Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, May 06, 2007

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?


At Sun May 06, 08:11:00 PM, Blogger XE said...

I think your approach is the right one. It doesn't make any sense to call up people you've never seen before.

At Sun May 06, 09:17:00 PM, Anonymous Anonymous said...

P4P is nuts. It assumes that patients are decorticate victims of circumstance - what an insult to their autonomy and intelligence. Why should YOU be penalized for a patient's freedom of choice? And no you shouldn't call strangers. That's a real invasion of privacy.

At Sun May 06, 09:26:00 PM, Blogger Lynn Price said...

"What do you think?"

I find it appalling that you have to even be aware of what's been litigated in order to solidify your status. I find it unconscionable that this is how you have to spend your time in order to make what few bones insurance companies are currently willing to throw a doc's way. I find it criminal that you simply aren't allowed to treat patients according to your standards.

At Mon May 07, 02:48:00 AM, Blogger MonkeyGirl said...

I know where your "strangers" are. They're in my ER. For their non-emergencies. They would call you, but they're busy sucking the life out of me. Sorry. I didn't realize you were being penalized. I'll be sure to send them right over. ;-)

At Mon May 07, 06:15:00 AM, Blogger #1 Dinosaur said...

Thanks, MonkeyGirl. I even have same-day appointments, so I can see them whenever they call. Same argument speaks to MinuteClinics. I couldn't be more available.

At Mon May 07, 11:01:00 AM, Blogger s. p. stanley said...

I have one daughter who has seen her doctor several times but I cannot get him listed as her primary; I have another daughter who has seen her most recent doctor once because her primary was unavailable at the time and the most recent is now listed as her primary without us even asking.

I find it absurd that you have no control over who claims you are their doctor, or what crazy systems make those claims on their behalf without their knowledge or permission, yet your income is affected.

At Mon May 07, 11:41:00 AM, Anonymous Anonymous said...

One other factor to consider: many enrollees are instructed to choose a doctor - ANY doctor - as a primary because the enrollment will not be processed without a physician's name filled in the blank.

So many find your name at random - or by your address or some other random type of data - and simply jump through the enrollment hoop.
They may not remember whose name they chose, and they may not have any idea that they are supposed to make an initial appointment.

So - I'd throw that back at the insurer/HMO/PPO/TPA and demand that the new enrollee contact info be presented to your office before the clock starts ticking on your obligation.

At Mon May 07, 03:49:00 PM, Anonymous Anonymous said...

At least the insurance companies are collecting those premiums for which they didn't have to pay a claim. God forbid they share the wealth with the people who actually take care of those "members" they put on such a high pedestal.

At Mon May 07, 04:13:00 PM, Blogger #1 Dinosaur said...

n=1: My point is that even if I were supplied with their contact info, why is it my responsibility to make the first move?

Also, just to play Devil's Advocate (against myself): I should point out that I am receiving a monthly payment -- not much, to be sure; rarely more than $10 -- for each of these patients even if I don't see them. I'm fine with that, given that one year's worth of capitation can easily "cover" a single visit, so accumulating that before the fact is perfectly kosher. Question: does that create an obligation on my part to be "pro-active"?

I still say no. The patient still has to do the bare minimum (initiate contact), otherwise I am still invading their privacy.

At Mon May 07, 08:57:00 PM, Anonymous Anonymous said...

I take your stance on the issue, but my IPA (of course) takes the stance that since you accepted the money, you therefore have a duty. Was I given a choice? No. But now I'm given the liability financially as well as legally.

The Dec. quartly "Patient Management Fee" (P4P in sheep's clothing) for me was $6,000 down from the previous quarter, just because of my bad customer service rating on a survey made up by that IPA. That is the equivalent of 500 patient-years (one patient, $10/patient/month) worth of your cap payment!!! And I only have 1900 age-adjusted lives assigned to me!!!

All this from a doctor recently voted "Best Doctor in Lodi" by a local newpaper and "America's Best Professionals" in Family Practice by a national non-profit survey company.

Shows you what little surveys mean.

At Mon May 07, 08:59:00 PM, Anonymous Anonymous said...

Oops, miscalulation. 50 patient-years.

At Tue May 08, 07:36:00 PM, Anonymous Anonymous said...

Agree with Val. It is not your responsibility to call patients (whether those you've never seen or those who choose not to have a test). I think the whole idea of P4P is ridiculous. At the very least, P4P should respect patients' choice to refuse treatment/tests as well as the choice not to go to a doctor unless they are sick. Preventive measures are a personal choice, they are not obligations.

And no, monkeygirl, most of these patients who never see a doctor are not in the ER. HMOs don't just pay for visits to the ER (unless admitted or directed by a PCP), at least based on what I remember from the time I had an HMO. Most of these are probably healthy people who choose not to go to a doctor unless they are really sick.

At Tue May 08, 07:41:00 PM, Anonymous Anonymous said...

Your point is valid, and I left out a major component of what I should have included in my suggestion: that the enrollee be given specific instructions by the HMO/TPBA/insurer about initiating contact with you and making an appointment.

I agree that the initial move isn't your obligation to make. But I also know that enrollees are jumping through hoops without all of the knoweldge and support they need to make sound health decisions.

The sole beneficiary from this mess is the insurer.

At Sat May 12, 10:54:00 PM, Blogger D.P. said...

Can you have these folks removed if they don't schedule an appointment in a specified time frame? It cannot possibly be patient abandonment if you have never met them.


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