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The Path Not Taken: Physicians

by Scott MacStravic

While hospitals have occasionally and partly meandered into the proactive health management (PHM), physicians have been equally tentative in their efforts.  For one thing, specialists are almost totally committed to sickness care, and the procedure-based payment systems used by third-party payors.  Of course, specialists that deal with patients with chronic diseases, such as endocrinologists with diabetic patients, and cardiologists with heart disease patients, can take on proactive disease management functions for those specific conditions, but are rarely qualified for or comfortable with managing co-morbidities common to diseases in their specialty domain, such as depression, for example.

Primary physicians, including family practitioners, general internists, pediatricians, geriatricians, and even obstetrician/gynecologists who serve as primary physician for women in many cases, are the most likely to engage in PHM.  Unfortunately, taking on PHM challenges and managing patients’ health problems and risks proactively falls mainly in the category of “cognitive services” which are notoriously uncovered or poorly compensated by third-party payers.

When the Family Physicians of Western Colorado, a group in Grand Junction, CO adopted the Chronic Care Model for its diabetic patients, it was able to keep its PHM costs down to $114 per patient per year.  And it was getting $120 per patient per year for the program from its major payor, along with a grant to cover the additional record keeping required.  Unfortunately, it applied the program to all its diabetic patients, and less than half were members of the HMO that was the only one paying for it, so it ended up losing over $25,000 a year thereby.  It chose to continue the program, anyway, given the significant benefits it delivers to patients, but losing money is not popular among physicians. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management 12:10 Nov/Dec 2005 50-56]

Medicare/Medicaid , insurers and employers are gradually investing in PHM for their beneficiaries, members and employees.  But CMS and commercial insurers look primarily at reductions in sickness care use by chronic disease patients, and only those that occur in the same year as their PHM investments as desired outcomes from PHM.  These short-term savings come mainly from only a small portion of patients, and represent losses of sickness care revenue to the same physicians, so are not usually seen as particularly attractive by those physicians.

Moreover, third-party payors seem to prefer specialized disease management (DM) providers when looking to outsource their limited PHM investments.  Including the physicians that already have a relationship with and serve particular patients in payor-sponsored DM programs would require enlisting a lot of different physicians, each of whom has only one or a few patients that would be involved in a specific payor’s program.  And physicians would have to cope with fitting into many payors’ DM programs, rather than just one in order to get all their patients with a given disease involved.

For these reasons, the physicians most involved in PHM tend to be those who are paid directly by their patients to do so.  “Patient-paid” practices include “concierge”, “boutique”, and similarly labeled physicians that are able to include a significant PHM element as part of their annual retainer services, or in some cases, practices that offer PHM “packages” dealing with specific conditions and risks.

One example is the MDVIP organization of practices, now numbering about 150 physicians and offered in 16 states.  These all include a major focus on maintaining and improving patients’ health under their $1500-1800 annual retainers.  This PHM focus is a major element of the organization’s appeal to physicians, and to patients alike.  It tends to dramatically reduce sickness care costs among its patients, though third-party payors have not rushed to help any patients served by these practices with paying the retainer. (www.mdvip.com)

Another far less common approach involves physicians that charge on a fee-for-service basis directly to patients, with specialized DM or PHM services, while not usually serving as these patients’ primary physician.  The Tempus Clinic in Los Gatos, California is one example, charging annual retainers for specific “preventive diagnostic” services, and ongoing coaching, often including membership in its own fitness center as well.(www.tempusclinic.com) Another is the Beyond Care practice in Branford, Connecticut, offering disease- and risk-specific packages of services that run from three to six months. (www.beyondcare.net)

The CareSouth Carolina organization of rural physician practices, headquartered in Hartsville, SC is another kind of example, offering DM for diabetes patients, including those with a co-diagnosis of depression, though not getting paid by insurers for it.  It was able to show annual management costs for such patients that were over $1200 less per patient per year than the average of other primary physicians in the state. [R. Chaufournier & K. Reims “Hidden Opportunities for Cost Savings in Disease Management” Healthcare Savings Chronicle  (Coalition America, Inc.) Mar 10, 2005 (www.imakenews.com)]

Primary physicians have two major advantages as providers of PHM services to their patients.  First, they are already familiar with such patients and their complete medical/risk status, and are a trusted source of advice, with their recommendations one of the chief motivators for patient adherence to medical care regimens and lifestyle changes.  Second, they are about the most powerful ally in getting patients to enroll in