DATE: Tuesday, June 17, 1997                TAG: 9706170290

SECTION: FRONT                   PAGE: A1   EDITION: FINAL  

SOURCE: BY DEBRA GORDON, STAFF WRITER 
                                            LENGTH:  116 lines

CORRECTION/CLARIFICATION: ***************************************************************** CLARIFICATION A story Tuesday about a new policy for Optima Health Plan stated that a $100 penalty some doctors will be assessed is roughly equivalent to the amount they receive for visiting their patients in the hospital. Several Optima doctors, however, said their average payment is between $40 and $60. Correction published Wednesday, June 18, 1997 on page A2 of THE VIRGINIAN-PILOT. ***************************************************************** LIMIT HOSPITAL STAYS, DOCTORS TOLD OPTIMA WARNS OF PENALTIES FOR NOT FOLLOWING ITS GUIDELINES.

The region's largest HMO has put its doctors on notice: Keep your patients in the hospital too long and it will cost you - possibly $100 a day.

Optima Health Plan, which insures 241,000 people throughout Hampton Roads, began the new policy Monday as part of its efforts to reduce the number of days its members spend in the hospital - a key indicator of an HMO's financial strength.

The policy penalizes doctors and hospitals if the doctor insists on keeping patients hospitalized when the HMO says they should be discharged.

Although Optima officials say such disagreements rarely occur, a physician advocate warns that the policy could create an environment in which financial incentives outweigh medical necessity.

``I'm not in favor of penalizing folks because there's the potential to put the money ahead of the patient,'' said Randy Killian, executive vice president of the National Association of Managed Care Physicians, a Richmond-based nonprofit organization representing 13,000 doctors.

Local doctors say they would never keep patients hospitalized longer than necessary anyway, because doing so increases a patient's risk of contracting an infection and because patients usually want to go home as soon as possible.

And they resent the implication that they can be pressured into ignoring sound medical criteria to avoid paying financial penalties.

``When I wake up in the morning I don't think how I'm going to meet the company's policy,'' said Dr. Philip Goldstein, a cardiologist with Portsmouth Cardiology. ``I'm going to take care of patients, and I'm not competing with other doctors on length of stay.''

Goldstein's group typically has 30 to 45 patients in the hospital every day.

But Optima officials insist they need the policy because some of the plan's 1,800 doctors don't do all they could to get their patients out of the hospital quickly enough.

If doctors used more home health care, sent more patients to skilled nursing facilities instead of keeping them in the hospital, and used disease management guidelines more often, Optima could reduce hospital days while maintaining medical quality, said Randy C. Axelrod, medical director for Sentara Medical Care Management, which runs Optima.

Hospital days are an important indicator of an HMO's financial health. Reducing the number of days is one way HMOs can reduce costs and avoid increasing premiums.

Optima's hospital days - at 270 per 1,000 members - are within the middle range for HMOs in this region. But they should be closer to 200 days per 1,000 members, Axelrod said. In areas of the country where managed care is more entrenched, like California, hospital days are typically below 150 days per 1,000.

This area will become more competitive as employers demand that health-care costs for their employees be contained, said Michael Dudley, president of Sentara Health Management.

``The plan is faced with pressure from employer groups of all sizes to minimize cost increases and to do our best to decrease costs.''

But local obstetrician/gynecologist Willette L. LeHew said the policy provides just a ``Band-Aid'' answer to the problem and drives a wedge between the physicians and the plan.

He agrees that the number of inpatient days is too high, but he thinks there are other ways to tackle the problem, such as training sessions for doctors that Optima has been providing.

Optima's new policy, which was approved by a panel of the plan's doctors, works like this:

Optima sends nurses into the hospitals each day to check on its members and determine whether the member is ready to be discharged. If the plan says the patient doesn't need to be hospitalized any longer, and the doctor disagrees and refuses to discharge the patient, the doctor will either receive no further payment from Optima - and cannot bill the patient - or must pay the plan $100 a day for every additional day the patient stays.

Optima also won't pay the hospital.

The $100-per-day charge, roughly equal to the amount a doctor gets for an in-hospital visit, applies to doctors who are capitated - paid a fixed amount each month regardless of what services they provide. About half the plan's specialists are capitated.

It is also levied when the doctor is paid a set amount for a procedure, such as delivering a baby, or performing an operation. This affects all of the plan's obstetricians and surgeons.

If the patient insists on remaining in the hospital even though the doctor is ready to discharge him or her, then the patient becomes liable for the bill.

And if the hospital is to blame for the longer hospital stay - if tests weren't ready on time, for instance - then the hospital doesn't get paid.

``It's a triangle effect,'' said Sentara spokeswoman Debby Myers. ``We truly believe that if we can get the physician, the HMO and the hospital aligned with the same incentives, then we've got synergy there where everyone can be effective.''

And there is an appeals process, Dudley stressed. ``Our hope is that this trigger gets pulled hardly ever,'' he said. ``It's just one more technique used elsewhere in the country to get the discussion started.''

Dudley said other plans around the country have implemented similar ``denied days'' policies, but Killian said he was unaware of any.

``Every positive thing I've seen happen is with positive reinforcement, not negative,'' Killian said.

A spokeswoman for Trigon's HMOs, which cover about 70,000 people in the area, said the plan never requires doctors to refund payments. ILLUSTRATION: GRAPHIC

[For a copy of the graphic, see microfilm for this date.] KEYWORDS: OPTIMA HMO CAPITATED PAYMENTS

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