Remember, a dual eligible is some who qualifies for both Medicare and Medicaid. Having Medicare implies that you are either old or disabled. Having Medicaid implies that you have limited income. So what does your life look like if you’re a dual? Your hopes and aspirations are likely not appreciably different than those of others but your ability to realize those goals is far more limited.

Today, it happens that you have a 10:00AM doctor’s appointment. You arise at 7:30AM and, assuming that you have a place to live and food to eat, you dress and prepare your morning meal. At 9:00AM you walk to the bus stop. Oops. This town has no public transportation so you walk to the neighbor’s house who has agreed to drive you to the doctor.

On arriving at the neighbor’s house, you find the neighbor not at home so you dial them on you cell phone. Oops. No cell phone either. So you wait. Your neighbor returns home at 9:45AM having forgotten that they agreed to drive you to the doctor. So you set off,arriving at the doctor’s office at 10:20AM for your 10:00AM appointment. The receptionist chides you for being tardy and informs you that your appointment will be delayed due to the lateness of your arrival. You stay. Your neighbor leaves.

At 11:30AM you are called from the waiting room, have vital signs measured and are place into an examination room. At 12:15PM, the nurse appears and informs you that the physician has had to take a lunch break and will be back “shortly”. At last, at 1:25PM the physician appears, asks a few questions, reviews your chart, listens to your heart and leaves you in the room, alone. At 2:05 PM the nurse reappears with paper work and prescriptions and sends you to the checkout desk.

Since you are a dual eligible, at least you owe no money for the service. The questions now arise: how do I get home? How do I get my prescriptions filled? Oh yes, and where is the lab that must draw my blood and how do I get there? At closing time, one of the physician’s office staff volunteers to drive you home and shortly after 6:00PM, nine hours after you left for your appointment, you arrive back home to see if you have food for dinner.

As we had a physician explain once “Our patients don’t pay with money, so we make them pay with time.”

How do we make this better? How do we come to know the situation in which each of our members reside? We must reach this level of knowledge because we must provide custom solutions if we are to make an impact not just to healthcare but to the life of each member. Of course, remember that not all will respond. Nevertheless, we need to assist each member with their needs, cheerfully. And not just their healthcare needs but also in helping find ways we can help return this member to a satisfying and productive role in society.

Yes, I do realize that my utopian view is just short of tackling world peace but beginning next week we will break it down into bite size pieces. How do you eat an elephant? One bite at a time.

Join me in the dialogue. You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog. As always, thanks for reading and for your input.

George Martin, MD

Hopefully, based on last week’s post, you decided that we should treat the dual eligibles rather than leave them to the “left overs” of healthcare. Remember, these are people that have both Medicare coverage, either through age or disability, and Medicaid coverage. As such they have a set of characteristics that makes them vulnerable. First they are more likely to have either a significant medical condition or multiple medical conditions. Second, they are economically disadvantaged. This combination of characteristics implies that they need access to care more than the average person and that they are less likely to have access readily available.

Why?

First – You become neither disabled nor aged without an increasing likelihood that you have health issues. General Medicare recipients use medical services at a rate 4x times that of a commercial population. So getting old, while still better than the alternative, implies that you are not as healthy now as you were 30 years age. No surprise here.

Second – Medicaid does not pay as well as either commercial insurance or Medicare. This varies state-to-state as Medicaid is a state-administered program with federal funding. As such, it comes as no surprise that providers actively discriminate against identifiable Medicaid recipients. That is, Medicaid recipients are excluded from provider access whenever there is a better paying customer available. Why would a provider chose to see a $40 patient when an $80 patient was available? To do so would not make economic sense. Historically, this applied to emergency departments as well but COBRA and EMTALA put an end to overt exclusion from EDs.

Actually, duals are not an economic drag on providers. In reality, duals have both Medicare and Medicaid which means that Medicare deductibles and co-pays are picked up, in part, by Medicaid. This makes them economically equivalent to Medicare patients. Unfortunately, the provider perception is driven by historic Medicaid payment. At issue here is not the physician generally but the office staff.

Duals are a drag on office work flow. Why? A physician’s office is geared to delivering a certain set of care per patient. This may be preventive care or episodic care but either way, it is focused on the “typical” office patient. This is similar to the issue of large parties at a restaurant. Let’s say the kitchen is expecting parties of two individuals. The kitchen has three chefs, each of whom can prepare two – meals simultaneously. Thus the kitchen can provide service to a maximum of six customers with the food being delivered at the same time. A physician’s office is similar. The infrastructure is established to deliver care efficiently to one patient with one problem. A patient with multiple needs confuses and bogs down the system. This can frustrate staff and ultimately, potentially affect access as a result. The potential for access limitations is driven further by the economics of a physician’s practice. Just as the restaurant will automatically charge a service fee, the physician’s office needs a fee that, at least, offsets the opportunity lost to see an additional “typical” patient in lieu of providing service to the more complex patient.

Practitioners also need tools to make it happen. But more about tools in following weeks.

Do you have thoughts on providing care to Duals? Will you? Won’t you? Tell me more! You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog. As always, thanks for reading and for your input.

George Martin, MD

Dual eligible – If this is you, it means that you qualify for Medicare, usually by age but often by disability. You also meet criteria to be covered by Medicaid. It also means that you are most often sick, poor and vulnerable. You likely do not have many years left, and those years are likely to be less productive than your resource consumption.

I read an interesting article entitled Principles for allocation of scarce medical interventions. It indicates that dual eligibles are at the end of the line when it comes to receiving healthcare services. In fact, it doesn’t just imply that duals are even expected to go away and “die quietly”. This is a quote from an ex-congressman from the Orlando area, who presumably is engaging in projection bias.

Projection bias or psychological bias, for those of you not familiar with the term, is a process by which we deny our own thoughts and emotions and project them onto others. If you believe that this is not possible read the above article on allocation of interventions and notice that one of the authors is the brother of the Mayor of Chicago. He has also had access to the highest policy levels in the United States government and therefore influential in the ACA including a rationing board.

Centers for Medicaid and Medicare Services (CMS) is currently pursuing an alternative strategy: identify those in most need, evaluate the care that they need and then see that the care is both provided and coordinated to yield the best result. The intent here is to see that each patient gets the care needed. The assumption is that if the needed care is delivered, then unnecessary care is avoided. Patients who received needed care at 2:00 PM are much less likely to visit the emergency department at 2:00 AM. If they avoid the emergency department, they also have a good chance of avoiding inpatient care.

If their care is coordinated it is less likely to be duplicated or, worse, to be in conflict with other care. The assumption is that good care not only will minimize the need for other care, but potentially allow the individual to be more productive. Productivity would offset the negative impact of the cost of the care to society.

Benjamin Franklin said, “Any society that would give up a little liberty to gain a little security will deserve neither and lose both. He who gives up freedom for safety deserves neither.” We have given this right to society out of fear. For an entire book on fear I recommend “State of Fear” by Michael Crichton. This is a most interesting and readable novel but also a political commentary. It seems that we have changed a lot from “We have nothing to fear but fear itself” and “Ask not what your country can do for you but what you can do for your country” to health care is a right and on pain of loss of liberty we make it a demand of others.

Does society have the right to decide the value of a life relative to the healthcare received? Are we already doing it?

You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog. As always, thanks for reading and for your input.

George Martin, MD

The current prediction from the American Association of Medical Colleges (AAMC) is that the United States will need 130,000 more physicians than will be available in 2025. One-half of these will be primary care. They further predict that the lack of access will increase the cost of care by a combination of delayed care and inappropriate access. Much of that access will fall on already overburdened emergency departments.

The obvious answer is that we need to produce more physicians. This could simply mean opening up medical school admissions to a larger number of enrollees, and/or allowing additional international medical graduates to enter the US residency system. There is, however, a complicating factor. Based on AAMC statistics, only 2% of those entering medical school in 2008 indicated that primary care is their desired field. If this trend continues, then to produce 65,000 primary care physicians we would need to produce 3,250,000 specialists. 

Extra complicating factors exist that the AAMC does not appear to have taken into account. The AAMC includes trending based on those going into primary care to limit their worked hours to a more traditional 40 hour week, and the decision by many internists and some family practice and pediatric physicians to become hospitalists. We know that hospitalists solely provide care to hospitalized patients, thus, removing themselves from the pool of physicians providing direct access to patients. Taking those additional factors into account increases the primary care deficit to 100,000.

So, while opening more medical school slots and admitting more international medical graduates may help, it doesn’t solve the problem. Last week’s post outlines the economics of primary care versus specialists, and given the economic realities, physicians are making sensible choices. For example, if you were given the choice of working a 60 hour week to make a comfortable living, or working a 30 hour week to make it well into the top 1% of wage earners, which would you choose?

This leaves two tracks available to solve the evolving crisis.

Track 1:  Regulatory – In some way, mandate that a certain percentage of medical school graduates or entering international medical graduates enter primary care residencies. Since, through Medicare and Medicaid subsidies, the federal government controls the available residency slots, let’s just change the mix of available training positions. Or, one might decide to forgive a graduate’s loan for a commitment to enter primary care, and to practice for a certain period of time. Similar to the programs used to entice physicians into underserved areas. We are sure that the bureaucrats can add to this list with additional ways to limit personal choice of career track.

Track 2:  Economic – Again, based on the power of the purse, Medicare has distorted the economics of physician reimbursement. Physicians are mainly paid based on what they do, not what they know. We require physicians complete a minimum of seven (7) years of education beyond college, and we pay them for a technical skill. Now brain surgery is important, but the decision to do the surgery is just as important. Yet, the reimbursement for the surgery may be as much as 100 times the reimbursement for the decision. None of this is based on market forces, but rather on the decisions of bureaucrats responding to lobbyists. Now we are not naive enough to expect that the bureaucrats will allow market forces to replace themselves, but a simple solution would be to allocate 25% of reimbursement to medical decision making, up from the 10% today.  

Such a solution would remove the worst of the economic disincentives to practicing primary care. Quality improvement theory and practice tells us that it is better to remove barriers than to create more. Pushing people will cause them to react. Removing barriers will also allow for more individual freedom. 

What are your thoughts on better solutions?

You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input.

George Martin, MD

Since World War II, the baby boom has driven the economics of the United States. We drove baby sales in furniture and then bicycles. We drove housing and cars. Now, we drive, and will continue to drive, health care demand for the next 20 years. We are aging and there are a lot of us so the needs for health care, from drugs to hospice, are a growth industry based on demand. Time to invest? Perhaps.

Hidden in the demand model is the supply model. Here’s where it gets scary. Among the number of baby boomers, is the largest supply of workers for the health care industry, most importantly, primary care and specialty physicians. Given that the delivery of health care services is, by definition, a local event; it is difficult to send these jobs overseas. Yes, I know that there is an opportunity to get your hip replaced in Thailand. However, if you fracture your hip, it’s unlikely that a trip overseas would be tolerable. Add to the local nature of healthcare deliver the fact that healthcare is a people industry, and we have double trouble. As baby boomers age not only do they require more care, but they will be providing less care to others. The reality is, retirement is upon us.

The American Association of Medical Colleges estimates that by the year 2025 we will be 130,000 physicians short of demand. Half of the total will be in primary care. As we touched on in last week’s post, the demand for primary care outstrips demand now. The AAMC further estimates that the shortage in primary care will increase the cost of care.

Why would the lack of a resource drive up the cost? The short answer can be explained by the law of supply and demand. However, healthcare finance is so regulated that the normal response to a shortage, which is to increase price, cannot happen. Take the cost of gasoline. Over the past several years the supply of gas and the demand for gas have been in exquisite balance. Tiny changes in demand send the price skyward and vice versa. The system is so sensitive because the supply has been limited by cartels and governments and nature.

In healthcare, supply and demand are both fully elastic but payment is fixed. Of course, price fixing inevitably leads to reduced supply as providers vote with their feet. The lead-time to ramp up new doctors in healthcare is long because the educational investment required of providers is large. For the same reason, opting out becomes difficult as there are significant loans to repay. Still, that time has come. Hence the increase in retirements, some as soon as financially feasible.

How then does reduced supply lead to increased cost? According to the AAMC, there are several paths:

• Since demand is still present, demand will seek alternate, more expensive pathways to care such as:
  • Urgent care
  • Emergency departments
  • Specialists
• Since access to care (supply) is reduced, patients may delay care until more expansive (and expensive) care, such as an inpatient admission, is required.
• The care that the patient receives is neither coordinated nor holistic resulting in the potential for expensive duplication of tests and effort on the part of treating physicians.

Then again, the American College of Physicians white paper of 2008 concludes that there is s 5% increase in the mortality rate for each decrease in the patient-to-PCP ratio of 1:10,000 primary care docs per population. So we have increased cost for decreased results. To quote Hannibal Smith “We love it when a plan comes together”.

My goodness. Where to from here? How do we address this critical shortage, not only for future generations, but for baby boomers like me, even for my own generation? Tell me, please.

You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog. As always, thanks for reading and for your input.

George Martin, MD

I am reminded of one late night at the emergency room. I was to provide care and admit a sick child to the hospital. While finishing the paperwork, the father of another patient appeared and recognized our presence. The comment was, “Well doc, have you got this shift?” My answer easily could have been “Yes and the shift before and the shift after and the shift …” You get the picture.

A common model for private practice then and now is for primary care physicians to gather into small group practices or small coverage groups. Thus three to five physicians will rotate on call “after hours”; perhaps every fourth night and every fourth weekend. Commonly, they will also have Saturday office hours and will make rounds on patients that are hospitalized. The average work week then is at least  60-70 hours. Because the need to generate revenue is the driver of the practice profit, little time is given to vacation. In total, this drives an average hourly wage of $50.

Pose the question to Ask.com, “What is the hourly wage for a plumber?” and here’s what you’ll find: [A] decent journeymen [will make] $90+ per hr, Master plumbers around $200 per hr and [plumber] Helpers normally $50 per hr.

So the average hourly wage for a primary care physician is about the same as for a plumber’s helper. Now the average surgical sub-specialist, such as a cardiovascular surgeon, is quoted to make four times the salary of a primary care physician. However, if you calculate the compensation on an hourly basis it calculates to $550 per hour or 11 times the compensation of a PCP! Can you spell primary care shortage? Is it any wonder with the financial disparity?

In this circumstance, we would expect that the delivery model must change. And it is changing. The most dramatic change over the past 10 years has been the advent of the hospitalist concept. Few, if any, large hospitals are now without a cadre of internal medicine physicians, practitioners who have limited their practice strictly to providing care to hospitalized patients. The compliment to this development is the cadre of internal medicine physicians that have given up their inpatient duties and are not solely practicing in the office.

The major issue is the improvement of life style for the primary care physician that is possible as a hospitalist. Now, PCP offices tend to be open defined hours and the demand is high enough that the schedule is full for the next two weeks. Any patients that need to be seen immediately are likely to be referred to an acute care facility. This includes the other major change – the development of walk in or urgent care centers – or they may be sent to the emergency department.

Care at either an emergency department or an urgent care center can be and often is excellent. However, they function without adequate access to historic patient information and they are, of necessity, problem and not patient focused. There is also the problem that the information generated at those sites fails to be available to the PCP at a later date, so coordination of care suffers significantly.

I am reminded of the truism: Our system is perfectly designed to achieve the results that we realize. The exception here is that our healthcare system was never designed. Like the metaphorphosis of Harriet Beecher Stowe’s immortal character, Topsy, I s’pose our new system “just growed”.

How do we right this ship? Or can we? Tell me what you think!

You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input.

George Martin, MD

Disease Management (DM) programs, as currently structured, are focused on prevention of acute exacerbations of chronic conditions. NCQA has a list of the things that should be done for patients with specific diseases. Within this measurement structure it has been demonstrated that if these measurable outcomes are met, the population being treated will have better health and cost less. So far so good, but my question is “Have we improved the health of the patient?” Further, have we empowered the patient to remain well (by removing any barriers and by education, access to health resources, etc.) or are they dependent on a DM program to maintain their health?”

Good DM programs can and do provide education and some level of empowerment to patients to live healthier lives. NCQA has chosen not to incorporate these efforts into their standards. NCQA is all about measurable standards and empowerment is difficult to measure. But, empowerment is what sustains the patient when they are again on their own. In  our current climate, employers routinely change health plans. Plan “A” may have a DM program that addresses congestive heart failure but plan “B”, the new plan, may have found that addressing asthma was their choice. If plan “A” has not empowered the patient but rather caused the patient to be DM dependent then the patient will not sustain improvement when the program disappears. It’s a vicious cycle that repeats itself every year at benefit renewal.

For those of you who have read much of the previous writing of this blog you will know that we are deeply committed to helping make those who can be independent, independent. There are those, of course, whose illnesses are so advanced that they are no longer capable of independence. Those patients are apt to have multiple chronic conditions and require Case Management (CM) or be enrolled in+ Special Needs Programs (SNP). The standard DM program is focused on the medical needs of a specific disease and its associated processes.

The complicating factor is that we forget that medical needs are not independent of behavioral needs. When I was in medical school, the Department of Psychology at our local VA teaching hospital decided to do psychological testing on the patients in the coronary care unit. Remember, at that time the care was only supportive. No clot busting. No CABG. No PCI. Tests were administered and a conference was held. The results demonstrated that the patients were depressed. Consider the full scenario for a moment: you have just gone through some of the worst pain in your life and now are in an ICU where you have limited access to family. The lights are constantly on and there is constant noise and frequent alarms. You do not know if you will live or die or if you will ever be able to function normally again. Surprise, you are depressed.

Now consider the flip side. You have depression and diabetes. Because of your depression you have little energy to address your medical condition. Your HgB-A1c goes to 14.1 and you develop chest pain, which you ignore. Your health continues to spiral down and soon you end up being in a DM program for your diabetes. Do they have the resources to understand your behavioral health needs or do they just push you to get to the doctor to get your dilated retinal exam (DRE) because it is a measurable outcome. Do not suppose for one minute that we think the DRE is not needed but this business is a balance of patient and population needs.

Let’s not lose sight of the patient needs.

Your thoughts? You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input.

George Martin, MD

A common commercial or public service announcement now airing starts off with a customer questioning everyone from a car salesman to a computer repair guy. He has endless questions for these people. Cut to a scene of him finishing an examination at the doctor’s office. The physician asks “Any questions?” The customer turned patient sits mute.

The reasons for this are two fold – trust and fear.

Trust is a necessary component of the patient’s relationship with their physician. How else would you be able to say to your surgeon “Go ahead and cut, doc.”? First, we must trust that the diagnosis and treatment are correct. Also, we must trust that the physician is competent to perform the procedure. Neither is always an accurate assumption.

When in medical school, the following was a common aphorism: “80% of your patients will get well no matter what you do, 15% of patients will get well because of what you do and 5% will get well in spite of what you do.” This leaves out how many patients suffer unnecessarily because of what we do or fail to do. Ronald Regan, when asked if we should trust the Soviet Union said yes “Trust but verify”. We give the patient no structure to verify but some manage on their own and the internet provides a service to many with questions but we have no idea of how many fail to verify their trust.

Fear is sometimes paralyzing. When a patient visits their surgeon about the results of the biopsy they had last week, it is not uncommon for them to bring someone with them. Frequently, this person is their significant other. Unfortunately, when presented with the dreaded diagnosis, it is not uncommon for the companion to be paralyzed with fear as well and still we leave without understanding the diagnosis, its implications or treatment options and the likely outcomes. Additionally, the physician is strapped for time and may not have all of the answers.

As part of my medical practice, I was on staff at a major academic teaching hospital. My group also practiced at a community hospital. At the community hospital, it was my job to diagnose and treat patients. At the academic center, it was my job to follow behind the professor’s retinue of clinicians and provide the patient and family with an explanation of what had just been said. It was also my job to ensure that the care being delivered was the correct care and that the patient knew the likely results.

So the patient and family need appropriate support to validate and verify their trust and to understand their diagnosis and the options associated with same. How can this be accomplished?

Readers of this blog will know that I passionately advocate that care management and coordination should be readily available to patients. The above scenario is a care management function. However, I also believe that a nurse is unlikely to be able to fill the role described above. This is not meant to disparage the quality of nursing or the skill of an RN. On the contrary. It is recognition that the patient may need a more robust support service when presented with a life threatening diagnosis. Nurses are highly skilled and adept at providing support, understanding and compassion to those in need while also bringing with them an innate ability to advocate on the patient’s behalf, asking questions, listening carefully and getting answers. The nurse case coordinator will need access to resources to assist with questions. The care coordinator can also prompt the patient for questions both before leaving the office and as part of follow up but should not be expected to be able to provide all of the answers. A support network will need to be established and protocols developed. Some providers will find this threatening to their autonomy and this will also need to be addressed.

An article in a recent Wall Street Journal indicates that primary care physicians are incorrect in their diagnosis as often as 17% of the time and even pathologists making the diagnosis of cancer to be wrong 16% of the time. Given those odds should a secondary review be less than expected?

What do you think?

You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input.

George Martin, MD

As doctor and Senator Bill Frist said, “America enjoys the best health care in the world, but the best is no good if folks can’t afford it, access it and doctors can’t provide it.

But while all patients want access, actually having access means different things under different circumstances. Let’s look at three possible scenarios:

Scenario 1:

For those patients who are otherwise well, access means being seen in a timely fashion when we want to be seen. Let’s say it is Saturday afternoon and I have fever. If the fever persists and I still feel bad in the morning I will want to be seen, diagnosed and treated. No matter that it’s Sunday morning, Tuesday or Christmas Day. Day of the week or hour of the day means nothing to me. I am sick and wish to get better so that I can do what needs to be done in my life.

But who will see me in these circumstances? It is highly unlikely that it will be my primary care physician. My access options have rapidly dwindled to either an urgent care center or the emergency department. No matter which I choose, will my primary care physician (PCP) be informed? Perhaps in the greater scheme of things a copy of the encounter will be forwarded to my PCP’s office. However, my PCP will not read the material or follow up to make sure that I got well. My new medical records will be filed and only referred to in the case of a malpractice claim.

Sigh.

Scenario 2:

Your primary care physician has just told you that your mammogram came back suspicious for malignancy and you will need to have a biopsy. At this point your response is shock – “Oh my God, he just told me I have breast cancer!” – This thought going through your mind precludes all hope of a rational discussion. You allow the “system” to take over. This probably means that you will be sent to the front window to check out and they will say that Dr. Smith, the physician to whom you are being referred, is not in the office on Thursday and that the office will follow up with  you tomorrow to establish when the appointment with Dr. Smith can be done.

Friday, after a nervous night for both you and your spouse, you expectantly await your PCP’s office to call. Late Friday, the anticipation peaks and you call your PCP only to be told that they were unable to get to the issue earlier in the morning and now the specialist’s office is closed until Monday. Have a great weekend. Really?!

Scenario 3:

You have a care coordinator assigned to you when you join your new health plan. As part of your intake or first visit to your provider the care coordinator takes the time to make you aware of the care coordination function. You now understand how to best assess issues. The coordinator explains about your need to ask questions so that you can better understand your situation and provides easy access for you if additional questions arise. 

 In either of the first two scenarios your care and issues will be coordinated and addressed. As part of the health plan in the third scenario, you have immediate telephone access to your care coordinator and your needs are promptly and effectively addressed. Ahhh.

Which would you prefer? Can you relate to one of these access scenarios? What can we do to better manage access as well as patients’ expectations of access?

Do tell! You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input.

George Martin, MD

In keeping with several comments from readers provided in December to this blog, I plan to begin this year with a focus on the patient. Making 2012 “the year of the patient” was a specific request and so we will try. In doing so, I would like to not only identify the patient’s needs but also their wants. They are, after all, the end user and ultimate customer of the health care system. Unfortunately, like most systems, healthcare would rather ignore the customer. As I have heard it said “This job would be easy if we didn’t have to deal with patients”.

So what do health care customers want? First, they generally want to be left alone during times they perceive as private, and often, rightly so. Witness the telemarketing issue and the national do not call list. As you begin to eat dinner the phone rings. Dinner time is well known to be an opportune time to reach people. So, be it telemarketer or care manager, this interrupts what the customer views as their private moments.

Since most people are polite, we get many to discuss their health care while dinner gets cold. Others screen the call with ubiquitous caller ID and just ignore the phone. Some answer and then hang up; others answer and are intentionally rude before hanging up. In any case, due to our own insensitivity to our patients’ personal needs, we have established resistance to further interaction. But, as a care management team, we chalk up another contact against the performance goals. Bully for us! What we really need is to establish more effective methods of contact and encourage participation for patients that need care management, not poison the well for future intervention.

So a rule of conduct might be:

• Leave the customer alone until and unless we can demonstrate that they need, or they indicate that they want, intervention
• Reach out to them at a time and in a manner that is mutually agreeable

These principles lead to two further actions:

• Provide the customer with constant education as to how and when to access the care management system. This includes patients, their families and their physicians. Having changed insurance carriers several times in the past few years, I have yet to see a company that is pro-active in this regard. I sense fear that allowing or even encouraging those durned patients to access the care management system will use resources that we wish to conserve.
• There is an obvious need for transitions in care to be identified in real time. Most systems rely heavily on claims data, either high loss ratios or specific high-cost events like hospitalizations, to trigger a care management referral. By the time that claims data make its way to the level of referral to care management the patient may be dead. Even relying on hospital discharge lists is sub-optimal. At best we would like to avoid the initial hospitalization but, at least, we should be aware of the admission – not the discharge.

Many health plans also use claims data to establish trends. HEDIS data exemplifies this use. For example, we know that dilated retinal exams (DRE) for patients with diabetes are important. Therefore, we track this service as an important measure and it is commonly used to assess health plan and provider performance.

When we fail to achieve our targeted goal (in this case, the number of diabetic patients getting DREs), we educate the population as to the need. We also educate, and sometimes punish, providers that fail to meet the HEDIS standard. Would it perhaps be better to transition from the HEDIS population measure to health plan specific goals once we have used HEDIS to identify a trend? By this I mean once DRE has been identified as an opportunity by the health plan, shift away from the use of generic responses such as education and move toward identifying the patients that should have had, but have not had, their DRE. Then we could identify the specific issues for those who did not have the exam and identify and remove barriers that have kept them from getting their DRE, as appropriate. Following this approach, we just might find out that the patient had actually had the exam and/or did not need the exam if, for instance, the patient is already blind. By setting specific goals, we will know whether or not the DRE is indicated. Claims data is often lacking in this level of detail.

It appears to be a human issue to pass general rules to address specific issues. A more effective path to improvement is to identify the specific issues and address them.

In this, my self-declared Year of the Patient, I look forward to your continued thoughts, feedback and suggestions. Can we get there? What will it take to make this paradigm shift? Will it be like turning around the Titanic? Let’s hope not!

You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input.

George Martin, MD