Health care reform driven by health plans, not physicians

By Stephen B. Kemble, M.D.
Honolulu Star Advertiser, Jan. 24, 2018

At the “2018 Hawaii State of Reform” health policy conference on Jan. 10, I saw only a handful of physicians in the audience of about 300, but plenty of participants representing health plans and their contractors and subcontractors. The conference featured updates on our physician workforce shortage, and the effects of homelessness and social determinants on health.

The only policy solutions offered were new payment models that reward “value,” not volume, and shift insurance risk onto doctors and hospitals. I did not hear anything about the adverse effects of new payment models on physicians, or on the rapidly worsening problems we are seeing with access to care due to physicians leaving practice or refusing new patients with Medicare and Medicaid (MedQUEST).

For psychiatry, the latest workforce data shows an adequate number of psychiatrists on Oahu. However, I recently retired from the private practice of psychiatry, and we could find only two Oahu private- practice psychiatrists still accepting MedQUEST or Medicare patients, and both are completely overloaded. I still work part-time in Queen Emma Clinic, seeing mostly Medicaid patients and doing collaborative care, but the need there is also far greater than I can meet.

My patients report similar problems finding primary care doctors who will accept new Medicare or MedQUEST patients. I strongly suspect this has a lot to do with increasingly burdensome prior authorization policies and the administrative demands and staffing required by new payment models being imposed by Medicare and HMSA.

I have been experiencing much more frequent, gratuitous and absurd formulary restrictions and prior authorization policies by the plans’ pharmacy benefits managers in the past year or two, worst for the MedQUEST plans.

Now MedQUEST wants to follow HMSA and Medicare and move to “value- based” payment models. These were designed to discourage unnecessary care driven by fee-for-service incentives, which has never been much of a problem in Hawaii’s Medicaid program anyhow.

These payment models also happen to discourage taking on sicker, more complex patients with a lot of social problems, which means the Medicaid population. What good are pay-for-performance incentives if almost no doctors are willing to see the patients in the first place?

Hawaii’s health reform initiatives have been driven by the health plans, and skeptical doctors have been ignored or excluded from planning. If those driving policy remain unconcerned with the reasons why almost no psychiatrists and fewer primary care doctors are accepting new Medicare or Medicaid patients, we will end up with a shrinking pool of doctors caring for increasingly restricted patient panels and doing well on quality metrics, while those who need care the most are unable to find any available doctor, leaving them with no access to care except the emergency rooms and urgent care clinics.

This has already happened with psychiatry, and it is a direct result of policies that ignore effects on front-line patient care. We used to have broad acceptance of Medicaid among both private practice psychiatrists and primary care doctors, but psychiatrists have been effectively driven out of MedQUEST, and primary care is not far behind.

This clearly is not good for quality care, or for the total cost of care in the community, regardless of the performance of the limited number of doctors who have invested in the computerization and staffing required for success under new payment models.

We urgently need a dialogue between policy makers — health plan leadership, the Ige administration and legislators — and practicing doctors, or we will soon face a catastrophic collapse of our once exemplary health care delivery system, starting with Medicaid.

Any new Medicaid waiver requests should be delayed until we can find policies that will not continue to drive doctors out of MedQUEST.

Health care reform without doctors is doomed to failure.