CareFirst primary care plan will be mired in bureaucracy

September 23, 2010

CareFirst BlueCross BlueShield is offering primary care doctors a 12 percent increase in reimbursement for preventive care ("CareFirst's promising idea for primary care," Sept. 23). Primary care doctors are expected to draw up care plans, have in depth encounters with their patients and follow their patients more frequently to be eligible, and if they show good outcomes with less hospitalizations and surgeries for the same patients, they will be rewarded up to 80 percent of the savings in cost that CareFirst anticipates it will reap from this program.

Sounds great, but there are many drawbacks. CareFirst is a bureaucratic nightmare where, in my experience, mistakes in how claims are processed and reimbursed are not uncommon. The claims processing unit of CareFirst, to my knowledge, is not integrated with the division that follows physician performance measures. I dread to think of how the inefficiencies inherent in CareFirst could not only hobble this program but could also frustrate physicians, who after meeting the standards set by CareFirst, may not be paid what was promised and instead may have to fight tooth and nail for what is owed to them.

Imagine the tons of documentation that primary care doctors, already chafing under an avalanche of paperwork, will probably have to forward to CareFirst for verification in order to reap this reward. Also imagine the overhead cost for generating and transmitting this proof of adherence and the cost in time to do so. Considering that primary care doctors were paid a dismal amount in the first place, the 12 percent increase in reimbursement from that low level is not bait worth biting for the effort needed to reel it in.

Also, here are the things that doctors cannot do to get an extra bonus from CareFirst: They cannot force patients who work two to three odd jobs to come to their offices more frequently or stay longer for in depth appointments.

Subscribing to the theory of "cost sharing," insurers have blithely increased premiums and office co-pays, and doctors cannot lure patients into their offices with the promise of preventive health care if that would cost patients dearly in out of pocket expenses.

Doctors certainly cannot cajole people to stop smoking or stop eating fatty foods when the greatest pleasure in their life is derived from their addictions as opposed to the ghastly and painful realities of their existence.

Doctors also cannot alter the toxic nature of many American workplaces that take a terrible toll on their patients. Neither can doctors order their patients who live in unsafe neighborhoods to get out and walk, nor can they make patients join gyms when they have no money for food. Doctors cannot preach fresh foods to seniors who live on fixed incomes or to patients who live in run-down neighborhoods because such patients usually dismiss those efforts as insensitive lectures from the privileged to the poor. To stubborn patients who even when led to the water will not drink, doctors cannot be tyrants with whips. And in many cases, doctors cannot stave off the ravages of old age or bad genes with the magic wand called "preventive care."

So this plan that CareFirst has proposed is a gimmick, good on paper but in reality impractical.

It is also discriminatory toward those doctors who take care of elderly patients and those prone to critical ailments requiring frequent hospitalizations and toward those specialists who play the role of primary care doctors to many of their complicated patients and reduce the burden on an overwhelmed and understaffed health care system.

The Baltimore Sun speaks from the warm fuzziness of ignorance when it cheers this program.

Dr. Usha Nellore, Bel Air

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