Health care gamble

By Marshall Allen

Sunday, Oct. 15, 2006 | 7:26 a.m.

About 40 retired cops are swigging beers in the upstairs room of Big Dog's, a tavern that smells of cigars.

It's the monthly meeting of the Chicago Police Association of Nevada. The old-timers fill the room with chitchat. When the conversation grows boisterous, guys raise hands to get attention.

They could be discussing crime trends or swapping old war stories.

But this is Las Vegas. These cops are griping about health care.

Leading the charge is Bill Ross, 62, who moved here about a dozen years ago. Misery loves company, and he's stoking the collective ire with complaints about Summit Medical Group. With 25 physicians, it's one of the largest local physician groups serving the valley.

A month ago, Summit notified Ross that it no longer accepts his insurance, Anthem Blue Cross and Blue Shield. He needs to find another doctor by December.

But Ross likes his physician; so he told Summit he would pay cash. Sorry, he's told, you can't.

That makes no sense to Ross. He's angry, confused and concerned about finding another doctor in a city where there's a severe shortage of physicians.

"It's just so cold," he said of being cut loose. "Not having enough doctors is one thing, but now when the doctors are here and they won't even take your money - that just floors me!"

Ross is one of 9,800 patients from numerous insurance groups being forced out of the Summit group to search for new doctors. In today's world, their experience is not unique. Health care is hardly a system, what with insurance carriers and medical providers constantly changing allegiances and amending contracts. Sometimes patients get dumped in the process. Dr. Don Havens of the Clark County Medical Society said the shuffling of patients is inconvenient but happens all the time.

That's the bad news.

The good news, according to Summit officials, is that their remaining 40,000 patients will enjoy improved access to doctors and better care under its novel approach.

Summit is banking on a patient-care business strategy called global risk, and it's nothing less than a calculated gamble. Under this system, Summit has negotiated a pooled payment from Pacificare, a large insurance company, to cover all inpatient and outpatient care for about 25,000 people. Every procedure, visit, test, hospital stay and treatment - from tonsillectomies to transplants - will be funded from that lump sum. Summit will then focus on providing preventive care because keeping patients healthy helps avoid costly procedures and hospital stays.

It's a risky proposition. Summit is betting the aggregate insurance revenue will more than cover the cost of patient care and leave a profit at the end of the day.

Summit will also keep about 15,000 patients who are covered in a more traditional manner through Medicare, the government's insurance for people who are disabled or over 65, and other insurance companies with long-term contracts. But the long-term plan is to convert all Summit patients to the global risk arrangement.

It's the first global risk plan in Nevada, according to Summit officials, though others are successful in other states.

Dr. Amir Bacchus, Summit's chief medical officer, said the switch was necessary because physicians were increasingly unhappy with the conventional system of insurance reimbursements based on individual procedures. Insurance companies are reducing their payments to doctors even as the physicians' costs are increasing, he said.

"You get paid less for doing the work you do, and you're trying to see more patients and you can't do as good a job clinically," Bacchus said. "It creates job dissatisfaction."

Summit plans to hire enough physicians to eventually reduce each doctor's load to about 700 patients. Doctors will see about half as many patients a day, Bacchus predicted.

Patients who receive more intensive, preventive care will be healthier, the doctors will be happier, and money will be saved because doctors will intervene before small problems develop into large, expensive ailments, Bacchus said.

One of Summit's physicians, Dr. Tracy Schifini, already has seen her load drop by about 1,000 patients who don't fit into the new arrangement. She has said goodbye to people she's treated for nine years, which can be difficult.

"But in the long run it's the right way to go," she said of the new business strategy. The old way, she said, is reactive and isn't designed to keep patients healthy.

The global risk plan "is the solution, the beginning of a solution, to something that's going to take a long time to change," Schifini said.

Medical consultant Dr. Ikram Khan said global risk contracts historically "have not necessarily been in the best interests of the patients" because doctors might be tempted to withhold expensive procedures to protect their financial bottom line. But, if immediate access to doctors, thorough treatment and preventive care are the cornerstone of Summit's plan, "it may be a model worth looking at," Khan said.

Barbara Thornton, chairman of the Nevada Center for Ethics and Health Policy, said she's concerned that the arrangement sets up another level of costly administration at the doctor level. Also, most physicians are not trained in the "nondisease" parts of medicine, she said, such as exercise and nutrition.

Ross, the retired police officer, is most concerned with competing with 9,800 other former Summit patients to find a new doctor. Earlier this year, Anthem Blue Cross and Blue Shield, Ross's insurance provider, reduced its reimbursement rates, and 111 doctors across the valley dropped the plan. His wife's physician isn't taking new patients - even if they are spouses.

"It's going to be harder and harder to find anybody who's going to treat you in Las Vegas," Ross said.