Medical homes: Taking what an insurer says at face value

American Medical News reported earlier this year the wonderful story of CareFirst BlueCross BlueShield, which covers patients in Maryland, Virginia and the District of Columbia.  They have come out and claimed that their patient-centered medical home program is benefiting everything it hoped to help: its own bottom line, patient care and physician pay.

Am I wrong to be skeptical when an insurance company says anything?   Philosophically, I love the medical home model (to a certain extent) because it is basically family medicine.  That being said, others are trying to morph it, change it, replace docs, hijack the concept, etc. to fit their own agenda.   Here is what CareFirst BCBS actually says in the piece:

  • It’s 1 million-member PCMH program spent $98 million less in health costs than projected in 2012, or 2.7% under expectations.
  • It’s savings is up from $38 million, or 1.5%, in 2011, the program’s first year.
  • Most of the savings was a result of reducing hospital admissions, emergency department use and drug spending, the company said.

Reducing hospital admissions and ER use sounds good.   Drug spending decreases sounds good unless it is because they pushed people to only the drugs on their their plan.   Here is more:

  • The company said 66% of eligible primary care panels — independent physicians and nurse practitioners who joined together to participate in the medical home program — earned incentive bonuses in 2012, up from 60% in 2011.
  • CareFirst said their incentive bonuses were 29% higher than in 2011.
  • The company did not release specific dollar figures on bonuses.

No figures on bonuses, huh?  Maybe the extra work done by the physician really wasn’t worth it?  You wouldn’t know because the AMA didn’t talk to any doctors and relies just on the report by the insurer.  But we can trust them, right?  And how about listing the amount of bonuses going to the CEO and other insurance company administrators.  Nope, not going to happen.

  • The study appeared to show that quality of care translates into cost savings, said Mike Sullivan, a CareFirst spokesman.
  • Quality scores for panels that earned incentive awards were 3.7% higher than for panels that didn’t earn the awards.
  • Quality scores were based on population health measures, such as whether patients with diabetes had A1c levels checked regularly. Sullivan said scores also are based on office hours, backup coverage and electronic health records.

Well, that proves it to me.  When an insurance spokesman speaks, I listen.   And all this great information about “quality scores” … means nothing!  What the heck does 3.7% “higher” really mean?  And who knows if things that were not measured decreased in so called quality?

It is possible that if someone looked at other indicators that were not measured (cholesterol, colonoscopy screening, amount of patients sent to urgent cares because they couldn’t be seen in the office, etc) it may show they did worse.  Remember, when incentives are on the line, the stuff that gets you a bonus gets done first.

So, why are we taking what an insurer says at face value?

Doug Farrago is a family physician who blogs at Authentic Medicine.

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  • southerndoc1

    It amazes me that the AMA and the AAFP consider reducing expenses (i.e., increasing profits) for for-profit insurers as a measure of success of the PCMH movement.
    Well, actually it doesn’t amaze me in the least . . .

    • EE Smith

      If you assume that the P in PCMH stands for Profit (“Profit-Centered Medical Home”), it all starts to make a lot more sense.

  • Mengles

    Apparently so does Ezekiel Emmanuel.

  • azmd

    The reason that the size of the financial incentives is not mentioned, is because they are not large enough to actually affect provider behavior in any significant way. And no study to date has documented an effect of incentives on patient outcome.

    http://www.dorlandhealth.com/clinical_care/trends/2250.html

    But, it is heartwarming to see that the insurance company saved money, which means that their shareholders probably profited, as did their executives.

    Until we have a healthcare system where the goals of all stakeholders involved are genuinely aligned towards the goal of good patient care, rather than in the interest of perverse incentives to ration care, this is what we will get.

    • LeoHolmMD

      Aside from a massive grant infusion, I am unaware of a model that makes the amount of human resources necessary for a PCMH feasible. I do not predict sustainability. It seems more and more like a management fad the longer it goes on.

  • LeoHolmMD

    A lot of what the PCMH is taking credit for would have happened anyway due to other forces. Because they are all happening at the same time, it is impossible to select them out. ER visits are down because insurers quit paying for them. ER systems set up triage points to put a brick wall limiter on unnecessary visits. Perhaps that is fine, but it is not because PCMH’s came out and caused that. The same is true of hospital admissions. Drug spending is down secondary to ramped up denial of care practices by PBM’s etc. No real science has backed the PCMH. When someone does some real science, it is unimpressive. I like the PCMH idea too…just be honest.

  • LeoHolmMD

    http://www.aafp.org/news-now/2013-cod-assembly/20130927answerspanel.html

    From the AAFP website:

    “Family practice physicians can expect to see a 40 to 50 percent increase in total revenue based on value provided instead of patient volume.”

    I don’t think anyone has seen anything like this so far in their PCMH. I’m not sure how this can be expected at all since valuation of Primary Care has been completely out of the control of the profession so far.

    “Hospitalization rates for our patients declined by 83 percent compared to our peers, while emergency room utilization by our patients was -218 percent compared to other practices in our area.”

    If anyone can demonstrate how any amount of utilization of anything can decrease by more than 100% without entering a black hole or another dimension…please post how.

  • DocNT

    First of all CareFirst is a NOT for profit branch of BCBS, meaning it operates on less than 1% margin, so the savings achieved in this program are going back to the docs via financial incentives and to the members in reduced premiums. Second, the quality measures do include colon, breast, and cervical cancer screenings, cholesterol, and a number of others and the docs who do achieve a cost savings receive a larger incentive if they have a higher quality score. And finally, it’s not a larger % of CF members who actually carry their PBM, so pushing their drugs isn’t really an option.