I handle the contracting for a private practice that employs the chronic care model, described on page 50 of this issue. My last attempt to convince a medical insurance company to financially support this successful program left me shaking my head.
I sat across the table from a pediatrician-turned-medical director for a large national medical insurance company. I told him we would happily sign a contract with his company if it would pay us for the cost of our chronic disease management program. He handed me a two-page laminated description of 11 chronic disease management programs that his company “does.” They ranged from diabetes to congestive heart failure to smoking cessation. Two of these programs had registered trademarks by their names, and most were accessed by one simple 800 number. Certain patients were automatically enrolled when their care became expensive. The list of 11 programs did not mention the pharmacy management letters the insurer would send our physicians in an attempt to get us to voluntarily implement its drug utilization program.
You know the rest. The disease management companies then start calling or otherwise interacting with our patients at a cost to the insurer of X dollars per patient per month. They turn in their numbers to the insurance company, and somehow someone somewhere feels that chronic disease management has been done.
My funding request for our program was met with, “We already pay for that service and have no mechanism or premium allowance to pay you.”
If you step back and look at the big picture, it makes no sense for medical insurance companies to do chronic disease management. Their role is to manage money. Their interest in chronic disease management is triggered by an opportunity to save money. What primary care physicians share with medical insurance companies is a disdain for wasted medical resources and overutilization, but at that point our common interest ends. Unfortunately, physicians need money to implement adequate disease management programs, and the insurance companies control the money. Primary care physicians and their national organizations have failed to step forward with a plan, and the insurance companies have designed and implemented much of chronic disease management as we know it today.
Few practices can implement chronic disease programs without up-front reimbursement and ongoing support. The insurance industry is evolving toward token payments for these functions after results can be demonstrated, but pay-for-performance makes no business sense to a medical practice. For example, we get paid to see a patient with an upper respiratory infection. We could not function if we had to wait for payment until the insurance company documented that our treatment kept the patient out of the hospital and saved the insurance company money.
Primary care physicians can do chronic disease management right and for the right reasons. We must be paid for implementing these programs and paid to sustain them. Guidelines must be established that define what constitutes an adequate program, and physicians must document compliance.
The medical community somehow needs to convince the for-profit insurance companies, the public and the government that primary care physicians should be doing chronic disease management and that it should be a billable service. Only then will more physicians be able to implement this relatively new concept and provide optimal medical care for our patients.
WHAT DO YOU THINK?
The opinions expressed here do not necessarily represent those of FPM or our publisher, the AAFP. We recognize that your point of view may differ from the author’s, and we encourage you to share it. Please send your comments to FPM via e-mail at firstname.lastname@example.org.