Why 'Cherry-Picking' Patients Is Gaining Ground

Leigh Page

Disclosures

December 19, 2013

In This Article

Where Does That Leave Patients?

Cherry-picking can have negative consequences for patients. For example, when physicians drop a plan, they are then "out-of-network" with that plan. Members may have to pay the physician higher rates or pay the physician out of pocket and then bill the plan.

Patients are also put under stress when a physician switches to a concierge practice -- another form of cherry-picking. They have the choice of paying a large monthly fee or finding a new physician.

Some physicians object to cherry-picking on principle, arguing that it erodes the profession's duty to help patients. "Nothing good comes out of it," said Michael Green, MD, a professor in the departments of Humanities and Medicine at Penn State College of Medicine in Hershey. "It's unprofessional when physicians don't acknowledge that they owe something to society." But Dr. Green said he did not object setting limits on Medicaid patients. "It's an unreasonable expectation that physicians should drive themselves into bankruptcy," he said.

Another form of cherry-picking, avoiding sicker patients, is more controversial. Fee-for-service payments usually do not reimburse for a lot of services that chronically ill patients need,[4] so the physician loses money on these patients and tries to avoid getting more of these patients.

Physicians may also steer clear of sicker patients in order to get extra payments or bonus payments in return for better outcomes. This occurs under emerging payment systems, such as P4P, gain-sharing, shared savings, bundled payments, and partial capitation. Dr. Bailey added that electronic health record systems make cherry-picking of existing patients easier by calculating how much money is lost on each patient.

When physicians are awarded for outcomes, scores are supposed to be risk-adjusted to account for sicker patients, but it is unclear how well these systems work. Studies[5,6] have shown inaccuracies in risk adjustments, including underpayments for the highest-cost patients. "The risk adjustment science is still not that good," Dr. Bailey said.

François de Brantes, Executive Director of the Health Care Incentives Improvement Institute, conceded there are still ways to game the emerging payment methods, but he has not seen them being used. "I've been involved in a lot of bundled payment arrangements, and I've never seen any cherry-picking," he said.

One way to reduce incentives to cherry-pick is to pay physicians to follow process measures rather than their outcomes, said Rick Kellerman, MD, Chair of the Department of Family and Community Medicine at Kansas University School of Medicine in Wichita, Kansas. An example of this is Medicare's Physician Quality Reporting System. "You can hold a doctor accountable for prescribing the correct meds, but not whether the patient takes the meds," Dr. Kellerman said.

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