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Physicians Need New Approach to Managed Care Contracts

HealthLeaders Media Staff, for HealthLeaders Media, June 27, 2012

Medical homes also are gaining more attention, though there is still some question as to how the infrastructure will be funded. The use of medical homes could increase the role of physicians as gatekeepers whose permission would be required for specialty care or hospital admission, Geilfuss says.

"There has been less of that role lately for physicians, but the rise of the medical home brings it back to the physician to play the gatekeeper," he says. "That can make the physician an important player in the medical home system."

Smaller physician practices have always faced a challenge when seeking and evaluating managed care contracts because the bigger systems have all the leverage. Geilfuss expects that challenge to become even greater in the future.

"Things like having a reasonable definition of medical necessity in the contract become a bigger issue as providers are pressed for justifying the type of care they're billing for," he says. "Also, another thing to look at is having the ability to change terms and conditions of the ­contract, including reimbursement and even in mid-contract term. When a big payer has control, they like to have the most flexibility they can build in."

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