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When The Doctor Works For The Insurance Company

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Some insurance companies are taking a page out of their own history books: running their own doctors' offices and clinics. Though the strategy previously had mixed results, insurers think that by providing primary care for patients, they might reduce costly diseases and hospital stays in the long run.

Dr. Michael Byrne spent eight years working for a Brooklyn hospital and he saw firsthand why the United States spends more on healthcare than any other country in the world.

"I would regularly see patients who were admitted to the hospital, I took care of, who got better and we'd discharge with plan of care," he said. "And they'd come back either to the E.R. sick or to the floor. It's a common occurrence."

Roughly 25 percent of patients hospitalized in Brooklyn were back in the hospital within a month, according to Byrne. They wouldn't fill their prescriptions or take their medications; they'd miss appointments for follow-up tests or consultations with specialists.

But Byrne recently started working for CareMore, a company that's figured out a way to cut readmission rates for its Medicare patients to about half the national average. Since being acquired last summer by WellPoint, one of the largest health insurance companies in the country, CareMore is expanding across the country – adding 13 new clinics to their existing 30 by the end of the year.

If Medicare patients choose to have a WellPoint affiliate administer their benefits, they can use their clinics for free, in addition to seeing their regular primary care physician. Additionally, the clinic staff does many things that most physicians don't offer. For example, they'll come to patients' homes and install a scale that automatically sends their weight to the clinic. They'll design a workout that patients can do in the clinic gym, which is specially designed for seniors. They'll even cut patient toenails in an effort to avoid foot infections.

The idea of joining insurers and medical providers was the original concept behind Health Maintenance Organizations, or H.M.O.s, says Anthony Schlaff, a professor of public health and community medicine at Tufts University.

Schlaff says this strategy can work – Kaiser Permanente, for example, has been using this model for decades and is generally well rated with its customers. But H.M.O.s became unpopular in the 1990s because people thought they tried to cut costs by limiting care.

Schlaff said consumers should be keep that concern as insurers again experiment with similar models.

"Where it doesn't work is where there aren't protections against skimping on care," he said. "If the insurer and the provider are one and the same organization, then how does the public know that the company isn't staying in business by collecting money and then not giving the care it should be giving?"

CareMore patient David Benavides says his diabetes has been much better controlled since he signed up for the plan about five years ago. He visits the clinic often for check-ups and blood work.

"Actually, I go once a month," he said. "And I feel better and better, like I got the power to do what I want to do."

Copyright 2012 National Public Radio. To see more, visit http://www.npr.org/.

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