Why 'Cherry-Picking' Patients Is Gaining Ground

Leigh Page

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December 19, 2013

In This Article

Physicians See Pressures to Cherry-Pick Patients

Lower reimbursements, busier practices, and the rise of outcomes-based payments are inciting more physicians to think about cherry-picking -- that is, selecting patients with better payments or fewer health problems. Many physicians admit they do it, although they may feel guilty about it, or they worry that being too aggressive in this realm could harm their practices and standing.

Health insurers have been well known for cherry-picking members, although new regulations have eliminated some of those behaviors. But physicians do some cherry-picking, too, said Jim Bailey, MD, a professor of internal medicine at the University of Tennessee Health Science Center in Memphis, who has written about the phenomenon. If you choose a higher-paying specialty or locate your offices in an affluent suburb, cherry-picking can be a factor in keeping your practice profitable, he said.

The most familiar form of cherry-picking is barring new patients who have low-reimbursing payers, such as Medicaid. In a 2011 study,[1] nearly one third of physicians said they did not see new Medicaid patients, and many others put a limit on how many they will see. Many physicians also limit Medicare patients and even drop low-paying commercial plans. A 2011 study[2] found that physician acceptance of patients in commercial plans fell from 93.3% to 87.8% from 2005 to 2008.

Cherry-picking may become more common with the influx of previously uninsured patients under the Affordable Care Act. More insured patients could mean even busier practices, pressing physicians to come up with new ways to limit patients, said David A. Fleming, MD, director of the Center for Health Ethics at the University of Missouri in Columbia. "The expansion is going to complicate the matter [of cherry-picking] hugely," he said.

The new health insurance exchanges have prompted their own wave of physician cherry-picking, owing to reimbursement cuts at certain exchange plans. In a September 2013 survey[3] of practices by the Medical Group Management Association, about 29% of practices said they would participate, but 14% said they wouldn't and 40% were still deciding.

David Aizuss, MD, an ophthalmologist in Encino, California, refused to join any exchange plan because of the reimbursement cuts. "I would be on one of them if they would pay us appropriate rates," he said, "but I can't accept a 30% reduction in my fees."

In a world of paltry reimbursements, cherry-picking has become a necessity, according to Jeffrey Denning, a practice management consultant in La Jolla, California. "The term 'cherry-picking' is pejorative, but we do not think it is a bad thing," he said. He advises physicians to rank-order their payers from best to worst, including extra payments in such arrangements as pay-for-performance (P4P). "Physicians should be firing their low-paying plan," he said. "You need to limit the low-yield patients."

This purely bottom-line approach, however, didn't sit well with Michael La Penna, a practice management consultant in Grand Rapids, Michigan. "If you want to become the Darth Vader of reimbursement and game the system, then you will make a very precise analysis of your local healthcare plans," he said, "but I don't think many physicians want to base their decisions solely on that."

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