Health Affairs, 23, no. 6 (2004): 48-50 doi: 10.1377/hlthaff.23.6.48 © 2004 by Project HOPE	New Online   New Issue: China & India   Obesity In China   Pay Cuts For Medicare Docs   Access To Care Woes

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Physician Practice

PERSPECTIVE

Professionalism Reconsidered: Physician Payment From A Health Plan Perspective

Abstract

 
Traditional fee-for-service health insurance rested on the assumption that doctors have primary responsibility for decisions about care. Those who long for unrestrained autonomy in an environment that is characterized by "information overload" and that continually demonstrates lapses in safety and quality fail to grasp the importance of physician and patient decision support systems and the key role that a health plan may play in dealing with these issues. The unbalanced allocation of resources between and among physician specialties is a contributing factor that must be addressed.

Medical professionalism is the cornerstone of medical care, and inherent in that notion, as perceived by most practitioners, is the concept of physician autonomy. Since prompt decision making and decisive action are necessary to meet the needs of urgent clinical events, this is a good thing. However, to the extent that it excludes decision support systems that could improve the accuracy of diagnosis, the precision of treatment decisions, error avoidance, and—where equivalent choices exist—guidance of patients to the most cost-effective options, physician autonomy is not such a good thing.

Our health care delivery system has worked well for many decades; during that time, insurance has played an irreplaceable enabling role in making the interventions of modern medical care available to more than 200 million Americans. At the same time, though, how did the perception of health insurers become so distorted? Cunningham touches on some of these factors in his paper. But let’s consider another: that notion of physician autonomy discussed earlier.

Physician autonomy. The perception of the physician as an autonomous agent is not confined to the profession. Patients also want and need to believe it. In fact, in urgent situations, patients must believe it. And since we are all patients at one time or another—whether we are employee benefit managers, benefit consultants, accreditors, or insurance company representatives—we are reluctant to question physician autonomy even in non-urgent situations.

Therefore, while acknowledging that process improvements were needed within the health care delivery system, it seemed expedient to everyone to let health plans take the lead—especially since health plans contracted directly with physicians. This was accepted as a reasonable expectation for health plans, so we took on this role. While it worked rather well, at least initially, the debate is intensifying as safety and quality issues become as prevalent as double-digit cost increases across the health care system.

At the end of the day, a health plan has but three courses of action it can take with contracted physicians: pay more (bonuses, pay-for-performance, tiered networks), pay less (fee schedules, withholds), or remove from a network. The latter, if related to the quality of care, has no positive impact on the health of a community. And as community citizens, health plans generally find removing a physician from a network unappealing.

Aligning incentives using a financial construct best fits performance and clinical compliance with quantifiable, measurable clinical goals for quality and safety. Therefore, as the expectations of employers and other purchasers shifted to increased clinical quality and safety, the role of health plans came under review again. Health plans have always been widely accepted and recognized for financial and marketing expertise—but clinical? While health plan physicians, pharmacists, and nurses have the necessary expertise, experience, and credentials to design programs to deal with these issues, acceptance by physicians and patients remained low.

There are indications, however, that this is changing. Experience has corrected some earlier assumptions: Physicians are not the sole problem, and health plans are not the sole solution. We now know that we are all part of the problem and that to be successful, we must all be part of the solution.

How might this work, and what might it mean to solo and small group practices? Cunningham quotes Eliot Freidson and Kenneth Arrow, who have "argued that complexity and uncertainty make it necessary for professional judgment, rather than market forces or bureaucratic regulation, to control medical decision making." Yet complexity and uncertainty are at the heart of our quality and safety dilemmas. How, for example, could a single health care professional, regardless of experience, knowledge, or prestige, manage a patient with multi-system disease and keep track of interactions for drugs prescribed by others or purchased over the counter; tests done in multiple offices/institutions; patients’ adherence or compliance; conflicting advice from other physicians, friends, family, or the media; or the impact of direct-to-consumer advertising on patients’ lifestyles, choices, or behavior?

Ask the experts. Recognizing the challenges and complexities facing individual physicians—and, for that matter, our entire health care delivery system—Blue Cross and Blue Shield (BCBS) plans have implemented a dramatically alternative strategy: ask the experts.

BCBS plans are engaged in a number of innovative collaborations with physician communities to begin to sort this out. We began by asking, "What are the five things a BCBS plan can do to help you be a better [fill in the specialty]?" They told us, and we began tackling common problems together. The issues are especially pertinent for primary care physicians, for whom, as Cunningham points out, the small-group model is most prevalent. To that end, BCBS plans have reached out to the primary care specialties, their societies, and others, to bring them into discussions that might previously have excluded them.

As health policy experts begin to move the pieces on the health care chess board in ways not previously considered. Imagine a Jackson Hole strategy, a Clinton defense, and an Institute of Medicine (IOM) offense. BCBS plans believe that hard-working, front-line clinicians must be full participants and an integral part of the process as we move ahead.

Why? If a single entity makes the rules—especially in a domain within which it is given little credibility by those impacted by the rules—and then creates financial incentives/disincentives based on those rules, its motives inevitably will be suspect. Against that backdrop, we should not be surprised at the dilemmas we now face.

BCBS plans are initiating multiple demonstration projects testing models of collaboration, shared decision making, and physician recognition. In addition to the initiative at Blue Cross of California, BCBS of Hawaii (HMSA) has provided five years of leadership, engaging local physician groups to define specialty-specific performance goals focused on patient experience and clinical outcomes, then tying their achievement to substantial rewards. In almost every market, innovations are in place, being tested and refined. The unique structure of the Blues makes the exchange of best practices routine and efficient, permitting adaptation to local geographic and demographic market characteristics. We are not doing this alone. Purchasers and specialty societies are key stakeholders and collaborators. Think about Bridges to Excellence, the Physician Consortium for Performance Improvement, and the Society of Thoracic Surgery database, to cite a few. Joining purchasers and plans are the most credible content experts: practicing physicians. The result is guidelines that are both clinically and financially meaningful.

We are still left with the dilemmas of the small-practice location: how to implement, manage, and catalog guidelines that would lead to a safer system and better clinical outcomes. The issue is not really just about finding capital for rural and small urban practices, is it? In truth, by happenstance rather than intent, primary care has been chronically undercapitalized. The redistribution of reimbursement between and among physician specialties has had a disproportional impact on pediatricians, family practitioners, and primary care internists. Addressing this issue will invariably require the support and participation of all who have a stake in the health care enterprise. Health plans are committed to the correct use of Current Procedural Terminology (CPT) codes and also generally apply the principles of the resource-based relative value scale (RBRVS) to fee schedules. The medical profession, therefore, must provide the necessary infrastructural changes to permit this issue to be resolved.

More, and more timely, data also will help improve the health care delivery system. Health plans can and will play a vital role in this arena, enabling informed decision making in real time, by guidelines and data and patient support systems; value-based reimbursement, which is related to the degree to which evidence-based medicine is embraced; peer pressure directed at poor quality; and inter-specialty trust and collaboration to deal with inequities that create barriers to a safer health care system.

Health plans certainly will help spearhead these efforts, but no one should expect us to make and enforce the rules. If the medical profession will not take the lead, those who ultimately fund the health care enterprise—led by large employers—have indicated a willingness to become involved. Clearly, we are all in this together, and what we do as an industry will be keenly dependent upon the willingness of physician communities to become constructively involved. I’m betting that they will.

Editor's Notes

Top Editor's Notes NOTE

 
Allan Korn (allan.korn{at}bcbsa.com) is senior vice president, clinical affairs, and chief medical officer, Blue Cross and Blue Shield Association in Chicago.

The author acknowledges Bill Hensley for his editing support.

NOTE

Top Editor's Notes NOTE

 

1. R. Cunningham, "Professionalism Reconsidered: Physician Payment in a Small-Practice Environment," Health Affairs 23, no. 6 (2004): 36–47.[Abstract/Free Full Text]

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