Like many doctors, Thomas Bodenheimer, M.D., has a lot of negative things to say about employer coalitions. But he doesn't stop there.
Bodenheimer, an internist on the clinical faculty of the University of California San Francisco Medical School, studies coalitions, and he's published his findings in such peer-reviewed journals as the New England Journal of Medicine.
His conclusion: The U.S. healthcare system has undergone a "revolution" in recent years, and "America's multibillion-dollar Fortune 500 companies set off the insurrection" by requiring employees to obtain insurance from HMOs. The latest phase of the revolution -- large employer coalitions -- may be the most troublesome, he warns.
Bodenheimer says physicians need to be wary of coalitions because their power to contract gives them control over which doctors employees can see, and "they can ratchet down what they pay HMOs, which means our capitation rate goes down."
And while coalition medical directors argue in support of their groups' efforts to provide outcomes and quality improvement data, Bodenheimer says that's an idealized view. He says a coalition with large publicly held members, like the Pacific Business Group on Health, "thinks about corporate earnings next quarter and stock and all that kind of stuff. They have this back-to-work mentality. They're not visionaries at all."
Michael Abel, M.D., chairman and chief executive officer of San Francisco's Brown & Toland Medical Group, shares some of Bodenheimer's fears. "We should be worried about (coalitions) because price is still first and foremost on their minds," he says. "They have pushed the premium dollar down too fast."
In addition, Bodenheimer says, physician representation on coalition boards is "atypical." For example, the California Public Employees' Retirement System has no doctors on its board, the Washington Business Group on Health has only five physician directors out of 23, and the Midwest Business Group on Health has one out of 16.
And, he adds, physician representation doesn't really matter if those board seats are held by corporate doctors. "Their main loyalty is to the company," Bodenheimer says. "If you had physicians from the grass roots, it would be different."
Abel says it might be better if corporate medical directors stayed in part-time private practice. At his group, every senior executive is expected to see patients. "It's not a mandate," he says. "It's just the right thing to do."
Steven H. Heimoff is an Oakland, Calif.-based writer who specializes in healthcare business topics.