Managed Care - February 2009 - (Page 35) by lowering payments for other services. Berenson says that health plans have contributed to the disparities in reimbursement by paying relatively more to specialists than to primary care physicians, because specialists often have greater leverage in contract negotiations than do primary care physicians. “Payment reform is absolutely required to change incentives and achieve a sustainable shift in the utilization of services,” says Helen Darling, CEO of the National Business Group on Health. “If we continue with the present system, we’re going to get more of what we pay for — more procedures, more fragmentation, and less coordination” says Brian Rank, MD, medical director of the HealthPartners medical group, a unit of the HealthPartners health plan in Minneapolis. Rank favors fixed-price episode-of-care payments that bundle professional and technical com- HealthPartners in Minnesota has expanded the role of primary care. “We are working to engineer a system of perfect communication among clinicians. Coordination is part of our DNA,” says Rank. The group relies on its electronic health record to improve coordination. It has also implemented team- based care. HealthPartners has a created an in-basket management process that evaluates all patient-care communication to determine what needs to be managed by physicians and what can more appropriatedly be managed by the care team. “We tried to match capacity to demand and to find options for patients that might be more effective for their care. Visit-based care is the most inefficient way to care for some issues, so we create options that may be more effective and efficient for patients and their doctors, such as e-mailing their doctor or viewing their lab results online.” “We know we waste a good part of a physician’s day. We’re learning to support them to the maximum use of their training, brainpower, and patient-engagement skills.” — Brian Rank, MD, HealthPartners ponents and support team-based coordinated care. The other change that needs to take place is to make primary care more professionally rewarding. “It is important to create a practice environment with a core infrastructure and tools that allow physicians to feel they are responsible for promoting the health of the entire population of patients,” says Benjamin Chu, MD, CEO of Kaiser Permanente’s southern California health plan. Chu says that Kaiser relies on patient registries to monitor groups of patients for gaps in care. “The model of care has shifted to prediction and prevention in place of diagnosis and treatment,” says Chu. The Kaiser model has moved many of the routine services “off the backs of physicians,” freeing them to focus on broader population health management tasks. Kaiser is in the process of rolling out rules that require all office staff members to monitor care gaps and address prevention needs. Chu says that Kaiser members average 15 years with the health plan, and that to focus on prevention is costeffective. Under this model, Kaiser’s medical group is 45 percent primary care, 55-percent specialist. HealthPartners’ mix of generalists and specialists is about 50–50, says Rank. The company regards its system as more efficient and as supportive of primary care when appropriate, though it will use specialty referrals and coordination when needed. Kaiser and HealthPartners have residency programs, and both organizations incorporate their delivery models into their residency programs. The medical-practice models at Kaiser and HealthPartners are limited examples, doable in part to the integration of the health plan and physician group. The ACGME’s Nasca thinks the key to resolving many of the open issues regarding the physician workforce, such as whether we need more doctors or a different ratio of specialists to generalists, is tied to how the delivery system is unfolding. “There are several different directional pointers coming from the provider and payer sectors. Policy makers, and we as educators, are limited in how far we can go to shape the physician workforce or teach new skills until potential changes in the delivery system like the emergence of a primary care-led physician sector are clear.” MC FEBRUARY 2009 / MANAGED CARE 35
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