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Health care is expensive, and the costs continue to rise. But rather than fixing the problem, insurance companies have made it harder and harder for doctors to get paid.

Pay for performance, prior authorizations for imaging, and now monthly capitation rates are just the latest ways that our local insurer has tried to cut costs. Has it led to better care? What do you think?

First came pay for performance. This started a few years ago. Doctors were given a list of “quality measures” for their patients, and while their standard reimbursement rates were frozen, they could earn a bonus if they could get their patients to meet all of the requirements.

It sounded like a good idea: help to make sure that all patients got��their colon cancer screening; women saw their gynecologists; patients had their blood pressure checked and were given enough medication to get the numbers to the desired level; diabetics were given pneumonia shots, had their feet examined, kept their sugars low, and had kidney screening done for damage from the high sugars.

In theory, it was a great plan.��But in practice, there was a huge problem.

The state has a shortage of gastroenterologists, and there are not enough to provide the test to screen for colon cancer, a colonoscopy.

In addition, insurance doesn’t always cover for the test. Lesser screening measures were adopted. The home stool kit was advised — my office even sent out over 120 of these to patients in order to meet the quality measure. But only 14 or so came back. It was not a successful way to try to meet this measure, and really didn’t give patients the opportunity to meet with a gastroenterologist to discuss their options.

Will doctors want to take sick, needy patients if they aren’t getting paid for their care? No.

My pay was also dependent on my patients getting their pap smears and mammograms done. The availability of ob/gyn’s is limited, and the average waiting time to get an office visit ranges from one to six months.

But in the absence of having adequate ob/gyn services, we developed a work-around: Mammograms were ordered without a breast exam, and all follow-up for abnormalities was done by a breast surgeon.

It was the only way to meet the quality measure, because like many primary care providers, I�������not do pap smears, and had no other options. I tried to engage the ob/gyns where I work to reach out to their own patients for their pap smears, to no avail.�� Their pay wasn’t dependent on following up on this, only mine was.

Pay for performance became an endless losing game of trying to meet measures that were not under my control. Diabetes, well, that’s best handled by an endocrinologist if someone has a severe case, but it’s my pay that is being docked if patients don’t get better control, not anyone else’s. Even if I did give a patient a prescription for medication, it didn’t count unless they actually went to the pharmacy and picked it up, which their insurance would consider meeting the quality measure.

Honestly, it seemed like the performance that I was being measured on was how good a cheerleader I could be to make patients do what their insurance company wanted.

Next came the prior authorizations for imaging studies. This started in December with HMSA announcing that all CT scans, MRI’s, stress tests, and more were going to require authorization from a mainland company, ,��or the test would not be covered.

The only way to work around this was to send stable patients to the emergency room. There they would wait for a few hours, only to tell the same story and have their CT scan done to diagnose their condition, which I could have treated easily in my office, had I been able to order the scan, and gotten results the same day.

When patients need stress tests, I send them to the cardiologist now, rather than try to take on the task of getting authorization to do a simple test to see if they have heart disease or not. I could lower the cost of the patient seeing the specialist, but the amount of time it takes to do that, and the liability of any delay in care, make it much easier to just order a consultation, and let the specialist decide which stress test is best.

For cartilage tears in the knee, I prescribe anti-inflammatory medication and instead of doing the MRI that I know the patient needs, I have to wait two to four weeks.

The tests have been refused by NIA because there is no evidence that the patient has completed physical therapy first. But does therapy fix a severe meniscal tear? No, it does not. Arthroscopic surgery by an orthopedic specialist does, but only after an MRI is done.

Now, with its��latest announcement, HMSA is trying to turn .

Back in the 1980s, the heyday of the health maintenance organization, doctors were paid per member per month, regardless of whether the patient was seen or not. For some doctors, this worked out great. Sign up a bunch of healthy people, and get paid to take care of them, in person or not.

Will this actually improve care? Or make more and more doctors either leave medicine, or refuse to take patients with HMSA insurance? It used to be that doctors were less likely to take Medicare patients — now it will be harder for anyone with the primary insurance in the state able to find a primary care provider, especially if they have health issues, or might need more time than doctors feel they are being paid for.

Instead of the insurance company taking on the risk of frequent flyers — those patients who want or need to come in every month or so for their care — now the doctors will be paid only for a limited number of visits, and anything over that will be for free.

Will doctors want to take sick, needy patients if they aren’t getting paid for their care? No.

Look at how hard it is for patients with Medicaid to find doctors, one of the formerly lowest-reimbursing insurance programs in the state. Will doctors want to take on patients when the pay for some of their visits will be nothing? Do you do your job for no pay at all?

The details are apparently going to be “worked out” by April 2017. But that leaves a lot of people feeling very uneasy about where health care is going in Hawaii. It’s well known that we have a primary care shortage in the state.

This is not going to make it any easier for patients to be seen. In fact, it will only make it worse.

Medicine used to be a profession that made me proud, but more and more, it’s making me sad that the quality of care I provide is dictated by the financial viability of the predominant insurance company in the state.

No studies have ever proven that the rise in health care costs is because primary care doctors see patients too much. Administrative costs, higher drug costs, hospital costs, technological advances in surgical procedures, .

But the lowest-paid doctors are those in primary care, and making it tougher to see patients and be paid fairly is not going to result in any savings in health-care costs.