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Massage Today
April, 2001, Vol. 01, Issue 04

Networks: The Good, the Bad and the Ugly — an Insider's View

By Editorial Staff

The recent proliferation of complementary and alternative medicine (CAM) networks around the U.S. has stimulated much discussion and debate throughout the massage community. I have read numerous articles relating to this proliferation, most of which have taken a negative slant against what is often perceived as the "evil empire." Much of the commentary is reality-based and much is not. The following is an attempt to bring some clarity about the network industry to massage therapists.

The first HMOs in this country were developed in the mid-to-late 1970s. The managed care industry evolved throughout the 1980s and 1990s as a solution to escalating health care costs. Annual double-digit inflation was becoming the norm, and if health care costs were not contained, they would have exceeded the Gross National Product by the year 2004. The development of physician networks that agreed to accept a particular price for a particular product enabled risk-bearing entities, i.e., insurance companies, to lower inflation and maintain premium levels at a rate that employer groups could afford. There is no doubt that cost containment measures have helped employers to continue to be able to provide health benefits to their employees.

As the managed care delivery system, i.e., HMOs, PPOs, etc., penetrated markets from a regional perspective, physicians who had previously benefited from the escalating costs in the traditional fee-for-service model reluctantly contracted with these managed care entities. Most kicked and screamed the whole way. Specialty physicians saw significant reductions in reimbursement, while general practitioners and family medicine doctors, often referred to as primary care physicians (PCPs) became more valued within the health care continuum. Essentially, there was a shift in the balance of power and incomes and overall consumers benefited in terms of access to affordable health care.

Much has been written and reported about the problems with managed care -- some true, some not true, but often sensationalized for political reasons. Today, employers, Medicaid and Medicare embrace managed care delivery systems and, despite negative reporting, customer satisfaction remains high. Some HMOs are better than others, and today consumers have the opportunity to compare between plans viewing statistics regarding performance measures. As cumbersome as this system is, it is better than runaway inflation or socialized medicine. Managed care seeks to find an economy of scale and deliver quality health care at an appropriate cost. As long as there are large patient populations managed by risk-bearing entities, there will be networks of practitioners.

The landmark studies of consumer usage of CAM, conducted in 1990 and 1997 by David Eisenberg, MD from Harvard University, helped to initiate a groundswell of activity surrounding CAM activity and network design. Much of this movement was fueled by venture capitalists and entrepreneurs who hoped to cash in on this perceived groundswell of consumerism. Unfortunately, most of these venture capitalists and entrepreneurs knew nothing about healing space, attended therapy or relationship-oriented health care delivery. Most tried to overlay the traditional allopathic, procedure-oriented model onto a system oriented toward mind, body and spirit. In many cases, the result has been dismal, creating a disconnect between the holistic practitioner and the managed care system. For example, many network companies started a credentialing process with an application designed for the traditional physician. These application forms did not honor the massage therapist as a professional, and much of the application was not appropriate for the CAM practitioner. Strike One!

Many network companies employed the "build it and they will come" approach. Unfortunately, the massage practitioner had to jump through the many hoops of the credentialing process in hopes of attaining referrals. The managed care industry was going through a shakeout of its own. Pharmaceutical costs were rising at more than 20% annually and HMOs were losing money. Most companies paid only lip service to this thing called CAM. Managed care executives were focused on stopping the bleeding and could not give the appropriate attention to a truly integrated approach, with CAM, not to mention the American Medical Associations' disgruntlement with this wave of CAM consumerism. Politics got in the way, network companies had difficulty contracting with HMOs, and the promised referrals never materialized. Strike Two!

It soon became apparent that the HMOs did not have the money, the talent or the inclination to provide a covered benefit for CAM. With pressure from venture capitalists, the networks were forced to become a second-tier player. The only hope of these CAM networks attaining any revenues was through the advent of value-added or affinity products. These products would not be paid for by the insurer, but would represent a percentage discount to the plan member based upon some nebulous usual and customary charge. Unfortunately, this model did not recognize the difference between medically managed massage and non-medically managed massage, thereby laying ground for a new usual and customary charge if these benefits were ever to be covered by the insurer. Revenues to the affinity-based networks were far less than the venture capitalists expected, and the search for an exit strategy for the money guys became the main concern. Strike Three!

Presently, there are numerous CAM networks throughout the United States. These networks are differentiated by their various levels of management experience, commitment to the practitioners, contracts they serve, and understanding of the mindset of their contracted health providers. Some are interested in discounts, some are interested in assuring quality, and a few are interested in collecting data and proving efficacies. The challenge for the massage therapist is to figure out which networks will best serve the interest of their profession.

My experience is that health care is a unique product produced locally, consumed locally, and always best managed locally. Every region is significantly different in terms of health care cost, health care delivery, i.e., best practices, and health care politics. When reviewing networks, it is essential to determine who, what and where the promised processes will be managed. The most successful networks have evolved from the West coast and were born in the chiropractic management arena. In the early stages, these networks were paid pennies per member per month as an access fee to their product line. As competition increased, HMOs were willing to pay less and less for access to these affinity products. Today, the networks with the largest patient populations are willing to give free access to the HMOs in hopes of selling supplements and nutraceuticals, and willing to share those revenues with the HMOs.

These scenarios have evolved like this. The HMO typically assembles a CAM task force. The task force members may know very little about CAM and have little to no budgeted monies. In walks the national network company with slick brochures, offering access to their network for free, essentially touting a turnkey solution that can actually increase revenues to the HMO through profit-sharing of nutraceutical sales to the HMO members. The problem with this scenario is that the focus is on revenue generation for the plan and network, not collecting data or proving efficacy. In the pharmaceutical industry, this type of arrangement is considered illegal. If nothing else, it provides for a significant ethical dilemma. These arrangements also cut into revenues for those contracted practitioners who can sell and prescribe supplements within the legally defined scope of practice, i.e., acupuncturists. There is also a problem with perceived value. If the plan does not pay for the product, the perceived value is minimal. At the same time, this national network might provide referrals for the massage therapist. If you can live with the fee schedule, and need new clients, this model may help you in the short term. However, the long-term ramifications can be significant if this model, which is financed through nutraceutical sales, not medical management fees, becomes dominant. Once again, it is illegal in the allopathic world for those who prescribe to financially benefit from the prescription.

The HMO world is highly regulated. Each state has a department of insurance (DOI) whose mission is to protect consumers. It is likely that some of these arrangements are and will be frowned upon by the DOI bureaucrat. Managed care organizations are licensed to manage care, not to sell supplements. When considering a network, it is important to know how they generate revenues.

The bottom line is that not all networks are created equal. In a perfect world, all services would be paid for by the patient. Every town in America has a few physicians who no longer accept insurance. Their reputations are so great that patients who are able to pay out of pocket, flock to them to receive the type of care they deliver. If only all Americans had plenty of disposable income, there would be no need for insurance. However, this is not the reality. Most physicians have to deal with the bureaucracy of managed care in order to make a living. Many massage therapists deal exclusively with cash-only clients. However, as we continue to train and license more and more therapists, and the benefits of massage become more commonly accepted throughout America, the prudent therapist will choose to do business with quality networks. The following are some guidelines to consider when contracting with a network:

Credentialing Standards

Does the network perform true credentialing that will stand up to the scrutiny of the medical community, regulatory authorities, accreditation boards and managed care executives? For example, do massage therapists require extensive experience and training, vs. state or nationally mandated minimum requirements for licensure or certification? What are practitioner selection criteria, and do processes ensure quality vs. quantity? Is the group contracting with everyone in your area and are consumers truly protected by the process? Does the network support advancement of your profession's practice standards by promoting stringent credentialing standards designed to identify quality practitioners? Does network require a meeting and site visit to discuss your practice philosophy and qualifications? Is the network application targeted toward your profession, or is it simply a standard medical doctor application?

Types of Practitioners

What types of practitioners are included in the network? Are they licensed and regulated modalities, and will they ensure legitimate acceptance within an integrative medicine model? If there are practitioners on the panel who are not regulated by the state, how are these providers credentialed?

Contracts in Place

Does the network have any contracts in place that will drive referrals? What is the geographic area the network covers, and how many members does it cover? What is the financial arrangement between the health plan and the network?

Data Collection

Does the network require collection of encounter or patient data that is shared with primary care physicians and will document outcomes and efficacies? Is communication between physicians and holistic practitioners supported and encouraged?

Scope of Contract

Is practitioner agreement comprehensive enough to support future covered benefit requirements? Does it contain language that is mutual holding you harmless and not requiring exclusivity? Will the contract withstand the scrutiny of HMO regulatory authorities?

Fee Schedule

Is there a fee schedule and if so what is it? Is medically managed massage differentiated from wellness massage? Or, is there a blanket 15-20% discount off charges? Is reimbursement driven by modality or time spent with patients? Where do financial incentives lie to protect your relationships with clients? If the network is based upon a discount off charges, the likelihood that members will shop price instead of quality remains predominant.

Provider Support

Is the organization available to support you and your profession with reimbursement and managed care integration issues? Does the network charge a fee to join...if so how much and why? What are the long-term goals and mission of the network? Are they committed and knowledgeable about your professional field of practice?

Marketing

How will network providers be marketed? Is there a directory? If so, how often is it distributed and updated? Is there online directory access?

In closing, the network is a business model that can bring value to health plan members and contracted massage therapists. However, in order to minimize future conflicts, it is important that each massage therapist practices due diligence when considering any business opportunity.

 

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