Rather than “Doctors blast new HMSA payment plan,” as heralded in a Star-Advertiser article April 10, we believe the real headline is “Health care costs are consuming us.”
They are the largest driver of the federal deficit by far.
The state has $16 billion in unfunded health care liability that is projected to grow to $32 billion in 10 years.
Our primary-care doctors in East Hawaii are stretched to the breaking point, and our hospital has had to cut staff and services. Health insurance premiums eat up more and more of an employer’s margin and an employee’s compensation. Some people are paying over $20,000 a year to insure their families today.
Actually, we believe HMSA’s plan to move primary care off of fee-for-service (FFS) payments is a step in the right direction to address the cost crisis.
Three years ago, 11 primary-care physicians (PCP) went off the FFS payment model and into the per-member-per-month (PMPM) payment model being piloted by HMSA. None has gone bankrupt, and all, including two more PCPs, elected to move into the next version of a PMPM model based on the median pay for PCPs nationally.
While they are still working on how to transform their practices to care for the health of all their patients, changing from FFS has taken them off the treadmill of many cookie-cutter office visits and stabilized their cash flow.
They are spending more time with their complex patients.
Rather than the economics of the FFS payment model driving care, it is the needs of the patient.
Both patients and doctors report more satisfaction in this new model of care in East Hawaii.
Putting primary care on a per-member-per-month basis does not mean that the physician is financially responsible for the total cost of all services for their patients. They are financially liable for only the care that they provide, not for services provided by specialists or the hospital.
To start such a change in their business model from volume of services provided to value of services performed, it makes sense to base the PMPM on the average of three years of payment divided by the number of patients. This gives physicians time to change their practice to a different business model.
The problem with this methodology is that it captures and rewards the inefficiency, inconvenience and costs that were generated by the FFS model, which promoted a higher volume of visits and procedures. Still it’s a place to start.
After three years on this model, the current version is built on a methodology that aims to get the “average” physician to the median compensation for primary care physicians in the nation assuming certain overhead factors and number of patients.
These assumptions, the weighting of risk factors and accountability for total cost of care, all are critical and complex elements that need to be refined over time.
We are convinced, however, that getting primary care away from FFS is a necessary step in the right direction.
From our perspective we need to make structural changes quicker, particularly in the community model of health care delivery where physicians, hospitals, pharmacies, labs and health plans are independent entities.
Only an unprecedented level of collaboration among us can keep this model of health care delivery viable.
Health plans must allow the community and providers to guide how resources are spent. We must pursue payment reform, information integration and care coordination in bold, new ways to make a difference, given the magnitude and urgency of the cost crisis.
In East Hawaii, we believe that a sustainable system must be “community-governed, person-centered, physician-led, data-driven and health plan-enabled.”
We have worked hard in the last few years to make this more than a motto.
