Dr. Burkhart, managing partner of San Antonio Orthopaedic Group, the largest orthopedics practice in South Texas, with 22 physicians, says the House bill talks about giving patients a “medical home.” He says the bill is vague about how this would work, but the common definition of medical home involves putting patients under the charge of a primary care physician for their care.
“In the 1990s, that was called the ‘gatekeeper’ model,” he says, “and it didn’t work.”
Dr. Burkhart and many other seasoned physicians across the country can remember the heady days of HMOs, before they fell out of favor. Insured members were assigned to a primary care physician, who acted as the gatekeeper. The HMO paid the gatekeeper a “capitation” rate, a set amount of money to cover each member for each month. If the gatekeeper overutilized services, he or she would lose money on the HMO contract, so the incentive was to limit care.
The gatekeeper system was hard on specialists and their patients because HMOs would only pay for services if the gatekeeper approved. If a patient came in with an orthopedic problem, “primary care physicians would try to treat things that they had no business treating,” Dr. Burkhart recalls. “The gatekeepers gave them injections for every kind of joint pain or told them they had arthritis when they didn’t.”
Likewise, the gatekeeper system was tough on the primary care physician, who had to keep expenses within the capitation rates or lose money. “With capitation, the insurers put all the risk on the doctor,” Dr. Burkhart says. Primary care physicians formed large IPAs to handle the risk, but by the late 1990s, several Texas IPAs were laden with huge debts and some declared bankruptcy. Capitation is still used by large practices in California, but in Texas and much of the rest of country it is a thing of the past.
