dr. solomon's dilemma






cost v care

The Game of Risk by Tom Jennings

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Jennings is the field producer for FRONTLINE's "Dr. Solomon's Dilemma"
More than anything, Jeffrey Bass, a popular family practitioner in Brookline, Massachusetts, regrets how the doctor-patient relationship has suffered in the past three years of the managed care revolution. Trapped in a health care system that limits the specialists to whom he may refer patients, the procedures that he can order or the prescriptions he can write, Bass says that his patients have tired of hearing him say "no." He senses a growing distrust.

What is interesting, however, is that Dr. Bass does not blame the usual suspect - HMOs. He's more penitent: "We screwed ourselves. Absolutely. We did this to ourselves."

It was three years ago that the group of roughly 1,200 doctors to which Bass belongs started a new approach to negotiating contracts with insurers. As a large group representing many patients, the doctors agreed that they would take on more "downside" financial risk for the patients they cared for. While the insurance companies would give them a monthly payment for each patient in the practice, it became the doctors' job keep the cost of patient care under the set, "capitated" amount they received. If they went above that capitated amount, they shared in the losses. But if they stayed under the limit, they could turn profits.

"It looked as though there was a lot of money to be made," says Dr. Martin Solomon, Bass's partner and profile subject of "Dr. Solomon's Dilemma." "So everybody jumped into it."

Like many trends, doctors taking on financial risk of their patients started in California. Grouping themselves together in large numbers, doctors there decided in the late 1980s that they would like to do what they were trained to do: Take complete charge of their patients' care.

But in the new world of managed care, that meant there had to be a trade-off. HMOs were happy to give more control over patient care decisions to the doctors, but only if the doctors would take on more of the responsibility of the cost of each patient. The more financial risk a group of doctors takes on, the bigger the potential financial gain - or loss.

Philip Boulter, Medical Director of Tufts Health Plan in Boston, says that taking on risk was the only way left to get control back: "The physician groups and the integrated delivery systems believed that by taking over a lot of the financial controls, they would take over all that goes with it, which includes medical management and care of the patients. It was a way to get control of something that they felt they had lost control over."

But the results are in, and, for doctors, it is not looking too good. In California, it is now estimated that 10 percent of capitated medical groups are in bankruptcy, and another 20 percent are teetering near the edge. The majority of Boston's medical practices are mired in losses because they have not been able to manage the unpredictable nature of treating sick people. What's more, doctors wanting the independence from HMO oversight have traded that in for fellow doctors lording over their practices, as well as the ethical questions brought on when doctors think about money when they make a care decision.

Doctors who just a few years ago thought they could master the business of medicine like they had mastered the craft of medicine have begun to understand the difficulty of the task.

It's become a predictable pattern, according to Peter Boland, author of The Capitation Sourcebook. "Doctors go in with a little bit of arrogance balanced with a lot of naiveté and without data to base any assumption of risk," says Boland,. "The health plans figure out by actuarial analysis what a favorable contract will be to them, and then effectively transfer the risk as opposed to manage it. Most doctors don't know the difference between risk transfer and risk management."

The result? It takes about three years for the doctors to realize how "actuarially intractable" the situation can become, Boland says: " [Financially] they get skewered."

"It seemed to be the right thing to do at the time," Bass now says in retrospect. "But it was a mistake."

In Boston, where "Doctor Solomon's Dilemma" takes place, the same forces that were affecting California medicine - doctors wanting more control over patient decisions, while at the same time wanting to make more money by taking out the middleman HMO - began to impact in the mid-1990s. It was this combination of forces that gave the doctors the financial risk they would now rather not have.

It started in 1994, with the creation of Partners, the parent company established with the merger of esteemed Harvard teaching hospitals Brigham-Womens and Massachusetts General. This merger dramatically altered the Boston medical landscape, according to Andrew Brotman, former senior vice president at CareGroup, the parent of Boston's Beth Israel Deaconess that arose in reaction to the formation of Partners. "This was a bold, in-your-face move, to basically say 'we have a vision of the new world,'" says Brotman. "They didn't just respond to a changing market. They changed the market."

The reaction at the other Harvard teaching hospitals, Brotman adds, was "absolutely chilling: There was anger, shock, surprise, even sadness." It was the end of the old medical gentlemen's club in Boston. And everything Partners has done since has put competitors like CareGroup, to which Jeff Bass and Martin Solomon belong, into a reactive position.

When Partners soon began negotiating contracts with health insurers that gave them more of the financial risk for their doctors' patients, it was only a matter of time before CareGroup would be forced to do the same. Taking on risk had become more and more popular in states like California, Arizona, Florida and Minnesota. Being capitated at that time was potentially lucrative. This was because the health care system was still bloated with inefficiency left over from the days of traditional, fee-for-service medicine, when doctors had control over every decision and were paid more depending on how much service they provide. Any cutback could mean tremendous savings.

Many primary care physicians at CareGroup wanted the risk. "It looked very attractive," says Solomon. "There were plans involved in capitated contracts around the country that were raking in millions of dollars because of the way they were managing their care."

There were, of course, other CareGroup doctors who protested the notion of letting money influence the care they gave. And then there were those who simply didn't understand what was going on. "I know a lot of the physicians who were presented with the agreements, told to sign on the bottom line, and didn't even know what they were getting into," says one doctor at the Joslin Center, a provider group within CareGroup renowned for the treatment of diabetes.

By many accounts, however, doctors at both Partners and CareGroup in Boston wanted the chance to take on risk. Around the region there had been sporadic efforts by medical groups to take on risk with capitated contracts, many highly profitable. At the same time in the mid-1990s, HMOs were becoming the target of animosity by doctors all over the US. They were, after all, the entities that had forced them to move away from the fee-for-service model of care.

So physicians in Boston - many Harvard-trained, and, as a group, arguably the most sophisticated practitioners of health care in the world - thought the gamble would pay off. What they didn't realize was that their timing was off, and that managed care, which during the early 1990s had been quite a profitable endeavor for the HMOs enforcing it, was destined not to be an industry with sustainable profits. By 1997, when CareGroup doctors started to take on more risk-based contracts, managed care companies were all too happy to limit their exposure, ceding the patient risk to doctors.

It may be true that doctors willingly sought the risk contracts, but physician groups most likely would not have acceded to the capitation arrangements if it hadn't been for broader economic pressures. Those pressures started with employers, upset with health care inflation, using managed care to force medical providers to cut costs. Then came the mad dash between provider groups for more patients to make up for the diminished revenue.

In Boston, the competition between Partners hospitals and CareGroup hospitals became so intense that insurers saw an opening. According to Brotman, Partners negotiated the first risk arrangements with the "big three" insurance companies in Boston: Harvard Pilgrim, Tufts and Blue Cross-Blue Shield. The insurers quickly used those agreements to leverage the transfer of risk at CareGroup. The threat was simply that if the provider group didn't agree, there was always a competitive alternative for the insurers' patients at Partners.

"I wouldn't call that choosing to take risk," says Brotman, who now is the Vice Dean at New York University Hospital. "I would call that choosing to take risk with a cocked gun at one's head. It was clear, however, that the market had fundamentally changed, that the insurance companies were all going to take the posture that if you wanted to negotiate contracts as a large integrated delivery system, the bottom line was there had to be some risk associated with that."

In retrospect, many health professionals in Boston believe, the desire to maintain unfettered control of patients and desire for more money may have led doctors to misunderstand the difficulty of being, in essence, insurers. But were they as naïve about the ways of managed care companies as some argue?

Not according to Philip Boulter, the Medical Director at Tufts. While he admits that Tufts "encouraged physicians to take [financial] responsibility on, it's only when they're ready and when they have the systems to do it." But the motivating principle has been clear. "In their pursuit of control, they understand that who controls the money controls the game, if you will. Not that health care's a game. It's not, it's a very, very serious, serious, important thing to all people. But with financial control comes financial risk and it is a challenge to balance the control needs you have as a physician and the financial stress that that can put on the system."

Bass, says that he hates being an administrator of money. In taking the risk of care, he is now put in a position of seeming to be a bad guy in the patient's eyes. He's the doctor who refuses to refer patients to receive an MRI the day after a pain medication is first taken and hasn't worked. He derides the many patients that complain and then go find a primary care physician who will prescribe the procedure.

To compensate, he's developed complex relationships with his patients around the idea of influencing expectations. If a person with a backache is led to believe the pain medication won't work in two days, but in two weeks, for instance, they won't complain. "I'm comfortable with the system now, and I think I can act in the patient's best interest and be well meaning. The trick is convincing the patient. What bugs me the most now is the friction between me and the patient. It has become so adversarial."

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