The American College of Physicians published recommendations for managed care Nov. 25 in the group’s flagship journal, Annals of Internal Medicine.
Managed care plans, like HMOs and PPOs, are insurance models that focus on mitigating costs and utilization while maintaining quality. They rely on contracted provider networks.
Here are highlights from the 13 recommendations:
1. Utilization management practices “must only encourage high-value, evidence-based and patient-centered care.”
2. Utilization management should align with physician guidance.
3. Utilization management criteria should be disclosed.
4. Health plans should reduce administrative burden with utilization review.
5. Patients and physicians can override or appeal utilization management decisions in a streamlined manner.
6. The institution of qualitative and quantitative network adequacy standards is encouraged. Health plans must maintain accurate provider directories.
7. Quality rating programs should be based on “patient experience, delivery of high-value care, attributable improvements in patient outcomes and administrative performance.”
8. All managed care plans should be accredited by a third party, and licensed by a state insurance department or the like.
9. Managed care entities should provide clear, direct benefits and coverage details.
10. Transparent consumer protections should be a priority.
11. Patients should have access to plans that provide regular primary care physicians. Patient-centered standardized plans and meaningful difference standards should also be adopted.
12. Centralized credentialing databases and a standardized physician credentialing process should be established.
13. Plans should abide by fair contracting and payment policies. Physicians should be compensated accordingly for associated administrative tasks.
