Lawrence’s introduction to big-time managed health care is not sitting well with doctors, patients or even state regulators.

For the first time, a private insurance company has a case manager on-site at Lawrence Memorial Hospital looking over doctors’ shoulders and deciding when patients will be discharged.

“Being the only hospital in town and a community hospital, we try to soften the blow somewhat,” said Dr. Richard Sosinski, a Lawrence physician. “It has been a difficult adjustment for everybody.”

The case manager is from Coventry Health of Kansas Inc.

Bethesda, Md.-based Coventry is a fast-growing health maintenance organization that has made significant inroads in the Kansas and Missouri markets with recent purchases of other insurance plans. Last year, Coventry became the health insurer for employees of the Lawrence school district.

Because of a significant increase in complaints against Coventry, Kansas Department of Insurance officials last week called in top brass from Coventry for a face-to-face meeting, according to department spokesman Scott Holeman.

“We are investigating complaints and pursuing resolution to these complaints,” Holeman said. Many of the complaints have been lodged “by the medical community” and mostly deal with delays in claim payments or denials of payments.

A spokeswoman for Coventry said the company had no comment on the complaints or its system of on-site case managers.

Economic decision

Under managed care, doctors sometimes duel with insurance companies about treatment of patients. But at LMH, the back-and-forth usually has been over the telephone or in letters.

Now there is a Coventry employee who works at LMH, analyzing medical records and in some cases telling doctors that payment will be stopped if further care is provided. While the doctor is in charge of discharging patients, stopping insurance payments usually prompts a discharge, officials said.

Sosinski, who is medical director of an LMH team that reviews patient care, said the presence of the Coventry case manager was a manifestation of the national condition of managed health care. On-site case managers are not uncommon at big-city hospitals, he said.

“Frankly, the whole concept of managed care — meaning that there are these criteria and recommendations made to the physician and there is a possibility that the insurance carrier will stop payment while a patient is still in the hospital — is not a popular concept among physicians,” he said. “Most physicians are not happy with the review process.”

A doctor can appeal an insurer’s decision to the insurer’s medical director. But if the stop-payment decision stands, the doctor faces the dilemma of continuing treatment for no pay. If the patient is in the hospital, the hospital eats the cost.

“The economics of the situation does put pressure on you,” Sosinski said.

Complaints heard

Jerry Slaughter, executive director of the Kansas Medical Society, said he had heard of recent complaints about Coventry telling physicians to stop a certain treatment for patients or telling them to discharge the patient.

“If a physician feels the patient needs to stay in the hospital but the health plan says we are not paying anymore, that puts the hospitals and physicians in a terrible spot,” Slaughter said. “A health plan may not discharge someone from a hospital, the physician has to sign the discharge order. But if a health plan says we are not going to pay for it anymore, that is tantamount to saying you’re not going to get any more care.”

Slaughter said the past few years have seen the emergence of more national health insurers in Kansas. “It has hit Lawrence lately because Lawrence has become more linked to the Kansas City metropolitan market,” he said. “They just do business differently than companies that grew up here in this area.”

Sosinski said the battle with insurance companies also becomes a time-management issue for doctors.

“Managed care has increased our workload tremendously — all of this data gathering for patients. If I want a patient to have an MRI scan, we have to pre-certify it with the insurer. That can take 20 minutes to 30 minutes of nursing time. I employ an R.N. who is on the phone 100 percent of the time,” he said.

Much of that phone time is spent dealing with insurance companies, he said.

At the Lawrence school district, the switch this school year from a self-insured plan administered by Blue Cross and Blue Shield of Kansas to Coventry has produced some headaches for employees, according to Barbara Lynch, employee benefits manager.

But, she said, that was to be expected.

“With any change in insurance carriers, there is some confusion and frustration,” she said.