Not a Real Hula Dancer

The Aloha State is having some growing pains with its Payment Transformation system, a capitated model run by “Hawaii Medical Service Association, the state’s largest health care insurer.”  It works like this:  HMSA pays a family doc about $24 per patient, per month.  All the doc has to do is keep costs in line, and figure out how to care for their panel with that monthly chunk.  It’s an exciting new innovation designed “to control rising costs and improve care.”  Which makes it basically Direct Primary Care, but backed by a larger payer.

Which of course is only innovative for anyone too young, too forgetful, or too dishonest enough to remember the 1990’s, when the HMO rage was certain to enrich family physicians, streamline services, and make patients happy with great, uninterrupted care.  Authentic administralian is spoken by Dr. Gerard Livaudias, vice president of not-for-profit (can you hear my eyes rolling?) Hawaiʻi Health Partners: “By not making them do certain things in order to get paid — instead just say, ‘Hey, here’s some money go figure out what is the best thing’ — that’s really liberating.”  As well it might be, but for pesky quality care goals which must be tracked, documented, collated, and submitted, all adding to an administrative burden that conveniently transfers the profit from the physician to the (ahem), “non-profit.”  This site has for years has explained to readers that “quality” goals are unproven, and there is no reason to believe that has changed.  While the state workforce assessment informs us that there is no data to show that the new payment system is driving doctors off the island, they do admit that the islands are short about 800 physicians, and that a third of those are in primary care.

 Will DPC work in Hawaii?  In a high cost area where more patients are having a tough time with costs and access, that may be the only sustainable solution.  The Payment Transformation system is NOT DPC, and there is no reason to think it is the answer.

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Pat Conrad MD

Pat Conrad is a full-time rural ER doc on the Florida Gulf Coast. After serving as a carrier naval flight officer, he graduated from the University of Florida College of Medicine, and the Tallahassee Family Medicine residency program. His commentary has appeared in Medical Economics and at . Conrad’s work stresses individual freedom and autonomy as the crucial foundation for medical excellence, is wary of all collective solutions, and recognizes that the vast majority of poisonous snakebites are concurrent with alcohol consumption. 

  2 comments for “Not a Real Hula Dancer

  1. Rick M Singel
    April 30, 2019 at 4:35 pm

    Aaaahhhh, capitation, our old friend.
    Yes, when a capitation patient would arrive to a dental office, they were run in and out, quickly and cheaply. Period. The dentist would scowl at their arrival and perform absolutely minimal treatment. And I do mean minimal. It was sickening to witness. Oh, and when a capitation patient would call for an appointment, they could only get the worst, leftover appointment times. One would NEVER, EVER give them a convenient appointment time. Impetus? Discourage them from appointing.

  2. Randy
    April 30, 2019 at 3:39 pm

    Going back a little further this is basically capitation, which was popular in the 80’s and the subject of much derision in the media. Supposedly doctors would be incentivized to have as large of a patient panel as possible and actually see the patients as little as possible, ultimately providing a lower level of care. Everything old is new again.

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