The ACP Advocate Blog

by Bob Doherty

Wednesday, March 16, 2011

When will insurers really do something real to save primary care?

A few days ago I received an email from a general internist about my posts about concierge practices. I have known this physician for over 20 years, and he has great insight into the challenges facing health care. This email was no exception; he had this to say how his group took the “middle way” of pursuing private funding for the Patient-Centered Medical Home (PCMH):

“My practice includes 3 primary care physicians and has invested heavily in IT infrastructure. We have re-engineered our workflows and have achieved benchmark levels of quality and service. We have won NCQA certification for our PCMH. Yet so far no payer has stepped up to underwrite our investment. So we have joined Privia Health in forming a ‘membership practice.’ Patients are asked to pay a small monthly membership fee. In return they receive some special attention . . . Plan sponsors and payers are invited to pay the fee on behalf of their employees. . . Patients like having same day access. They like secure email communication with their doctor. They like having a personal health record. They like having a case manager helping them navigate the system. And they like going online in the evening to make their own appointments. ACP policy supports the medical home but is silent on the question of what a medical home is to do before local payment realities catch up. I owe my patients my efforts to assure that when I retire an eager young internist will welcome the opportunity to take over my practice. Absent public or private funding for the medical home that is just not going to happen.”

This good doctor is absolutely right—“absent public or private funding for the medical home [it] is just not going to happen.”

In my view, it is a damning indictment of the health insurance industry that even though this physician’s practice has re-engineered its workflows, invested heavily in information technology, achieved benchmark levels of quality and service, and won NCQA certification as a PCMH—everything that primary care practice are being asked to do by payers!--not a single one of them has stepped up to underwrite the investment. This, despite the fact that dozens of health insurers are listed as members of the Patient-Centered Primary Care Collaborative, a coalition of “major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians and many others who have joined together to develop and advance the patient centered medical home.” (ACP is a founding member of the Collaborative and sits on its governing board.)

Now, I anticipate that health insurers will cry foul about my blanket indictment of their lack of support for primary care practices. They will, with some legitimacy, point to the 27 multi-payer pilots in 18 states that are being supported, at least in part, by health insurers. I wonder, though, how many of those pilots are paying the practices anything close to what it really will take to restore primary care as a viable practice model and to reduce the inequities in primary care compensation compared to other specialists. Not many, I expect.

In a couple of weeks, the Patient-Centered Primary Care Collaborative will be hosting a “stakeholder’s meeting” billed as PCMH: A Foundation for Transformation and Reform. I imagine that many health insurers will be at the meeting to talk about all of the wonderful things they are doing for primary care. And some of them, no doubt, believe that they are making things better. But the fact remains that primary care is in crisis, and not enough health insurers--and for that matter, government and employers--have demonstrated that are willing to put their money where their mouth is.

Enough with the happy talk by well-meaning people at yet another conference about how they really care about primary care when the facts on the ground suggest otherwise. Instead, I have just one question for them: when will they really do something real to save primary care?

Today’s questions: Do you think the insurance industry is really committed to saving primary care? And yes, I’d love to hear from the insurance companies). And if not, what can be done to get them to step up and put their money where their mouths are?

7 Comments :

Blogger Roy M. Poses MD said...

Are you kidding?

Read Wendell Potter's Deadly Spin to see what the insurance companies really care about, that is, revenues, and by inference, the executives' compensation:

http://wendellpotter.com/deadlyspin/

You may want to look at these summaries of some of his main points:
http://hcrenewal.blogspot.com/2011/02/health-care-corporate-disinformation.html

http://hcrenewal.blogspot.com/2011/02/wendell-potters-deadly-spin.html

The insurers' public relations teams have become extremely adept at making them appear to be on the side of good, while simultaneously using fear-mongering approaches implemented by third-parties to discourage any new policies that might harm their interests.

It is likely that the insurance companies' ostensible support for the PCMH was part of their effort to appear to be on the side of good while they tried to influence the writing of health care reform bills to support their interests. According to Potter, they were largely successful, although it is still possible the bill that was passed will do (slightly) more good than harm.

By the way, it is likely that other big health care organizations similarly use propaganda and disinformation campaigns to promote their interests.

March 17, 2011 at 3:07 PM  
Blogger Steve Lucas said...

Bravo to these doctors for finding a solution that works for both their patients and their practice.

Steve Lucas

March 17, 2011 at 4:46 PM  
Blogger Arvind said...

Medicare should be the first to start paying since it is the larges insurer in the land. Others will follow. Ultimately, there has to be a free-market solution to this problem. Simply calling insurance companies names will get us nowhere.

March 17, 2011 at 9:45 PM  
Blogger Harrison said...

Do we really want a business to focus on anything other than generating income?
If the business makes money by providing a service the business does well to provide the service in the most efficient way possible and to charge money for the service to the extent that the market will bear.
It does not help the business to hurt the over all market, because the business has to have a healthy market place in order to operate.
But businesses make the assumption that they are in competition and so they offer services in competition with other who offer services and the most efficient and those best able to generate income will thrive.

Why would we expect something different from an insurance company?

If a primary care model will help the insurance then it will be all over it.
But does it?
Primary care aims to treat day to day illness effectively and it helps to manage chronic disease in an efficient way.
An insurance company really doesn't want anything to do with chronically ill people.
Healthy people.
That is a good insurance market.
Make people pay for health care in anticipation of needs when it is a good bet that they won't need them.
That is insurance.

Primary care is about managing people who have health care needs.
Medicare does that.
The government does that.

Private insurance companies are only going to be willing to do that under the guise of something like the PPACA, which mandates that healthy people buy insurance.
Then they will be willing to take a risk on those with chronic disease.
But it has to make money for them.

So why would the government pay private insurance companies for something they will only do if they make a profit on it?
Why not just do it directly?
Why have a company in the middle skim off a profit for a service that the government has proven for years that it can run efficiently?

I just don't get that.

I'm in primary care.
And I think I have an important role in healthy patients and sick patients alike.

And I'm sure that if patients had to pay out of pocket they would pay to see me and they wouldn't pay for a specialist unless I told them that it was just beyond me and that I needed help.
I'm sure of it.
Even when the cost of seeing the specialist involved only a drive of about 10 miles, I found patients didn't really want to go.

I don't thnk we can count on private insurance companies to do anything for us.

I also think it is naive for us to think that there are small local private insurance companies.

There is Aetna, United Healthcare, and Humana, and Kaiser -- and that is about it.
The cover the healthy people in this country and make great profits.
And Medicare covers the chronically ill.

That leaves about 10% or 20% for Medicaid and a handful of smaller companies, and cash.

Primary care, with our biggest benefit being in the realm of chronic disease management in the outpatient setting is of main interest to Medicare.

Lets not hold our breath for any support from the rest of the industry.

Harrison

March 18, 2011 at 7:47 PM  
Blogger doc777 said...

Arvind is on the right track. Those believing the insurance companies are the root of all evil simply don't have a clue. In many areas of the country, insurers have little or no leverage over the large hospital systems. The systems own the hospitals and employ a large majority of the physician base. The systems have all-or-none contracts with the insurers. Take all of a system’s hospitals and physicians (and include their pharmacies and home nursing services) or exclude them completely. It just is not often feasible to exclude an entire system, so the insurer has to include the entire system and is left without the ability to pick and choose within various sub-markets.

Further, the insurers have no incentive to try new reimbursement models. It is much easier for the insurer to raise their premiums than to try to negotiate lower rates with the hospital systems. An added problem is that the hospital systems generate the bulk of their income on high cost imaging studies, procedures, surgeries and hospitalizations (not on primary care). Even if a physician is reimbursed more by an insurer for caring for a patient in the medical home model, I’m not sure the money would trickle down through the hospital system to that physician. Until there is an incentive for the hospital systems and/or the insurers to change, change will not happen. Contrary to popular belief, health care runs on a small margin. Why take a chance at swinging into the red if what you are doing is currently profitable? The old adage “if it ain’t broke, don’t fix it” applies nicely.

Unfortunately, we all know that our health care system is broke (in more ways than one). The cost increases are clearly unsustainable. So where is the leverage in the system to make sure change happens? The leverage is with the purchasers NOT the payers. Instead of the government stuffing more people into the same broke system, they should be working with other large private purchasers of health care to insist that Medicare, Medicaid, and private insurance companies abandon the current archaic fee-for-service reimbursement structure that rewards primarily volume, and instead move toward a model that reimburses for better outcomes and improved efficiency. That model must address the fragmentation in our current health care delivery system by instituting gain sharing and risk sharing across all the pieces of our health care delivery system so that all the pieces are working in synergy. The patient also needs to be included in the gain sharing and risk sharing. Unlimited everything plans may work for cell phones, but they are failing miserably with health care.

March 21, 2011 at 10:24 AM  
Blogger southern pcp said...

Please!

The insurers never forced anyone to "transform" their practice into a PCMH.

This hare-brained scheme for patient care was designed, named, and promoted by the primary care societies. It was obvious from the start that the PCMH meant more work, more administrative burden, more overhead, and less revenue.

The ACP and the AAFP need to accept the blame for urging/forcing this financially non-viable practice model on their membership.

March 22, 2011 at 10:43 PM  
Blogger doc777 said...

Those believing the insurance companies are the root of all evil simply don't have a clue. In many areas of the country, insurers have little or no leverage over the large hospital systems. The systems own the hospitals and employ a large majority of the physician base. The systems have all-or-none contracts with the insurers. Take all of a system’s hospitals and physicians (and include their pharmacies and home nursing services) or exclude them completely. It just is not often feasible to exclude an entire system, so the insurer has to include the entire system and is left without the ability to pick and choose within various sub-markets.

Further, the insurers have no incentive to try new reimbursement models. It is much easier for the insurer to raise their premiums than to try to negotiate lower rates with the hospital systems. An added problem is that the hospital systems generate the bulk of their income on high cost imaging studies, procedures, surgeries and hospitalizations (not on primary care). Even if a physician is reimbursed more by an insurer for caring for a patient in the medical home model, I’m not sure the money would trickle down through the hospital system to that physician. Until there is an incentive for the hospital systems and/or the insurers to change, change will not happen. Contrary to popular belief, health care runs on a small margin. Why take a chance at swinging into the red if what you are doing is currently profitable? The old adage “if it ain’t broke, don’t fix it” applies nicely.

Unfortunately, we all know that our health care system is broke (in more ways than one). The cost increases are clearly unsustainable. So where is the leverage in the system to make sure change happens? The leverage is with the purchasers NOT the payers. Instead of the government stuffing more people into the same broke system, they should be working with other large private purchasers of health care to insist that Medicare, Medicaid, and private insurance companies abandon the current archaic fee-for-service reimbursement structure that rewards primarily volume, and instead move toward a model that reimburses for better outcomes and improved efficiency. That model must address the fragmentation in our current health care delivery system by instituting gain sharing and risk sharing across all the pieces of our health care delivery system so that all the pieces are working in synergy. The patient also needs to be included in the gain sharing and risk sharing. Unlimited everything plans may work for cell phones, but they are failing miserably with health care.

March 23, 2011 at 12:26 PM  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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