A new model for reimbursing doctors at the state's largest health insurer is causing concern -- and some argue it could hit the sickest patients hardest.
Under the Hawaii Medical Service Association's new payment reimbursement model, which is being rolled out as part of a pilot project, practicing physicians get monthly lump sums of money to be used for all of the patients in their practice.
The current method reimburses doctors for individual patient visits.
But now, HMSA wants to pay doctors a set amount no matter how many patients they see – based on how much they've been paid in the past.
Dr. James Ireland is participating in the pilot and said revenues have actually increased.
"So for us, it's been good for our patients and good for the practice," he said.
Not all doctors think the change is worthwhile, though. Primary care physician Erlinda Cachola begins the new program on April 1 and is already worried her income could go down.
"If my reimbursements get lower, I don't know how to make up for it because I have a fixed overhead," she said. "I cannot pay my staff less."
HMSA insists the new system, called payment transformation, is "an innovative way to support the relationship between patients and doctors" and "gives primary care doctors the freedom to practice how they want."
Scott McCaffrey, of doctors advocacy group The Hawaii Medical Association, said the focus on preventive medicine is good but he fears some doctors won't accept sicker patients.
"We don't want a system to develop where doctors are penalized in some way by going the distance for the patient, no matter what goes wrong," McCaffrey said.
HMSA's new payment system rewards doctors who spend more time with patients who need extra care, as well as for annually checking in on all their patients. "There is extra work, printing these lists, calling these patients. There's extra documentation," Ireland said.
Physicians are also encouraged to handle some routine ailments without seeing the patient face-to-face, a practice Cachola fears could lead to malpractice lawsuits.
"They encourage telephone consultations or emails. I don't feel that is a very effective way of examining the patient and deciding what the patient needs," she said.
In a statement, HMSA called payment transformation an "innovative way to support the relationship between patients and doctors. We pay a physician an overall fee to care for their patients in the way the doctor believes will help patients the most."
The statement continued:
Payment transformation improves patient care:
It gives primary care doctors the freedom to practice how they want.
Payment transformation has measurable quality goals to make sure HMSA members are paying for and receiving quality care.
Financially, doctors can make the same amount of money with payment transformation by delivering high quality care to patients, and in some cases make more.
Payment transformation is a new way of doing things for some doctors, and we know change can be hard.
That’s why we did a pilot last year with about 100 PCPs to learn how to do payment transformation right. We took the feedback from the pilot to heart, and improved the program through several changes.
We’re now rolling out payment transformation slowly across the state, in partnership with doctors.
Next week, state lawmakers will discuss whether the state Insurance Commissioner should analyze HMSA'S new reimbursement method, now that the health insurer is rolling it out to more physicians.