The Obama administration is recruiting as many as 20,000 primary care doctors for an initiative it hopes will change the way physicians get paid and provide care.

The program, which was announced Monday, will be run by the Centers for Medicare and Medicaid Services. The aim is to stop paying doctors based on the number of billable services and visits provided to Medicare beneficiaries and instead to tie payments to overall patient health and outcomes.

“We think there will be a high level of interest across states and regions among primary care providers,” said Dr. Patrick Conway, the chief medical officer at CMS. “The model aligns with how doctors and patients want to practice medicine.”

Under the five-year project, CMS will recruit primary care doctors into two separate payment tracks. Both will include a monthly payment to doctors for each Medicare beneficiary, but the amounts will vary.

The fee for doctors in the first track will average $15 a beneficiary; the physicians will also still be paid for each service they provide. The fee for the second track will average $28; doctors will receive lower fees than those in the first track for each service. (In both tracks, the monthly payments will be higher for patients with more complex health problems.)

The idea is that doctor groups will use the payments that aren’t tied to specific services to develop different ways to provide care, including telephone and video consultations. They might also use care managers to help patients with their medications and chronic illnesses.

The payment change “really allows them to move away from a visit-based, fee-for-service structure,” Conway said on a conference call with reporters.

Doctors who want to participate in the program have to commit to offering patients preventive care, support for chronic illnesses and 24-hour access to health care and health information.

Conway says CMS expects the second track, with lower fees for itemized services, to save Medicare about $2 billion over five years.

The project is based on a pilot program set up under the Affordable Care Act to test new ways to deliver and to pay for health care. The goals are to improving care and cut costs.

Fee-for-service systems encourage too much medical intervention, says Robert Berenson, a fellow at the Urban Institute who has written about medical payment systems. But, he adds, programs that only pay a flat fee for care and result in physicians or hospitals cutting back too much.

“This is an attempt to balance paying for visits at a reasonable rate and then reimbursing substantially for all the other activities that are necessary to provide care,” he says, such as phone calls and coordinating with other doctors.

The CMS program is similar to successful health care payment systems in Denmark and the Netherlands that combine fees for itemized services and flat fees per patient.

Berenson says, however, that CMS’s goal of including 20,000 doctors may be too high. CMS would be better off working out the glitches in the approach with a smaller number of physician practices before rolling it out more widely.

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Poor people who reside in expensive, well-educated cities such as San Francisco tend to live longer than low-income people in less affluent places, according to a study of more than a billion Social Security and tax records.

The study, published in The Journal of the American Medical Association, bolsters what was already well known — the poor tend to have shorter lifespans than those with more money. But it also says that among low-income people, big disparities exist in life expectancy from place to place, said Raj Chetty, professor of economics at Stanford University.

“There are some places where the poor are doing quite well, gaining just as much in terms of life span as the rich, but there are other places where they’re actually going in the other direction, where the poor are living shorter lives today than in they did in the past,” Chetty said, in an interview with NPR.

For example, low-income people in Birmingham, Ala., live about as long as the rich, but in Tampa, Fla., the poor have actually lost ground.

Chetty and his co-authors collected more than 1.4 billion records from the Social Security Administration and the Internal Revenue Service to try to measure the relationship between income and life expectancy.

“There are vast gaps in life expectancy between the richest and poorest Americans,” Chetty said. “Men in the top 1 percent distribution level live about 15 years longer than men in the bottom 1 percent on the income distribution in the United States.

“To give you a sense of the magnitude, men in the bottom one percent have life expectancy comparable to the average life expectancy in Pakistan or Sudan.”

And where lifespans are concerned the rich are getting richer.

Since 2001, life-expectancy has increased by 2.3 years for the wealthiest 5 percent of American men and by nearly 3 percent for similarly situated women. Meanwhile, life expectancy has increased barely at all for the poorest 5 percent.

Among the study’s findings was that poor people in affluent cities such as San Francisco and New York tend to live longer than people of similar income levels in rust belt cities such as Detroit, he said.

What accounts for the disparity isn’t clear, Chetty says.

It may be that some cities such as San Francisco may be better at promoting healthier lifestyles, with smoking bans, for example, or perhaps people tend to adopt healthier habits if they live in a place where everyone else is doing it, he says.

The study suggests that the relationship between life expectancy and income is not iron-clad, and changes at the local level can make a big difference.

“What our study shows is that thinking about these issues of inequality and health and life expectancy at a local level is very fruitful, and thinking about policies that change health behaviors at a local level is likely to be important,” he says.

Chetty notes that the study has clear implications for Social Security and Medicare. The fact that poor people don’t live as long means they are paying into the system without getting the same benefits, a fact that needs to be considered in any discussion about raising the retirement age, he says.

The study was co-authored by Michael Stepner and Sarah Abraham of the Massachusetts Institute of Technology; Benjamin Scuderi, David Culter and Augustin Bergeron of Harvard University; Shelby Lin of McKinsey and Co.; and Nicholas Turner of the U.S. Treasury Department’s Office of Tax Analysis.

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In an emergency, hospitals, by law, must treat any patient in the U.S. until he or she is stabilized, regardless of the patient’s immigration status or ability to pay.

Yet, when it comes time for the hospitals to discharge these patients, the same standard doesn’t apply.

Though hospitals are legally obligated to find suitable places to discharge patients (for example, to their homes, rehabilitation facilities or nursing homes), their insurance status makes all the difference.

Several years ago I began caring for a man who’d been in our hospital for more than three months. He was in his 50s and had suffered a stroke. Half his body was paralyzed and he couldn’t swallow food. After weeks of intensive physical, occupational and speech therapy, he regained his abilities to eat, drink and walk with only minimal help. But he still wasn’t well enough to live on his own, prepare food or even get to the toilet by himself.

Ideally, we would have discharged him from the hospital to a rehabilitation facility so he could continue therapy and make more progress toward his prestroke state.

But our plan faced insurmountable barriers. First off, the patient was an immigrant who had entered the country illegally. Second, he didn’t have insurance.

Because he lacked health coverage, no other facility would accept him. His immigration status meant that we couldn’t find an outside charity that would cover the costs of his care or pay for insurance.

Our comparatively expensive acute care hospital was therefore compelled to hold him — with the meter running. After another month, it began to seem that he’d become a permanent resident of our hospital ward.

“Could he go back to Mexico?” our case manager asked.

We were startled. No one on my team had ever experienced a situation like this, so we began researching the possibility. As it turned out, it’s a murky legal and ethical area that drew some public attention after an expose in The New York Times in 2008.

Nevertheless, our hospital faced a real financial burden, and the case manager pressed on. After reaching the patient’s family in Mexico, and discussing issues with the Mexican consulate, the case manager began making travel arrangements to a rehabilitation hospital in Mexico.

Medical air transport to another country is an expensive proposition — roughly $50,000, depending on the equipment needed and the distance to the receiving facility in the patient’s home nation.

From the hospital’s point of view, it was easy to see that this large one-time expense would be worthwhile. The transfer to Mexico would put a stop to the indefinite, uncompensated costs of continued hospitalization. Further, the transfer would open up the patient’s bed to a new (and presumably insured) patient.

After several meetings between our medical team, case management services, and a hospital administrator, I reluctantly agreed to sign off on the transfer.

Though the discharge plan left me feeling uncertain, I became more comfortable with the idea because our patient had the capacity to make his own decisions. He consented to return home to Mexico because it was clear that he was no longer physically able to work, and his family was also on board with the plan to help him.

A few weeks later the transfer was completed. The last I heard about the man, he had successfully arrived at the rehabilitation hospital near his hometown in Mexico.

I hadn’t thought of this case for years until the combination of a recent Shots piece about dialysis and the heated rhetoric of the election season about immigration caused the memory to bubble back up into my consciousness.

Reflecting on the man’s case, I began to wonder all over again: Who were we to send him back to Mexico? On the other hand, what alternative did we have for a safe and reasonable discharge?

I also hoped to understand if our experience was part of a broader trend or a sporadic occurrence. I could only find estimates of the number of so-called medical deportations because there isn’t any required reporting or specific oversight. It’s a murky area that falls in the gap between federal health and immigration regulations.

The best estimates suggest dozens or maybe a few hundred cases occur each year. I called several air ambulance companies to gauge the demand for such services, but none was willing to provide numbers or even go on record to discuss the practice in general.

One group that has studied the phenomenon offered a conservative estimate of 800 cases of medical deportation over a period of six years. “We field calls from across the country, so it is a national problem and not confined to border states,” Lori Nessel, director of the Center for Social Justice at Seton Hall University School of Law, told me in an email.

Even in the absence of hard numbers, the medical community has responded to the investigative reporting and advocacy around the practice. In 2012, the American Medical Association added an opinion to its Code of Medical Ethics that states, in part, a “discharge plan should be developed without regard to socioeconomic status, immigration status, or other clinically irrelevant considerations.”

A 2014 piece in The New England Journal of Medicine concluded with the opinion that doctors “…are uniquely equipped to display the moral courage necessary to advocate effectively for patients by calling attention to the profound ethical issues raised by repatriation,” using a slightly fancier word for deportation.

Health care for immigrants is a hot button issue. Though the Affordable Care Act excludes immigrants who entered the country illegally from the mandate to purchase health insurance, many U.S counties have taken steps to provide preventive and chronic care for them. The obvious rationale is that this care saves money and prevents suffering in emergency situations.

I’m confident that the transfer home of the Mexican man who’d had a stroke was both consensual and sensible. But given reports of patients being transported without their consent, this practice needs legal clarity to match the ethical aspirations of my profession.

One thing is clear: Without a policy change, hospitalized people who entered the country illegally and who don’t have insurance will remain vulnerable to the seemingly irreconcilable conflict in our society between commerce and medicine.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa’s Medical Matters. He’s on Twitter: @GlassHospital.

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