Health & wellness

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In the new system of ‘global payments,’ patients will have more contact with their primary providers — like it or not

Tomasz Walenta

Each month, Dr. Richard Dupee and his office staff work their way through a sizable list of patients. They put out e-mails and calls to men in their 40s with slightly high blood pressure that warrants re-checking. They track down 55-year-olds who are avoiding colonoscopies, diabetics who require eye exams, and patients with chronic lung disease who need breathing tests.

“You bring in every one of your patients and you watch them like a hawk,’’ said Dupee, 66, an internist and geriatrician in Wellesley.

Dupee is an early adopter of a new strategy for providing medical care that is expected to expand rapidly throughout Massachusetts, and that promises to transform the relationship between primary care doctors and their patients.


As this system spreads across the state, nearly everyone with health insurance will be required to choose a primary care provider; insurers are considering assigning providers to people who don’t make a choice. Residents who have primary care doctors can anticipate hearing from them and their staffs more often, as they focus on bringing patients into the office for preventive care.

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Doctors will be motivated to do this not only because it’s better care, but because they will earn more money if they keep their patients healthy - and thus out of hospitals, emergency rooms, and specialists’ offices.

You’ve heard of helicopter parents. Similarly, primary care doctors will hover over their patients. “This will increase the amount of contact people have with their doctors,’’ said Dr. Thomas Hines, a family practitioner at South Boston Community Health Center. “Everybody is going to have to learn new ways.’’

Because primary care doctors are in short supply, especially in Western Massachusetts and on Cape Cod, many doctors, including Dupee, are hiring nurse practitioners and physicians’ assistants to form teams that will fill the gap. Some patients may end up choosing a nurse practitioner as their primary care provider, as allowed under a new state law. And certain popular physicians whose practices have been closed to new patients for years are opening up slots.

Patients naturally will be looking for more information on how to make these important choices, and state regulators and legislators are discussing how to provide people with more information about the quality and cost of medical care in different practices.


This new system works like this:

Primary care doctors, specialists and hospitals typically have billed insurance companies and government programs such as Medicare and Medicaid for each individual service they provide to patients, including office exams, lab and imaging tests, emergency room visits, and hospital admissions - with few limits on the number of services.

Critics say this system, called fee-for-service, encourages doctors to provide more treatment than is necessary and discourages coordination of a patient’s care among different providers.

In the new system of “global payments,’’ insurers generally put doctors on an annual per-patient budget. This budgeted amount is higher for patients with complex medical problems.

Doctors are expected to cover all costs associated with caring for the patient with this flat fee. When primary care doctors keep patients healthy and prevent expensive hospital stays and specialists’ visits, they get to keep more of the budgeted payment. If a patient’s care exceeds the budget, doctors lose money on the patient.


This arrangement may sound uncomfortably familiar to “managed care’’ popular in the 1990s - when patients accused doctors on budgets of withholding needed care. But insurers and doctors insist this time will be different, because the budgeted amounts are more generous, and because insurers are tracking the quality of care doctors provide to make sure they are not denying necessary care to stay within their budget.

Doctors will earn more money if they keep their patients healthy.

“It’s not just the primary care doctor, people are going to have a primary care team that’s going to involve nurses and other professionals,’’ said Brian Rosman, research director at Health Care for All, a Boston-based consumer group. “You will have the sense that there is someone to talk to who is looking out for your health.’’

More doctors will want to discuss problems by phone and e-mail - forms of contact that insurers have not paid for in the past but that doctors may find more efficient now.

For doctors to keep close track of patients, they need sophisticated electronic medical record and billing systems that can spit out lists of patients who are due for certain services.

Dupee is a member of the New England Quality Care Alliance, a network of community and academic physicians affiliated with Tufts Medical Center that receives global, or budgeted, payments for 88,000 patients under a contract with Blue Cross Blue Shield of Massachusetts.

The network’s administrators track patients for the doctors, giving them monthly lists of who needs a mammogram and who requires a cholesterol test. While a few generally healthy patients have been irritated by the extra attention, most like it, Dupee said.

One longtime patient, Julie Doran, 48, of Natick, said she and her husband are getting more phone calls from Dupee’s staff to schedule colonoscopies, blood pressure checks, mammograms, and pap smears - reminders they welcome. “I am so busy, this is really helpful,’’ she said.

As more doctors enter into these types of agreements to care for patients, however, access could become even more strained, Hines pointed out. A survey last year of 126 internal medicine practices by the Massachusetts Medical Society, which represents physicians, found that just 49 percent were accepting new patients, down from 66 percent in 2005. The crunch was similar for family practitioners.

Several longer-term initiatives, including medical school loan repayment programs, are underway to attract more doctors into primary care. Meanwhile, primary care doctors whose practices have been closed to new patients for years are opening up, including many who work for Brigham and Women’s Hospital, which has started paying physicians extra to take on more patients, said Dr. Thomas Lee, president of Partners Community HealthCare, the hospital’s physician network.

These efforts alone won’t be enough, and the state’s 6,000 licensed nurse practitioners are ready to step into the void, said Barbara Rosato, president of the Massachusetts Coalition of Nurse Practitioners. They can provide most of the care doctors do, except they need physician oversight to prescribe medications.

Health insurers have begun listing nurse practitioners in their provider directories and allowing members to designate them as their primary care providers, as allowed by new Massachusetts regulations. The nurses coalition filed new legislation this year that would allow nurse practitioners to sign medical forms, such as college health exams and medical clearances to return to work.

Given these evolving relationships, patients should carefully consider their choice of providers, doctors said. Websites provide basic information such as whether a doctor has a clean disciplinary record and whether patients are satisfied with the office staff, but patients also should determine to which hospitals a doctor refers patients, Hines said. Physicians will be less willing to refer patients to hospitals and specialists outside his or her network under global payments.

Dr. Beth Lown, medical director at the Schwartz Center for Compassionate Healthcare and an internist at Mt. Auburn Hospital, said patients should weigh a doctor’s style. Some people want to make medical decisions for themselves, while others prefer a more paternalistic physician. In the end, she said, “the relationship has to click.’’

Liz Kowalczyk can be reached at