Like a lot of doctors, Patrick Kilduff has too many patients and too little time. He and the five other physicians in Shavertown, Pa., oversee the care of about 12,000 people, and a typical office visit lasts just 15 minutes.
Because health insurers pay him as little as $45 per visit, Dr. Kilduff and his colleagues say they have little choice but to squeeze as many patients as they can into their day. That makes it virtually impossible to spend time explaining to patients the importance of keeping their blood sugar under control or how to take their medicine. But the insurers' penny-wise approach can lead to as much as $1 million in hospital bills, if a person with under-treated diabetes has a heart attack.
That is why some of the nation's insurers are now trying to avoid those high medical bills by taking the longer view. They are giving primary care doctors more help — and more money — to take care of the sickest patients and help prevent them from becoming sicker.
Otherwise, insurers know they risk being overwhelmed by rising health care costs as an older, sicker population copes with serious chronic conditions.
"The essential business model of medical insurance will have to change," said Dr. Glenn D. Steele Jr., the chief executive of Geisinger Health System, which operates a network of clinics and hospitals in Pennsylvania.
Geisinger is known nationally for its innovative approaches to delivering high-quality care at lower cost. It also owns a health insurance plan that covers about 250,000 people — including many of Dr. Kilduff's patients in Shavertown.
As an insurer, Geisinger now pays the salaries of extra nurses in doctors' offices, whose full-time job is to help patients with chronic diseases stay on top of their conditions and, ideally, out of the hospital. The doctors, including Dr. Kilduff, help hire the nurses, who work closely with the doctors to oversee the patients' care.
The nurses make sure patients who need quick appointments are squeezed in, and they alert the doctors to any early indications of trouble by keeping in close contact with the patients and looking out for the results of patients' lab tests.
One of Dr. Kilduff's patients, Rose Ann Cox, 69 years old, began working a few years ago with a Geisinger-paid nurse, Karen Thomas, to control her diabetes, talking by phone at least once a week. Ms. Cox had gone to the emergency room when her blood sugars were too low, but she has not been in the hospital for about three years now.
"You don't always think you should call the doctor," Ms. Cox said. But she has no qualms about reaching out to the nurse.
The initiative is part of an overall effort by Geisinger and other insurers to create a so-called medical home — the place where patients' care is carefully coordinated by a doctor and staff, with particular attention given to the chronically ill.
Geisinger began experimenting with this approach three and a half years ago and now uses it in 37 practices, most of which are part of its own network of doctors' offices.
But five of the doctors' offices, including Dr. Kilduff's, are independent practices that accept Geisinger as one of several insurance plans. Under the arrangement with the outside doctors, Geisinger pays for the nurses and shares with the doctors any savings they can achieve by reducing medical expenses. So far, Geisinger says it is pleased with the early results. In an unpublished review of 2008 data, Geisinger experienced an 18 percent drop in hospital admissions; overall medical expenses fell 7 percent. Geisinger expects to publish a study on its results later this year.
