CareFirst or Fees First?

The Washington Post has a story about a new approach to organizing health care delivery now being tried in the Washington DC area (http://www.washingtonpost.com/national/health-science/carefirst-says-exp...):

CareFirst says experimental program improves primary care, reduces costs
By Lena H. Sun
Washington Post 6/8/12

CareFirst BlueCross Blue­Shield, the largest private insurer in the Washington region, said Thursday that an experimental program that rewards doctors for coordinating care of their sickest patients resulted in better care and savings of nearly $40 million last year.

The program, part of the health-care overhaul, is one of the largest among dozens of public and private experiments testing this approach. Known as the patient-centered medical home model, it rewards teams of doctors, nurses and other staff members for coordinating care of patients with multiple chronic diseases. The goal is better care for patients, as well as lower costs because of fewer emergency visits and hospital stays.

About 3,600 primary-care doctors and nurse practitioners are taking part in the CareFirst program, or about 80 percent of those actively practicing in the District, Maryland and Northern Virginia. They serve nearly 1 million CareFirst members.

The program is based on a host of financial incentives. Doctors who join the program receive a 12 percent increase in their insurance reimbursements, plus $200 for each detailed care plan they set up for a patient. They can earn additional fees if their patients’ health-care costs at the end of last year were below expected costs.

Participating doctors work in groups of five to 15 clinicians. Last year, 253 such groups took part for at least six months and so were eligible for the additional fees.

Of those, nearly 60 percent of the teams cut their patients’ overall health-care costs by an average of 4.2 percent.

The program’s health-care costs totaled about $2.5 billion last year.

CareFirst will pay about $23 million in additional fees to those doctors from July 1 to June 30, 2013. They will receive an average 20 percent increase in fee payments from the insurer.

Linda Burke-Galloway MD wrote the following comment on the WP website:

I like everything about this plan except the "earning additional fees if costs are below expected costs." We have to be careful about that model which is reminiscent of the old "capitation" model. We should compensate based on outcomes, not cost savings. Also, with coordinated care and so many healthcare providers taking care of one patient, you want to make certain that someone is tracking the patient's labs, everyone has the same level of expectations and are following the same standard of care. And, there should definitely be some oversight and risk management conferences; especially because you're dealing with chronic illnesses. Some preventative interventions such as lifestyle modification would also be helpful.

Carol Ring wrote:

"The program is based on a host of financial incentives. Doctors who join the program receive a 12 percent increase in their insurance reimbursements, plus $200 for each detailed care plan they set up for a patient. They can earn additional fees if their patients’ health-care costs at the end of last year were below expected costs."

I worry about programs which offer money incentives to doctors for saving money. Too often it could mean skimping on care and the looser is the patient. I'm in favor of putting doctors on a salary so there is no incentive to give expensive, unnecessary tests. I believe this is working at the Cleveland Clinic.

My comment:

Every single one of those doctors, when applying for medical school, told the medical school faculty who interviewed them that they wanted to become a doctor in order to help heal people. Altruism is (or should be) the primary motivator for doctors and nurses. If we are not motivated by helping patients, no amount of financial incentives will organize health care in the patient's interest. What financial incentives actually do is become perverse incentives favoring the financial interests of someone or something and distracting health care delivery away from the patient. People who are not motivated to care for patients do not belong within the practice of medicine or nursing.

Dr. Joe Jarvis