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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