HOW DOES THE comprehensive model of MS care fit with the healthcare reform that is currently happening throughout the United States? Interactions between doctors and their patients are being re-defined in the face of the growing need for cost containment. Managed care is a system for organizing large numbers of healthcare providers within a single corporate structure, with the goal of providing quality services to patients while simultaneously controlling costs.
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| Multi Sclerosis Treatment |
There are major differences between traditional and managed healthcare. In traditional healthcare, the patients choose the doctors they want caring for them, and the insurance company pays for all or part of the visit. In managed care, the health organization contracts with healthcare providers to provide services to patients who are enrolled in their insurance plans. The patient must abide by the rules of the plan or face the possibility of not being reimbursed for services provided. Although these rules vary from one insurance plan to the next, they typically require patients to choose from a list of participating providers and use their primary care physician as the "gatekeeper" for access to specialty care.
As a result, the primary care physician, rather than the patient or family, decides when consultation with an MS specialist is desirable or necessary. Referrals to specialists are usually for a specific number of visits or a limited time period. In other words, specialists do not provide ongoing care for people in many managed care programs. In addition, services once covered by insurance are gradually being shifted outside the traditional healthcare environment. Thus, although counseling, rehabilitation therapies, and education are still important, the new emphasis is on how to provide care at a lower cost. Financial responsibility for many services is being shifted from the insurers to the healthcare providers, their patients, and the patients' families.
Patients and families with reduced access to MS specialists need an even greater understanding of the issues related to MS and its management, and must work closely with primary care physicians to make certain that their needs are addressed. Primary care physicians who traditionally have not provided neurologic care need to expand their expertise in areas such as MS.
A likely outcome will be that the ongoing or "maintenance" care of a person with MS will be provided in the primary doctor's office, with referrals being made to specialists for a difficult diagnosis, immunologic therapy, and the management of difficult problems or complications. The patient and family may need to depend more on information from publications, lectures, the Internet, voluntary health organizations (e.g., National MS Society, the Multiple Sclerosis Association of America, United Spinal Association), and other resources, to make certain that they are aware of the latest developments in MS. Prepared with this information, it is appropriate (even important) for a patient or family member to ask the primary care physician for a referral to a specialist when they perceive that he or she is unfamiliar with available treatment strategies or is unwilling to pursue additional treatment options.
Is managed care good or bad? Medical treatment managed in this way may initially reduce overall healthcare costs. It is yet to be determined whether it will reduce costs in the long run, or how it will affect the quality of MS-related care. Although managed care seems to provide adequate and cost-effective preventive medicine and treatment for acute illnesses, managed care has yet to demonstrate its effectiveness in chronic diseases, including MS. Specialists in MS care have concerns about the quality of care given to MS patients by healthcare providers who lack experience and expertise in the management of disease symptoms and who may not understand the potential complications of the disease or the side effects of various medications.
The new immunosuppressive treatments in MS have provided an interesting point of contrast between managed care and MS care provided in comprehensive specialty centers. Once patients with MS have been started on disease-modifying medications such as Betaseron, Avonex, Copaxone, or Rebif, their ongoing care is typically provided by physicians who are not MS specialists. These physicians are often less familiar with the subtleties of treatment, patients' emotional reactions to medications or the injection process, and the management of side effects. Not too surprisingly, one study demonstrated that the dropout rate for one of the medications was much lower for patients who are followed by MS specialist physicians and nurses than for those patients who were being followed by other healthcare providers.
This clearly has significant implications for the health and well being of people with MS. The effectiveness of the new immuno-suppressive therapies will ultimate|y be determined by the ability of patients to use and tolerate them over a long period of time. Simply prescribing a treatment is not enough; teaching patients how to use it and supporting their efforts to continue doing so are essential.
In the long run, the effectiveness of managed care for people with MS will depend on the degree to which patients and families believe that they have access to the kind of treatment and support they need in order to manage their symptoms and live comfortably with MS. A close working relationship between primary care doctors and MS specialists has proved quite successful in the past. The question will be whether this kind of collaboration can continue to flourish under managed care.
An alternative to the comprehensive model in MS care, known as "principal care," is currently gaining momentum. In this model, the MS specialist provides ongoing care, while referring the patient to the primary care physician for non-MS medical care. Some managed care insurance plans are becoming more amenable to specialists providing the comprehensive care.
Whichever approach takes hold in the days ahead, it will be important for individuals who have MS or other chronic illnesses to make their needs and feelings known to their insurance companies. Since people live to an older age and survive for longer and longer periods with diseases like cancer and AIDS, chronic illness is becoming much more prevalent. In order for insurance companies to be able to survive, they must meet their clients' needs and become responsive to this growing segment of the population. Although the pendulum of healthcare management and insurance reimbursement is unlikely to swing back very rapidly, it will eventually respond to the demands of educated and assertive consumers. Consumers will be the ones who educate insurance companies about the unique and ongoing needs associated with chronic illness. To find out more, you can check out Multi Sclerosis Treatment.