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Case Histories

Allergists Tackle Managed Care Issues

Challenge

To preserve their patients’ choice to seek specialist care for allergies and asthma, the American College of Allergy, Asthma and Immunology worked with PCI to mobilize a “Managed Care Liaison Council” (MCLC) to talk facts and figures with HMOs and other managed care organizations about the benefits of patients being treated directly by allergists.

At issue was:

  1. the patient’s direct access to an allergist
  2. opportunities for allergists to participate in managed care organizations
  3. preservation of fee-for-service as a payment option
  4. prevention of restrictive formularies

With the majority of Americans enrolled in managed care organizations, the stakes were high. Armed with the best available research that documented the outcomes and cost-effectiveness of care by an allergist, an MCLC team of physicians was trained and dispatched to meet with major managed care groups, HMOs and insurance companies. Packets of information were mailed to many others.

Action

In preparation for the campaign, the College conducted surveys of both specialty associations and managed care organizations to see who was talking with managed care organizations about how they reimbursed or covered care provided by specialists. Through interviews with national medical specialty groups, the College found that most were very concerned about managed care issues and some were devoting attention to member education and legislation, but few, if any, were talking directly to managed care organizations.

In contrast, the College’s survey of medical directors of 22 major managed care organizations found that most were open to receiving information about outcomes and costs of treatment.

A variety of program components and tactics were used to achieve the campaign’s objective of educating managed care organizations about treatment by allergists:

Outcomes Documentation. A review of scientific literature was conducted to document outcomes and cost-effectiveness of care by an allergist. The studies were summarized in a compendium, The Role of the Allergist in the Cost-Effective Treatment of Asthma, which was used as a leave-behind after MCLC meetings with managed care organizations. The compendium also contained the College’s Guidelines for Referral.

Training. MCLC members took part in a two-day training program to analyze managed care issues, understand newly developed data on outcomes of care and cost savings, and role play meetings with managed care representatives. A training manual for the managed care initiative was developed to provide MCLC members with guidelines for meeting with managed care organizations and key message points.

Visuals. A presentation based on the outcomes documentation that showed that allergists achieve better outcomes at less cost was produced for MCLC members to use in meetings. Key message points to accompany the visuals also were provided.

Appointments. Appointments were scheduled with the managed care organizations located in the home markets of the MCLC members. After local meetings were completed, MCLC members began traveling to nearby major markets to meet with additional managed care organizations.

Managed Care Organization Mailing. The outcomes documentation was distributed with a cover letter from the College president to medical directors at approximately 550 HMOs and 765 PPOs. The letter offered the managed care organizations the opportunity to order additional copies of the document through the College.

Results

In the first seven months of the program, PCI arranged for MCLC members to meet with 27 managed care organizations representing 3.7 million covered lives. The MCLC members reported that managed care representatives were very receptive to hearing how referral of asthma patients to allergists can help achieve better outcomes at less cost. The organizations also were interested in the College’s Guidelines for Referral.

Some of the MCLC meetings had an impact that extended beyond the initial appointment with members assisting the managed care organizations in evaluating treatment protocols, facilitating training programs and working on quality assurance committees.

In the year following the MCLC launch, the program was expanded to include a “Key Contact Network” of more than 200 ACAAI members who volunteered to help ensure patient access to specialist care. Network members met with an additional 167 managed care organizations representing 56.4 million covered lives.