Health Care Reform Driven by Health Plans, Not Physicians

By Kemble, Stephen B. | Honolulu Star - Advertiser, January 24, 2018 | Go to article overview

Health Care Reform Driven by Health Plans, Not Physicians


Kemble, Stephen B., Honolulu Star - Advertiser


At the “2018 Hawaii State of Reform” health policy conference on Jan. 10, I saw only a handful of physicians in the audience of about 300, but plenty of participants representing health plans and their contractors and subcontractors. The conference featured updates on our physician workforce shortage, and the effects of homelessness and social determinants on health.

The only policy solutions offered were new payment models that reward “value,” not volume, and shift insurance risk onto doctors and hospitals. I did not hear anything about the adverse effects of new payment models on physicians, or on the rapidly worsening problems we are seeing with access to care due to physicians leaving practice or refusing new patients with Medicare and Medicaid (MedQUEST).

For psychiatry, the latest workforce data shows an adequate number of psychiatrists on Oahu. However, I recently retired from the private practice of psychiatry, and we could find only two Oahu private- practice psychiatrists still accepting MedQUEST or Medicare patients, and both are completely overloaded. I still work part-time in Queen Emma Clinic, seeing mostly Medicaid patients and doing collaborative care, but the need there is also far greater than I can meet.

My patients report similar problems finding primary care doctors who will accept new Medicare or MedQUEST patients. I strongly suspect this has a lot to do with increasingly burdensome prior authorization policies and the administrative demands and staffing required by new payment models being imposed by Medicare and HMSA.

I have been experiencing much more frequent, gratuitous and absurd formulary restrictions and prior authorization policies by the plans’ pharmacy benefits managers in the past year or two, worst for the MedQUEST plans.

Now MedQUEST wants to follow HMSA and Medicare and move to “value- based” payment models. These were designed to discourage unnecessary care driven by fee-for-service incentives, which has never been much of a problem in Hawaii’s Medicaid program anyhow.

These payment models also happen to discourage taking on sicker, more complex patients with a lot of social problems, which means the Medicaid population. …

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Health Care Reform Driven by Health Plans, Not Physicians
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