programs the athletes are still covered by their parents' plans as the primary insurance. Most colleges provide secondary insurance to cover injuries that may not be completely covered by the athlete's primary insurance. For professional athletes, injuries are generally treated under workers' compensation programs, which place fewer restrictions on referrals and ancillary treatment services.
This variety of patient coverage makes it less likely that physicians and athletes will participate in the same insurance plan, and more likely that physicians will face problems in providing care specific to athletes or sports teams.
Managed Care and Athletes' Needs
Compounding the difficulties is the reality that the medical needs of athletes, especially elite athletes, can be quite different from those of most patients. In fact, what an insurance plan considers quality care may fall short of athletes' needs. Team physicians, coaches, parents, athletic trainers, and competitive or recreational athletes themselves frequently want immediate attention for injuries, and optimal care may require rapid diagnosis and aggressive treatment to minimize the impact of an injury on an athlete's career. In the practice of sports medicine, every effort is made to facilitate participation while an injury is being treated, or to help a patient resume sports activity as soon as it is safe to do so after an injury. This approach may warrant aggressive use of diagnostic tests, physical therapy, and protective or therapeutic bracing.
In the managed care environment, however, where preauthorization is often required and utilization of medical services is closely examined, there can be a conflict between the athlete's needs and what the insurance company will allow. There may be limitations on how quickly, what quantity, and what type of services can be provided. And insurance companies typically do not recognize athletes as having needs different from those of any other patient in the plan.
Exploring the Problems
In managed care, the major difficulties that pertain to sports medicine include fragmentation of care, limitations on referrals, cost constraints, uncertainties about legal liability, quality-of-care concerns, and the dilemma of whether to choose specialist or primary care designation.
Fragmented care. Continuity of medical care is desirable (7). Ideally, all aspects of an athlete's medical care are coordinated by a single medical team. Treatment can become fragmented if an athlete and a team physician are not participants in the same insurance plan. The team physician, for example, might not be permitted to order diagnostic tests or physical therapy or initiate referrals, and may need to refer the athlete to physicians less familiar with the athlete's needs, particularly with return-to-play issues. Also, communication between physicians in different plans may be difficult.
Referral limitations. The athlete's insurance plan may have a limited panel of specialists (4,8), and the available specialists may be less skilled with a particular surgical procedure or diagnostic test than other physicians in the community. However, referral to the less skilled physician may be the PCP's or team physician's only option.
Insurance company preauthorization is often required for a referral. Delays in obtaining needed medical care while the referral request is being processed can be a frustrating experience for coaches and athletes as well as for the physician. In some managed care plans, all aspects of the patient's care must be coordinated by the patient's designated PCP. If the team physician is not the designated PCP, then that team physician must go through the extra steps of coordinating the patient's care through the PCP.
Cost constraints. Some insurance plans limit coverage for some types of diagnostic tests, procedures, and ancillary services such as physical therapy (2,4). Patients and physicians must work within these economic constraints or the patient must pay out-of-pocket for the desired services or equipment.
Durable medical equipment such as braces poses special problems. If braces are for protection, some managed care plans view them as medically unnecessary and will deny reimbursement. In other instances, the review and authorization process may take several weeks, delaying the athlete's return to activity.
If the team physician and the athlete are not on the same insurance plan, the physician may not be reimbursed or may be reimbursed at a discounted rate. The athlete may have to pay out of pocket to be seen by a nonparticipating physician. Many team physicians ultimately provide free care to an athlete in this situation.
Liability. Physicians are held to the same standard of care regardless of patient coverage (9), and referrals to less skilled physicians and fragmentation of care pose liability issues for the PCP (9,10). The team physician can be caught between insurance company restrictions and the needs of the athlete. The team physician is expected to provide care to the athletes on the team, but if the physician is not a participant in the athlete's insurance plan or a patient's designated PCP, he or she may not be able to coordinate or provide the necessary care.
Questions arise, such as: What is the legal responsibility of the team physician to provide care for athletes who are not in the same insurance plan? Is the physician obligated to provide free care and, if so, at what level? What is the liability of the team physician or PCP if he or she refers an athlete to a less skilled physician who is in the plan? The answers to such questions remain unclear.
The burden for liability does not fall completely on physicians—schools also share responsibility. The degree of liability depends on the particular situation.
Quality of care. The potential conflicts between athletes' needs and managed care were noted earlier. Despite how physicians may feel, there is no evidence that patient care under managed care programs is inferior to that of indemnity insurance plans (11,12). However, to our knowledge no studies have examined the quality of sports medicine care within the managed care environment. Given the specialized needs of athletes, a watch-and-wait approach to injury treatment may not be acceptable. Delays while obtaining authorizations or referral to a less skilled physician can have an adverse effect on a sports career.
Specialist vs primary care designation. Some insurance companies provide separate categories for sports medicine physicians and some may allow a physician to be classified as both a PCP and a specialist in sports medicine. However, other insurers do not allow this dual classification and require the physician to choose one or the other.
The choice a physician makes often determines patient access to the physician. Both classifications have advantages and disadvantages. Patients can self-refer to your office if you are designated as their PCP. However, a designated PCP would be excluded from seeing other PCPs' patients. If you are classified as a sports medicine specialist, you can treat a broad base of patients on a referral basis, but patients need to be referred to your office by their PCPs.
Some healthcare plans allow a physician to be designated both as a PCP and as a sports medicine specialist. It is usually very desirable to maintain your identity as a PCP and at the same time point out your expertise in sports medicine to colleagues, insurance companies, and patients. Athletic patients or patients who have musculoskeletal problems will frequently choose a PCP because of a physician's interest in sports medicine.
When a plan requires a physician to take either a PCP or a sports medicine specialist designation, it is probably best to select the PCP classification, because the specialty designation will limit your ability to practice primary care. An exception may be if a PCP wants to work almost exclusively with patients' musculoskeletal injuries. In this case a referral-type practice may be desirable. This decision needs to be individualized for each physician's practice.
An insurance company may also fail to recognize the special expertise of the PCP who is classified as a sports medicine physician. The plan's policy may routinely deny MRI requests from PCPs (including those having the sports medicine designation) unless a specialty consult has been obtained. Insurance companies may balk at authorizing the procedure even though the physician may have fellowship training and a certificate of added qualification in sports medicine. This can be frustrating for the physician.
With a sports medicine designation, there can also be the perception of overutilization of services. For example, more x-rays and MRI scans may be ordered by the sports medicine PCP, causing aberrations in the physician's utilization profiles.
Primary care sports medicine physicians can use a variety of strategies for coping with managed care issues, as described below.
Become familiar with your insurance plans. Take the time to learn what the plans cover and how the referral systems work. Check on details such as whether the plan covers braces, whether PCPs can order MRI scans, and which hospitals and ancillary service providers are covered in the plan. An understanding of pertinent details and a working knowledge of covered services, utilization policies, and appeal procedures can help physicians and their office staffs work through the complexities of a managed care plan's referral systems. The proper knowledge can also prevent delays or denials of desired care and can help prevent financial penalties for using out-of-plan providers.
In addition, the more you know about a plan, the better prepared you are to make decisions about whether you want to continue to be a provider for the plan. You may also be able to suggest changes in a plan if you find things that don't work well.
Communicate effectively. Strong communication skills, a cornerstone of good medical practice, become even more critical when working in a managed care environment (13,14). The physician frequently must discuss referrals to specialists, physical therapy groups, labs, and hospitals. Effective communication is essential not only with the athlete, but with coaches, athletic trainers, parents, and insurance companies as well.
It is also helpful to develop lines of communication with other provider groups and PCPs in your community. Even when the team physician is not the athlete's PCP, he or she may help coordinate the athlete's care by effectively communicating with the PCP or specialists.
Sign up for as many plans as possible. Ensuring the ability to care for the athletes on a team may at times take precedence over rejecting a less-than-optimal contract. Consider carefully which plans to join, particularly when financial risk is involved. Keep in mind, though, that it is much easier to withdraw from a bad insurance plan than it is to get into a plan that has a closed panel.
Cultivate sports medicine referral options. Take the time to find out which physicians on your provider panel or panels (and for team physicians, the panels of the athletes' plans) have an interest or training in sports medicine. Even if you are not participating in the plan, maintaining contact with other physicians interested in sports medicine who are in the plan can be helpful. The effort will pay off when you need an urgent referral or have a complex sports medicine problem.
Designate a referral specialist. Encourage one of your office staff members to become an expert on referrals. Being familiar with the referral processes of various insurance plans allows your office personnel to get authorizations as quickly as possible.
Develop a sports medicine program within a plan. In large, fully integrated health plans such as the California-based HMO Kaiser Permanente, or with self-insured companies, it may be possible to develop a sports medicine program within that healthcare system (see "Sports Medicine and Managed Care: A Positive Partnership," April 1995, page 33). This type of program may include sports medicine clinics, educational programs, and medical coverage at sporting events. It may be possible also to hire athletic trainers or physical therapists and develop a sports physical therapy program. With this strategy, the athlete's needs are met within an insurance plan. The educational and preventive medicine components of such a sports medicine program may be very advantageous for the health plan as a whole.
Align patients' plans with yours. Require athletes you treat to join a plan in which you participate. You may be able as team physician to direct the purchase of the team's health insurance. When possible, make sure you, the athletes, and the consultants you plan to use are on the same insurance plan.
Negotiate directly with insurance companies. Don't be afraid to negotiate. Even in capitated health plans, some services may continue to be reimbursed on a fee-for-service basis, ie, "carved out" of the capitation fee (15). Physicians can negotiate with insurance companies or with medical provider groups to carve out services necessary for a sports medicine practice. Reimbursement for x-rays taken in the PCP's office or costs for braces or special splints may be negotiated as carve-outs, for example. This strategy is most likely to be successful in smaller communities where fewer medical resources are available.
It may also be necessary to discuss utilization review policies with representatives of the insurance company. Make sure the reviewers are aware that your practice is different from that of the non-sports medicine PCP. Referral and utilization patterns may vary from the benchmark primary care practice. The sports medicine physician typically will see more musculoskeletal problems and will use services such as physical therapy and diagnostic imaging more frequently than the average PCP. Educating the utilization review physicians and committees you must work with about your background and special expertise may help you obtain authorization for services more quickly. This may also help you avoid developing a negative physician profile if the insurance companies are tracking your utilization and referral patterns.
Form alliances with other sports medicine physicians. There can be strength in numbers. You may gain access to an insurance plan by affiliating with other physicians who are already participants in the plan. For example, sharing office space or call responsibilities or formally joining with physicians who are participating in a certain plan may allow you to enroll in the same plan.
Another coping strategy is to form a new physician group. A group of physicians may be able to negotiate a contract where individual physicians were not successful.
Provide some free care. Get comfortable with the idea that, if you are unable to arrange for reimbursement for your services, you may need to provide free care to some athletes. Many team physicians attend a training room several times per week where they see all the athletes on a team whether or not the physician is reimbursed for care.
The concept of donating time and skills to patients who are unable to pay is as old as the practice of medicine. Obviously, this has to be kept at an acceptable level. It may be helpful to view this as a cost of doing business as a sports medicine physician.
Maintain your identity as a PCP. The PCP contributes to sports medicine a broad perspective and the ability to treat common problems, both orthopedic and nonorthopedic. The PCP brings training and skills to the sports medicine team that complement the orthopedic surgeon's. By maintaining skills in all aspects of primary care as well as in sports medicine, the primary care sports medicine physician will be able to function effectively in the managed care environment.
In the Long Run
Managed care will continue to be an evolving force in medicine and, at least for the foreseeable future, will continue to affect the practice of sports medicine. Primary care sports medicine physicians will function better in the managed care environment if they take the time to educate themselves about how managed care is affecting their practices and develop effective strategies for coping with present and future practices and trends.
Dr Henehan is a clinical associate professor at Stanford University School of Medicine in Palo Alto, California, director of the primary care sports medicine fellowship program of the Columbia San Jose Medical Center family residency program in San Jose, California, and a team physician for San Jose State University and for the San Jose Clash soccer team. Dr Jones is a clinical assistant professor at the Stanford University School of Medicine in Palo Alto, a faculty member in the primary care sports medicine fellowship program in the Columbia San Jose Medical Center family practice residency program, and a team physician for the US Olympic water polo team. Address correspondence to Michael Henehan, DO, Columbia San Jose Medical Center, Family Practice Residency Program, 25 N 14th St, Suite 1060, San Jose, CA 95112-1982.
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