P4P in Real Life: What Would You Do?

One of the two 600-pound insurance company gorillas in my area has a P4P plan they've been running for several years now. Towards the end of each year they send me lists of patients who haven't received certain preventive health care services, according to their records. I have a chance to go over those lists and either fill in the information for patients who have indeed gotten the pap, mammogram, colorectal cancer screening or diabetic care the plan doesn't have records of. But I am also told that I have the opportunity to make sure these patients receive those services before the end of the year, so they will "count."

Because this has been going on for several years now (and because I'm pretty damn good at talking people into getting preventive services when I happen to see them in the office for other things) I'm down to my hard-core folks who continue to refuse these things year after year. I confess there have been times I've called patients -- usually people I know well, so I know I can get away with this -- and said, "Please get your mammogram [etc.] before December 31st so your insurance company won't take money away from me."

There's another group of people, though, and these are the ones I'm asking about.

Because this is an HMO -- a capitated plan -- there are people on this list who have never called for an appointment, who I've never seen in the office; indeed, I've never met them face to face, nor had any contact with them at all. Apparently the insurance company is trying to take the position that merely choosing me from a list is enough to make someone my patient, so they now feel justified in holding me responsible financially for these patients' lack of preventive health care.

I don't know if this has ever been litigated, but my position is that a doctor-patient relationship cannot possibly be established in the complete absence of actual contact between the doctor and said patient. I am aware of case law that describes calling for an appointment as the point where the doctor's responsibility begins (the Friday afternoon call to the OBG's office by a patient with vaginal bleeding, given an appointment Monday but who dies of a ruptured ectopic pregnancy over the weekend) but I hold that there still has to be some kind of direct contact, and that that contact must be from the patient.

My monthly capitation list gives only name, age, ID number, plan and amount of capitation paid for each "member." (To me, they're patients, and I'm a doctor. To the insurance company, they're "members" and I'm a "provider.") No address, phone number or any other contact information. Even if I wanted to (or thought it appropriate) there's no way I could contact new patients who pop up on my list. Interestingly, the annual P4P review sheets do include this information. Apparently, I am supposed to call up complete strangers and say, "Hey, you signed up as my patient. How about coming in so we can get to know each other. I can give you a checkup and make sure you get all these vital preventive health services that would certainly be a good idea for you but would also put a little more money in my pocket."

Even with all the talk about "patient responsibility," we doctors are expected to do a lot of the heavy lifting: making sure patients go for labs, studies and other doctors we recommend; following up on no-show follow-up appointments; rewriting all twelve of their prescriptions three times a year (two of each: a 30-day supply to fill at the pharmacy and a 90-day supply to mail away) when they change insurance plans; stuff like that. I draw the line at calling a non-patient -- also known as "a stranger" -- to try and get him to come into the office. The very least the poor slob should be expected to do is to pick up the damn phone in the first place.

What do you think?