American College of Physicians: Internal Medicine — Doctors for Adults ®


Doctors caught in prevention squeeze

Health plans want more prevention but offer little in the way of pay

From the February 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Jennifer Fisher Wilson

When Bernard P. Shagan, FACP, treats diabetic patients, much of his time is spent on prevention.

During initial and follow-up visits, the Red Bank, N.J., endocrinologist regularly performs retinal and foot exams, blood glucose monitoring, counseling and education.

According to Dr. Shagan, Governor for ACP's New Jersey Chapter, investing so much time in prevention clearly helps his diabetic patients. Last year, not one suffered any of the common complications of diabetes like loss of sight or a limb.

The problem is that the health plans Dr. Shagan contracts with barely pay him for such preventive care. Not too long ago, Dr. Shagan received nearly $300 for an initial 90-minute exam of diabetic patients. Today, he receives slightly more than $90, an amount he says is financially straining his practice.

It's not that health plans don't value preventive care. In fact, even as medical directors insist that preventive services—everything from retinal exams for diabetics to counseling—don't warrant extra pay, they are pressuring physicians to provide more of these types of services. HMOs and health plans are closely tracking their physicians' use of preventive medicine in an effort sell employers on their plans.

For Dr. Shagan and other internists, this push for prevention presents a dilemma: Although a handful of health plans are beginning to financially reward physicians for these services, most don't. As a result, most physicians are left wondering how they can fit preventive care-which can be time-consuming and difficult to deliver consistently—into already busy practices.

The stakes can be high. Should chart reviews and other audits indicate poor delivery of certain prevention measures, physicians may risk withholds or even deselection from HMO networks, according to Larry L. Dickey, MD, chief of the office of clinical preventive medicine in the California Department of Health Services.

The force behind much of the pressure on physicians to provide prevention comes from the Health Plan Employer Data and Information Set (HEDIS). Data from HEDIS questionnaires are collected and compiled in what is basically a report card on health plans. The plans try to parlay good HEDIS scores into more subscribers.

HEDIS prevention measures include how often health professionals administer flu shots to older adults, provide eye exams for people with diabetes, advise smokers to kick the habit, prescribe beta-blocker treatment after a heart attack, and screen women for cervical cancer and breast cancer.

While the focus on prevention may be due to a number of factors, Dr. Dickey attributes at least part of it to the pressure from health plans. "Before there was no mechanism for oversight," he said. "Nobody was in the loop to make sure prevention was getting done. Managed care has provided that entree."

At physicians' expense

Delivery of at least some prevention measures appears to have markedly increased since HEDIS was launched in 1993 by the National Committee for Quality Assurance. One study from the Center for Disease Control and Prevention (CDC) showed the percentage of women who had received mammograms within the past two years jumped from 54% in 1991 to 61% in 1994. Another CDC study found influenza vaccination among people 65 and older increased from 23% in 1985 to 58% in 1995.

But some doctors claim that the increased focus on wellness comes at their expense. "Physicians are being told by third-party payers to do prevention, but it's a negative incentive for prevention if people can't make a living doing it," said Sidney C. Smith Jr., FACP, an interventional cardiologist, chief of the division of cardiology at the University of North Carolina (UNC) at Chapel Hill and past president of the American Heart Association.

Physicians complain that managed care has already forced them to spend less time with patients; now they're being told to fit more into each patient visit for the same reimbursement. And perhaps even more importantly, they are being told that they need to change how they practice to squeeze in even more prevention.

General internist Alphonse J. Baluta, ACP Member, for example, said that he incorporates preventive care in his solo internal medicine practice in Londonderry, N.H., but quickly acknowledges that his practice is not set up to do as much as he would like. "I administered over 450 flu vaccines this year but have no way of knowing how good that intervention has been, or how much better it could have been," he said.

Like many internists, Dr. Baluta does not have the sufficient tools to track his patients and make sure they all come in regularly for preventive testing, education and counseling. To do so, he would have to set up a practice-wide framework to consistently offer preventive measures. He said that so far, insurers have not given practitioners much help in setting up such systems.

"I try to do prevention in an individualized, case-by-case, fashioned into the routine of a busy practice," Dr. Baluta said. "I ask patients who are not being followed for a particular problem such as hypertension so see me periodically for a routine exam, or I address the issue of a routine mammogram or serum cholesterol when they come in acutely for a problem such as sinusitus."

In addition, Dr. Baluta said that he takes the time to explain to new patients what tests and treatments they should regularly undergo and gives them handouts on prevention. He said that he has also tried to implement a flow sheet system to track the prevention care his patients have received.

That's not always good enough. With a third of his patients enrolled in health plans like Matthew Thornton, Healthsource, Blue Cross and Aetna, Dr. Baluta's charts are audited occasionally by one HMO or another. "They're all interested in proving their quality of care," he said. "But they have not been uniform in emphasizing what they consider to be appropriate preventive measures."

In addition to the hassle of regular record audits, Dr. Baluta worries that the reviews will not accurately reflect the preventive care he has provided, a fear that experts say may be justified. According to Dr. Dickey from the California Department of Health Services, reviews based on administrative data may underestimate what care physicians provide by as much as 50%.

Wrong emphasis?

For physicians like Drs. Shagan and Baluta, health plans' motivation is suspect. If they were truly interested in keeping their patients healthy, these doctors maintain, the plans would pay physicians for their time to provide such services.

Health plans typically cover immunizations and screening tests, but physicians complain that those payments only cover tests like mammograms and not the services many physicians consider the most effective form of prevention—time-intensive education and counseling.

Health plans counter that physicians are already paid for such services. "Counseling needs to be part of the visit, so we do not reimburse extra," said Robert G. Harmon, MD, an internist who is the national medical director for United HealthCare. He added that federal government data show patients typically visit the doctor's office about three times a year, allowing opportunity for periodic follow-up.

But physicians see another reason for health plans' reluctance to pay for education and counseling. UNC's Dr. Smith, for example, said that because the average patient changes plans every year and a half, spending money on lifetime disease prevention-strategies like behavior modification-is a low priority for most health plans.

Critics say that the reluctance of many health plans to pay for prevention ends up costing patients as well as physicians.

"HMOs don't seem to have broader strategies to prevent disease in many cases," Dr. Smith said. If health plans really wanted to provide cost-effective care, he added, they would focus more on long-term prevention measures like counseling for patients with high-risk behaviors.

Instead, some plans do just a little, like send prevention-oriented mailings to their members. United HealthCare, for example, has sent notes to women over age 50 to remind them to get a mammogram, and Kaiser Permanente provides members with self-care books. If health plans were more serious about prevention, Dr. Smith contended, they would find a way to reward physicians for providing such time-consuming care.

The argument raises the question of what really counts as prevention. "Changing people's diet and exercise habits and smoking habit are probably the areas where we could have the biggest effect on the most number of lives," said California's Dr. Dickey. But he said that such care is difficult to deliver and measure, and in the short term can appear costly. In addition, Dr. Dickey said, most patients can only make significant lifestyle changes if they get help through long-term follow-up care, counseling and patient education, which many physicians feel they cannot afford to provide for free.


Perhaps to address some of these issues, some payers are considering the idea of paying for prevention.

HCFA has CPT codes for preventive medicine counseling, but Medicare—along with many HMOs—doesn't reimburse for them. If the HCFA codes did pay, they would reward physicians almost as much for counseling as for a midlevel office visit. For example, code 99401, which represents 15 minutes of preventive counseling, would be reimbursed at $35.22 on average, compared to $41.46 for code 99213, a 15-minute midlevel established focused patient visit, according to Sharon Mikolanis, ACP's Senior Associate for Payment Policy.

And Dr. Harmon from United HealthCare said that some HMOs are considering instituting financial incentives for delivering particular prevention measures at a high efficiency rate. Among some prevention medicine specialists, this approach is favored as an important aspect of getting prevention done, said Paul Frame, MD, a family physician in Cohocton, N.Y., and a member of the U.S. Preventive Services Task Force. Financial incentives have been shown to work in Great Britain, where general practice physicians receive a higher salary if they can show, for example, 90% child immunization compliance. With such a motivating incentive, Dr. Frame said, most British children receive their shots.

While health plans' use of HEDIS lacks any financial incentives for physicians, supporters argue that future measures may well focus on more long-term prevention. Already, some HEDIS measures being considered for future use include the efficiency of health plans to control high blood pressure, provide cholesterol management for patients hospitalized after coronary artery disease and follow-up after an abnormal Pap smear or abnormal mammogram.

Three tips to make prevention work for your practice

Experts say that there are some easy ways to fit prevention into regular medical practice—without breaking the bank.

  • Create a system. Whether it's a questionnaire, flow chart or computer system that prompts you when preventive care is needed, create a system to do prevention consistently. "You need some kind of a system so that every time you see the patient, you are reminded about what has been done and what needs to be done," said Paul Frame, MD, a family physician in Cohocton, N.Y., and a member of the U.S. Preventive Services Task Force. "You can't do that if you have to thumb through the chart and look for all the lab tests."

    The most popular technique is the simple manual flow chart, which many practices put in the front of patient charts. But the charts have a major drawback: They only work if they're updated. Frequently, physicians don't take the time and the chart falls out of date, Dr. Frame said. His practice uses a computer system that prompts physicians when prevention measures are in order.

    One tip: Consider having a nurse or assistant help track your preventive efforts. But make sure to allocate an adequate amount of time for whomever gets the responsibility, Dr. Frame said.

  • Focus on quality, not quantity. Try shortening the amount of time you spend on prevention by mailing patients a questionnaire on lifestyle behaviors.

    Harold C. Sox, FACP, a professor of medicine at Dartmouth-Hitchcock Medicine Center in Hanover, N.H., ACP's President-elect and chairman of the U.S. Preventive Services Task Force, said that questionnaires not only prompt patients to assess their health habits, but they also allow physicians to quickly assess where intervention is needed for high-risk behaviors.

    Dr. Sox said that being able to integrate prevention into regular patient visits is the key for busy physicians. "The current environment is one in which physicians are under pressure to see patients quickly, so there's less time for counseling," he said. Consider keeping handy the charts from the latest "Guide to U.S. Clinical Preventive Services" to choose interventions to include in periodic health exams. The tables for ages 25 to 64 and for ages 65 and older may be the most appropriate for internists, said Robert G. Harmon, MD, an internist who is the national medical director for United HealthCare.

  • Make prevention services self-pay. One way to integrate prevention—particularly strategies like lifestyle counseling—into practice is to have patients pay out-of-pocket for care that is not reimbursed. While some physicians may be uncomfortable with this strategy, internists like Victor Gong, MD, said they find it useful.

    "A lot of physicians provide mammograms and other screening, but they don't provide the other elements of prevention," said Dr. Gong, who practices in Ocean City, Md. Besides acute care, patients visiting his practice have the option of paying for wellness or nutritional counseling or a vitamin supplement regimen. "This is a large market where you can help people and still generate profits for the practice," Dr. Gong said. Plus, he said, "Patients like this approach."

    Bill Hettler, MD, a family practitioner and director of health services at the University of Wisconsin, Stevens Point, said that patients who pay out of pocket for prevention are more motivated to comply with weight loss or smoking cessation programs since it's their own money—not a health plan's—at stake.

    For practices just starting to offer prevention programs, Dr. Hettler suggested sending a letter to patients letting them know what new prevention services are being offered or posting a notice of the new services in the waiting room. He suggested starting patients with a health appraisal assessment, for which a practice might charge $10 to $50, not including lab work. For diet counseling, stress management, smoking cessation and guided fitness programs, stay competitive with existing programs in the community, he recommended.

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