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

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Pay remains a barrier to physician involvement in disease management

By Phyllis Maguire

While many physicians would like to get more involved in disease management, there is one big problem: They rarely get reimbursed for time they spend administrating disease management programs.

Coastal Medical Inc., a Rhode Island primary care practice with 60 physicians, has hired clinical pharmacists to educate and track chronic care patients. The group also uses nurse practitioners to coordinate inhaler management, smoking cessation and anticoagulation programs. But so far, said Coastal internist David L. Fried, ACP-ASIM Member, the group hasn't been reimbursed for any of those services.

"It's coming out of our pockets," Dr. Fried said. "We hope that the pharmacists can get their own provider numbers so we can bill for their services, but right now that's not happening."

Part of the problem is that health plans aren't used to paying for disease management services. Instead of receiving a flat fee for their efforts, most disease management programs receive a percentage of savings in care that they help produce.

To date, however, it appears that health plans have been reluctant to share those savings with physicians. Some capitated group practices say that they have been punished financially for successfully using disease management programs. Groups in California, for example, report that when their disease management programs drove down costs, health plans and employers responded by slashing their capitation rates.

"The more efficient you are, the harder you're pushed to lower your price," said Michael E. Abel, MD, senior advisor to Brown & Toland Medical Group, a multispeciality independent physician association in northern California. The group has scaled back its disease management programs because reduced capitation rates could not support the costs.

Today, Dr. Abel said, all that remains of the group's disease management program is "a core" of pharmacy management and data tracking. Social services, which analysts say are crucial to encourage patients to manage their own diseases, were the first program components to go.

Some physicians have found ways to get reimbursed for their disease management efforts. William A. Fawcett IV, MD, an allergist-immunologist in solo practice in Beaumont, Texas, helped design a five-hour software program for asthmatics that he uses in his office in five one-hour sessions to educate patients and improve their skills with different equipment like peak flow meters. A health plan has developed a code that Dr. Fawcett can use to be reimbursed for administering the program.

But Dr. Fawcett appears to be the exception, not the rule. And the consensus is that until payers reimburse physicians to get involved with disease management, more physician-led programs won't happen. "There's no clear economic incentive for providers to make this type of investment," said David J. Shulkin, FACP, former chief quality officer for the University of Pennsylvania Health System and now chief executive officer of DoctorQuality.com Inc. "Without directly rewarding physicians and provider systems, physicians won't be willing to put resources into these programs."

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