LETTER: HMSA and Primary Care Physicians

Primary Care is comprehensive medical care by those specifically trained in first contact and continuing care for patients, serving as the central hub for all of the patient’s health care needs. Primary Care Providers (PCPs) specialize in the management of chronic medical diseases, treatment of acute issues, and preventative care. A good PCP is an invaluable asset to your health.

Yet somewhere along the way, that value has come into question. HMSA has promoted its new payment transformation model as a way of supporting primary care. But they failed to actually calculate a fair and reasonable wage for such services.

The Big Island is in the midst of a population expansion, in addition to a staggering physician shortage of 33%. In the last 8 months alone, Hilo has lost 6 PCPs, only one of which was not related to income. This magnifies the physician shortage, and not due to the expected upcoming retirements, making the acuity of the situation pronounced and urgent.
 HMSA advised us that as PCPs we should be able to safely and effectively care for 2,500 patients, an industry standard.

We practice evidence based medicine in my office, and a search of journals revealed that this number was actually a speculative remark in a journal that has since been discounted on numerous occasions. Estimates based on the time required to provide all recommended acute, chronic and preventative care for 2,500 patients is 21.7 hours/day. To manage chronic conditions alone for a panel of patients in whom those conditions are already controlled, it is estimated to take 3.5 hours/day. When those conditions are uncontrolled, the time commitment increased to an estimated 10.6 hours/day.

Other time management studies suggest a conventional medical model of primary care can manage approximately 1,000 patients with appropriate care. Time delegation models validate Team-Based Primary Care, with a PCP supervising a medical team including midlevel providers, nurses, medical assistants and receptionists to maximize high quality care to a larger population of patients. However there needs to be a system in place that allows for appropriate reimbursement of such a model.

With an average reimbursement of $24/month, working 200 hours/month, we need to manage over 1500 patients to pay a fair and reasonable salary to a single physician, and over 2100 patients to support Team-Based care. And that does not include any overhead or supplies; just salaries. There is no change in the HMSA reimbursement, no matter what services the patient requires – acute illness or injury, nebulizer for asthma flare-up, routine follow up, skin biopsy to check for cancer. We get the same $24/month.

With this reimbursement model, the PCP actually loses money by offering more to their patients. Patients lose their opportunity to receive the best medical management – at a true medical home. Ultimately, the insurance company actually loses more money and worse, patients will visit urgent care and ER more frequently, as more PCPs shut their doors, unable to afford the primary care the patients need and deserve.

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