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

Whew! We made it. The end of another year. And a new year about to begin. Last week, we paused to reflect on the events of 2011. This week, we begin to plan for 2012.

For the moment, we believe that we have covered care management and the PCMH concept fully. Surely issues will develop in the coming months that will allow us to return to the topic but, for now, we will move on.

On to what, you ask? To the external forces that exist and how they are likely to impact the healthcare delivery system. Are they positive or negative for outcomes and how wll they impact people? Only time will tell.

Among those forces are whole arrays of players (not listed in any particular order):

• Patients and their caregivers
• Concerned citizens
• Providers including:
  • Hospitals
  • Physicians
  • Home health care
  • Chiropractors
  • Physical and occupational therapists
  • Long term care hospitals
  • Rehabilitation facilities
  • Nursing homes
  • Nurse practitioners
• Insurance companies
• Government
• Employers
• Regulators
• Advocacy groups
• Others?

Each of these groups has an agenda  as well as fiscal needs. For many, the healthcare delivery system  represents their livelihood, for others their very existence.  Bringing these groups to consensus has not proven possible to date. Without such agreement a comprehensive solution is likely to be more divisive than inclusive of facilitating excellence in care and care delivery.

What do you think? Can we make a positive difference in healthcare in 2012?

Share your predictions with me! You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

As always, thanks for reading and for your input. We’ll be taking a break for the holidays and will be back with more thoughts on healthcare in January 2012.

George Martin, MD

Welcome to years end, a time for reflection, and soon to the New Year and a time for planning. This week and next we will do both. First, the reflection:

For many of us, college is far too far in the past. Personally, mine started with physics as a major. In the midst of my junior year, there was a realization of two things:

• Physics was boring
• The were no jobs in physics

A good friend was completing his PhD. He sent out 200 resumes and only got 2 responses. Thus my ensuing career change to medicine, which has not been boring. For those of you who follow the developments in physics, that has not been boring either. But I digress.

For the past year, we have focused on the needs of patients for care management services. Frankly, coordination and continuity of care in the US stinks. With rare exceptions there is no system. One cannot even be admitted to a hospital without answering the same demographics questions multiple times. Must have been a Freudian slip, but initially, I wrote “tomes” instead of “times”. It certainly feels like tomes when answering the same questions the third time being admitted to the same facility you were at 3 weeks ago.

Systems do not talk to each other. Providers don’t talk to each other. No one asks the end users for input about the needs to perform their tasks. If you begin to feel the frustration, that is my intent. And yet we progress. Somehow and some times, in spite of our self. Often it feels like one step forward and two steps back. But it is motion. And things change. Like it or loathe it, we have a health care reform bill chugging along and we are all changing our behavior to meet the mandates.

Someone must begin to take responsibility for the management of the care each individual receives. I can see only two choices:

1.  A comprehensive and possibly coercive care management system will develop with the focus on cost containment. Such a system could eventually include rationing and end of life exclusions without patient choice. Such a system, of necessity, would be focused on the needs of the collective.
2.  We design and implement a system that meets the needs of the individual patient and empowers each of them to manage their own life and their associated healthcare. Such a system would provide needed support but require individual responsibility.

Thus the conundrum of our times. Does our system become one of central planning and control or do we allow for failure to achieve healthcare goals knowing that when an individual fails they may pay, literally, with their life.

Wherever you decide to enter this discussion, it also applies to the wider scope of life in these United States of America. This is a philosophical difference that has little room for compromise. To compromise here is essentially to admit that one has no core beliefs and perhaps no moral compass. Free choice as the morality of either can be supported but the choice is collective responsibility versus personal responsibility.

Are you as frustrated as I am? 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

Last week, we got you through the challenges of care coordination up to age 18. Now we will look at the needs of the 18 to 35 year old group. The problem here, so to speak, is that this group needs little intervention but they can most certainly still benefit from it. After all, to quote the old adage, an ounce of prevention is worth a pound of cure.

This group is young, active and vibrant. Interested in career and family, the opportunities to affect change here are limited. Yet this is a crucial time in their lives to influence beneficial habits as they are cementing lifestyle behaviors that will have a major impact in later years.

Based on nothing other than personal observation there are opportunities to make and impact:

1.  Family planning – Historically, it has been unusual to see a man joining a woman in an obstetric office and pre-planning a pregnancy is often an afterthought. Once a woman is expecting, the current recommendation is for ten prenatal visits to monitor a normal pregnancy. Some health care professionals advocate the addition of an eleventh visit that is not only prenatal but pre-conception. This visit and other key visits, such as when the infants sex can be determined, can and should involve the father. Not only is this likely to be good for the family but also it would allow a care coordinator to interact with the father to assess his potential needs and to provide the parents-to-be with education specific to the pregnancy as well as to general issues.

2.  Injuries – This demographic group is active and many minor injuries including sprains, contusions etc. tend to occur. Some of these are treated in the emergency department but most of these injuries do not require that level of care and are treated elsewhere. Urgent care centers have been a recent development. These walk in clinics are designed to treat simple acute illnesses and injuries. They generally do not provide follow up but rather send the patient back to their primary care physician or to the appropriate specialist, such as an orthopedist, for additional care. The presence of a virtual care coordination function at these sites would ensure that the patient got active continuing care and provide an opportunity for education.

3.  Psychoactive drugs – Unfortunately, there is a darker side to this age group. Psychoactive drugs from narcotics to the atypical anti-psychotics are routinely prescribed by physicians without specific training in their use. The typical response of a physician treating an acute injury is that the narcotic prescribed is not addictive if used for acute pain or that they are required by regulation to treat pain with narcotics. Wrong on both counts, but they are an  easy and fast fix.

So even though this group does not access routine preventive care, there are opportunities for both intervention and education. There are those who would advocate for routine preventive care for this group. I have two comments for them. First, there is little, if any, evidence that preventive care such as the routine physical, as currently constructed provides medical value in this age group. And second, good luck. This customer group finds no value and has no desire in wasting their time or money. Trying to force them into a preventive solution reminds us that “Control is an Illusion.” Get over it.

Are there other ways to intervene effectively for this age group? What are 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

Generally, the response to health care issues is that the system is broken. Out-of-control costs are often cited as the issue and short term solutions typically are proposed. Previously, we discussed end of life issues. Now, here is the other extreme. More than 50% of all children born in the United States are eligible for government assistance to meet their health care needs. Medicaid is the largest of the programs. It also includes programs for “Healthy Children” and for those with specific disabilities.

One common complaint from both governments and payors is that this population accesses the system through the hospital emergency departments. The response is often to establish programs that are forms of demand control. Nurse call lines, increased co-payments and “education” are all attempts to modify behavior by inhibiting use of the “inappropriate” resource.

What should be well known is that placing barriers in front of people only causes reaction. Push me and I will push back. This is normal human behavior. Certainly, it’s possible to  place barriers before people that are increasingly difficult to surmount but this runs the risk of unintended consequences including inhibiting children from receiving appropriate care in a timely fashion and thereby increasing the ultimate cost of care.

The issue is access to appropriate care. Or rather lack of same. High volume and long waits for office visits, lack of preventive care and no access at all at the time the public desires/needs it all contribute to use of the emergency department as a source of acute care that might better be delivered elsewhere.

At 2:00 AM, if the only source of support for a parent with a febrile child is the emergency department, then that is where parent and child will go. It’s possible that the only service needed might be to have a grandmother available to reassure the mother that the child would be alright but granny was not available. Given the potential for additional lifestyle issues and the not being able to get into the child’s physician in the morning, why not go to the emergency room?

A more effective way to approach change in human behavior is to remove barriers. Access to health care is the main barrier. Lack of access for children is driven by many issues. Not the least is that the system has long treated payment for the care of children at a lesser level than that of adults. Medicaid state rules often limit the reimbursement for level four (4) and five (5) evaluation and management (E&M) CPT codes to no more than one every six months. State health departments administer vaccines at no charge in direct competition with the medical home concept. Free vaccines are a good thing, but getting to a state health department is a challenge for many families.

So what should we do? How do we remove barriers and positively influence behavior to ensure that care and treatment are provided by the appropriate provider at the appropriate location?

1. Support the Pediatric PCMH concept.
2.  Recognize that access is an issue.
3.  Enhance access at the times that the patient or family desires.
4.  Shift payments from procedures to primary and preventive care.
5.  Support coordination of care.
6.  Anticipate the upcoming needs of individual patients and educate the caregivers.

What else would you do to remove barriers? 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

Care Coordination Summary

Based on the blogs of the past few weeks we have tried to rough out the functions that care coordination must accomplish. To be effective, it must be literally cradle to grave with special emphasis on life’s transitions. And it should be continuous, though not necessarily obvious.

Children need preventive medicine and preventive education. Protection against infectious diseases and anticipatory guidance to drive life style choices are equally in need. Smoking cessation would be unnecessary if one never started. Small pox, once a scourge of mankind, is now extinct (except in captivity) due to vaccination.

Young adults probably need fewer checkups and more check-ins. They should be encouraged continually to make healthy choices. Seeing a doctor for a physical exam is not likely to be of much a value.

The value proposition changes with age and the development of health issues but the need for continuity of care coordination does not. Care coordination requires a comprehensive and flexible structure. It cannot be one size fits all if it is to be successful.

Much of the care coordination function has been left to payors. Sometimes this is the insurance companies and sometimes the employer. Neither of these strategies is optimal as the likelihood of staying with either an employer or an insurance company for life is remote. Insurance contracts are reviewed annually and employment rotates on the average every five years. This leads to short term strategies to drive returns.

Thus a disease management program to improve the health of asthmatic patients is common. Such a program will decrease cost almost immediately. However a smoking cessation program that yields continuing returns for many years is all outgo with no income in the short term and any reduced cost of health care is at risk to be reaped by the next payor.

These issues suggest that the care coordination function should follow the patient and not the insurer. Similarly to the mandate that insurance should be continuous when changing jobs, care coordination should be continuous as well. Patients could be assigned to a permanent care coordination function that was funded by payors but not managed by payors. Care coordination would be a standard part of the insurance package but managed in the best interest of the patient and paid with a simple per member per month stipend.

Such care coordination would continue as long as the patient was covered by insurance. The nature of the insurance (Medicare, Medicaid or commercial) would not be immaterial. The needs of the patient would drive the resource allocation.

An interesting and potentially utopian thought perhaps. What do you think?

Thanks in advance for your input. You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

George Martin, MD

 “No one wants to die. Even people who want to go to heaven don’t want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life’s change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true.”

 – Steve Jobs Stanford Commencement Address Spring 2005

In 2009, total expenditures for Medicare were $2.5 trillion. That same year, the Centers for Medicare and Medicaid Services (CMS) estimated that 25% of those costs were spent on end of life care. Over 10 years, reducing end of life costs by 50% would reduce the expenditures by approximately $3 trillion. Yet we fail to use available resources to advise patients and families when the obvious end is near.

A plethora of resources exist from social work to hospice to assist with end of life decisions, but the common starting point is with the attending physician. And the physician has no skill at this. How much sadder we must make patients and families by not appropriately adjusting their expectations. But we neither train for the skill nor support the skill when used. It seems that we are wonderful at treating disease but not well equipped to treat patients.

To treat patients requires knowledge of their needs and desires, empathy and training. But physicians are trained to treat disease and we are not trained to assist with the big questions. Who takes the lead on asking what the point is to end stage care and when does that conversation take place? End stage disease comes for various organs. Heart failure, Alzheimer’s, ESRD and ESLD patients may have their lives extended. When do we take them into our confidence and allow them to know that they are not going to get well? The answer is almost never because we are so focused on treating disease.

Here, then, is another critical transition. Based on the preceding blogs, we decided that communication and handling transitions appropriately is critical. This next to last transition, the last being to the undiscovered country, must be done by the medical profession. If we do not,the work will be done for us and likely, not by those with the most knowledge. Good care coordination will preserve choices for patients and families. Poor choices will result in central governmental planning that will be one size fits all and rigidly applied. See above for the dollar value of limiting end of life choices.

Transitions to end of life choices are not easy. People are dysfunctional and families differ on choices. If this transition was easy it would have been accomplished.

What do you think?

Thanks in advance for your input. You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.

George Martin, MD

Going forward, much of the care coordination function will, of necessity, be centered at the site where we receive the bulk of our care: at the office of our primary care doctor. Based on previous postings, this will exclude those patients with serious chronic disease as well as those patients transitioning from stable to serious chronic disease, both of which will be managed through their specialist or via a virtual function.

For the rest of us, is the primary care office ready to manage the care coordination needs of the bulk of their patients? Have you been to a primary care office lately? I think not. I know dog owners who tell me they get treated better when they take their pets for veterinary care.

Start with the office layout. You walk in the door into a holding area. A reception window is across the room. The room is filled with others already waiting and the window is closed. After signing in you take a seat amongst the crowd and wait without information. Finally, you are summoned to be weighed, measured and placed into an examination room. And again, you wait with no information except that “The doctor will be here shortly”.

Flash forward. You have now spent one and one half hours waiting. At last, the doctor appears and spends less than ten minutes with you before telling you that you are free to go to the check out desk to settle your bill. You have spent a total of two hours of your time for a total of fifteen minutes of clinical intervention.

Those two hours could be productive with no additional physician time required and patients likely would be much happier. Three interactions come to mind:

1.  An onsite care coordinator could discuss your concerns, issues and needs and prepare them for the physician.
2.  A virtual care coordinator could educate you about your condition.
3.  An interactive website could be preparing a profile such as a health risk assessment for review.

Both 2 and 3 above could be done off site before you arrive – as could the routine issues at the front desk. Then, you would not be exposed to the contagious diseases lurking in  the holding pen, I mean waiting room, and could go straight to the care stage.

Interestingly enough, the waiting room model from above seems to work reasonably well for specialists. This is primarily because they only schedule 2-3 patients per hour. Your primary care physician will schedule twice that number due to financial requirements, reimbursement and provider contracted requirements. Waiting time is dramatically reduced and patient satisfaction is improved with increased face time with the physician. No wonder patients hate the gatekeeper model where you must have a primary care referral to see a specialist.

In these days of increasing transparency of patient satisfaction, putting the care back in primary care is essential. Truly, specialists and veterinary care physicians have figured out that satisfaction is more than a reflection of just clinical expertise … it’s a result of the total patient experience.

An interesting video makes this point well,  if you can get a copy. Video trailers  can be viewed online at http://www.crmlearning.com/its-a-dogs-world. The story demonstrates the parallels between human and veterinary medicine from the service mindset which is pertinent here.

The biggest barriers I see are time/money and mindset /change.

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 sharing your thoughts.

George Martin, MD