A Health Insurer Pays More to Save

Like a lot of doctors, Patrick Kilduff has too many patients and too little time. He and the five other physicians in Shavertown, Pa., oversee the care of about 12,000 people, and a typical office visit lasts just 15 minutes.

Because health insurers pay him as little as $45 per visit, Dr. Kilduff and his colleagues say they have little choice but to squeeze as many patients as they can into their day. That makes it virtually impossible to spend time explaining to patients the importance of keeping their blood sugar under control or how to take their medicine. But the insurers’ penny-wise approach can lead to as much as $1 million in hospital bills, if a person with under-treated diabetes has a heart attack.

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Doctor talking to female patient in office

That is why some of the nation’s insurers are now trying to avoid those high medical bills by taking the longer view. They are giving primary care doctors more help — and more money — to take care of the sickest patients and help prevent them from becoming sicker.

Otherwise, insurers know they risk being overwhelmed by rising health care costs as an older, sicker population copes with serious chronic conditions.

“The essential business model of medical insurance will have to change,” said Dr. Glenn D. Steele Jr., the chief executive of Geisinger Health System, which operates a network of clinics and hospitals in Pennsylvania.

Geisinger is known nationally for its innovative approaches to delivering high-quality care at lower cost. It also owns a health insurance plan that covers about 250,000 people — including many of Dr. Kilduff’s patients in Shavertown.

As an insurer, Geisinger now pays the salaries of extra nurses in doctors’ offices, whose full-time job is to help patients with chronic diseases stay on top of their conditions and, ideally, out of the hospital. The doctors, including Dr. Kilduff, help hire the nurses, who work closely with the doctors to oversee the patients’ care.

The nurses make sure patients who need quick appointments are squeezed in, and they alert the doctors to any early indications of trouble by keeping in close contact with the patients and looking out for the results of patients’ lab tests.

One of Dr. Kilduff’s patients, Rose Ann Cox, 69 years old, began working a few years ago with a Geisinger-paid nurse, Karen Thomas, to control her diabetes, talking by phone at least once a week. Ms. Cox had gone to the emergency room when her blood sugars were too low, but she has not been in the hospital for about three years now.

“You don’t always think you should call the doctor,” Ms. Cox said. But she has no qualms about reaching out to the nurse.

The initiative is part of an overall effort by Geisinger and other insurers to create a so-called medical home — the place where patients’ care is carefully coordinated by a doctor and staff, with particular attention given to the chronically ill.

Geisinger began experimenting with this approach three and a half years ago and now uses it in 37 practices, most of which are part of its own network of doctors’ offices.

But five of the doctors’ offices, including Dr. Kilduff’s, are independent practices that accept Geisinger as one of several insurance plans. Under the arrangement with the outside doctors, Geisinger pays for the nurses and shares with the doctors any savings they can achieve by reducing medical expenses. So far, Geisinger says it is pleased with the early results. In an unpublished review of 2008 data, Geisinger experienced an 18 percent drop in hospital admissions; overall medical expenses fell 7 percent. Geisinger expects to publish a study on its results later this year.

The doctors involved in the Geisinger experiment say they would not hesitate to hospitalize a patient if necessary. Part of the nurses’ work, in fact, is to keep tabs on anyone who is admitted and make sure a treatment plan is in place when a patient is discharged.

Many other insurers are also trying new, similar ways of rewarding primary care doctors.

“What we’re trying to do is get doctors off the traditional fee-for-service hamster wheel,” said Dr. Gus Manocchia, the chief medical officer for Blue Cross and Blue Shield of Rhode Island, a nonprofit insurer that started a program similar to Geisinger’s earlier this year. “A lot of the Blues plans are at least thinking about this, if they haven’t started it already.”

WellPoint , Aetna and Cigna , which are some of the nation’s largest for-profit insurers, are also flirting with the concept. In one case, in Texas, a nurse whose salary is paid by Cigna discovered that a diabetic patient was missing check-ups and not filling his prescriptions because he had lost his job. He was insured through his wife, but without his income the couple could no longer afford to pay his share of the cost of prescriptions or the co-payments for the office visit.

The nurse worked with the doctor to find cheaper medicines for the man and arranged for him to pay back his share of the cost of office visits over time.

By getting this patient’s diabetes under control, the insurer very likely avoided paying what could have been a $500,000 or $1 million claim to treat a heart attack or start kidney dialysis, said David Toomey, Cigna’s general manager for north Texas, where the insurer is starting to experiment with such programs.

Who do patients trust?

The same patient had been ignoring telephone calls from Cigna representatives, responding only when someone called from the doctor’s office. “They trust their doctor and there’s a level of distrust with the insurance company,” Mr. Toomey said.

Even though such experiments seem promising, more evidence is needed to show that this model works, said Dr. Jaan Sidorov, a former Geisinger insurance executive who is now a consultant. “We need some research and some outcomes,” he said.

Others also worry that Geisinger, often cited as a national model for health care delivery, may be a tough act to follow. By investing heavily in technology, Geisinger has developed an unusually sophisticated way of tracking patients, and its own doctors — unlike many around the nation — have long made use of electronic health records.

“Because Geisinger has a health plan, because of its system, they have the ability to do things that a lot of other insurers or hospitals cannot,” said Paul B. Ginsburg, the president of the Center for Studying Health System Change, a nonpartisan health research group in Washington.

But Mr. Ginsburg says insurers with many customers in a geographic market — like Blue Cross of Rhode Island, which covers two-thirds of those who are privately insured in the state — are also in a position to team with local doctors to provide better care.

Geisinger’s willingness to share the savings generated when patients stay out of the hospital may also be rare. But doctors say it is important.

“Two to three thousand dollars just doesn’t do it,” said Mark Stephens, the chief executive of InterMountain Medical Group, the medical practice of 52 physicians where Dr. Kilduff works.

Geisinger offered InterMountain Medical at least half of any money saved from preventing readmissions to the hospital, among other measures. “The upside was so strong that it just got everyone’s attention,” Mr. Stephens said.

His group, which cared for 900 patients insured by Geisinger, received $320,000 last year, which he said was divided among the whole staff, even the receptionists. The reward was based, too, on various measures of the quality of care delivered.

“We wanted the team to succeed,” said Janet Tomcavage, a nurse who helps oversee the program for Geisinger. “We wanted to put the dollars on the table that are meaningful.”

Other insurers may not be so generous. While WellPoint is willing to pay for an additional nurse in the doctor’s office, for example, so far it has not chosen to pay the doctor anything extra.

And Dr. Albert Puerini, chairman of the Rhode Island Primary Care Physicians Corporation, says he has had no luck in persuading his state’s other major insurer, UnitedHealth Group, to talk about creating a program similar to Blue Cross’s, although the insurer says it has other initiatives in the state.

But such efforts are increasingly necessary, if patients are going to get better care, Dr. Puerini. “None of this is going to improve,” he said, “unless plans and physicians learn to work together.”