A New Way To Improve Primary Care Yet Reduce Total Costs

PCPs in the current reimbursement model are obliged for business reasons to see too many patients per day which of course means less time per patient. PCPs are frustrated and patients are less satisfied. With less time it is hard to build a strong doctor – patient relationship and without it there is less opportunity to build trust. Readers of my posts know that I am a strong advocate for primary care and for granting the PCP added time per patient but doing so with no decrement in income. Here is an innovative experiment by an insurer to incent PCPs to offer more time to those patients with chronic illnesses while enhancing preventive care to all. 

Added time and good care coordination will improve the quality of care for the individual patient with a chronic illness and yet will reduce costs by eliminating excess specialists visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. That was the assumption underlying a program by a large not for profit BlueCross/Blue Shield plan - CareFirst. Fundamentally the plan incents PCPs with opportunities for increased income in return for giving added time and good care coordination to those with chronic illnesses along with enhanced preventive care to all patients. 

The insurer calculated that about 80% of their medical expenditures went towards the care of just 15% of patients. These were patients with complex chronic illnesses. Knowing that primary care physicians receive about 5% of total healthcare expenditures it was hypothesized that they are in a position to strongly impact much of the other 95%. The insurer also wanted to raise awareness of healthy lifestyles to assist all of their enrollees to remain healthy. So the agenda was to create incentives for PCPs to have an impact to reduce the total cost for those with chronic conditions while improving the care and concurrently maintain the health of the remaining enrollees. 

Oversimplified, the new program works like this. PCPs form into actual or virtual groups or panels of 5 to 10 and enter into an agreement with the insurer which then increases their reimbursement by 12% for each visit. The insurer also agrees to pay the physician within one business day, reducing the doctor’s need for working capital.  

An actuarial analysis of the PCP group’s patients is done using claims data from the prior year to create an anticipated “global budget” for the coming year.  The 15% or so of patients that need chronic illness care coordination are “flagged.” The PCP’s obligation is to give those patients whatever added time is needed per visit, to create a complete care plan and to post it in an electronic medical record (for which the PCP gets an additional $200). This serves as automatic preauthorization; no further calls will be needed for tests, procedures, etc. – a major time saver for the PCP and the office staff. The concept also anticipated that with extra time per patient, the PCP would be able to handle most issues including those of patients with complex chronic illnesses, reducing the need for specialist referrals. Finally, the insurer makes available a nurse “care coordinator” at its expense  to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever else the PCP has built into the care plan. The expectation starting out was that this approach of incentives for giving the patient with a chronic illness the intensive primary care and the care coordination needed would enhance quality yet reduce the overall expenditures for that patient.  

If, at the end of the year, the PCP groups’ total claims came in under the projected global budget, the members of the virtual group would get back a portion of the savings. With these incentives, it was anticipated that the PCP would be sure to carefully coordinate care so that there were no excess specialist visits, no unneeded tests or procedures and, with better care overall, less ER visits and less hospitalizations. The end result, it was hoped from the start, would be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Now three years in, the plan seems to be working. The physicians are pleased with the added income and the insurer is pleased that total costs have dropped. 

The whole concept was to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It is a transformational change in how the PCP functions. It is an equally huge transformational change for the insurer –a change that accepts that extensive primary care with care coordination costs extra money but recognizes that the end result is better quality at a lower total cost.  

After two years, it was reported that it saved $136 million with the 297 panels of 3,600 PCPs that had joined the program caring for about one million individuals. All of the PCPs enjoyed the added income in their reimbursements and two thirds received end of year incentive payments as a result of the savings. Overall the average PCP in the program received about 29% more than they otherwise would have under the standard fee schedule.  

At the end of three years and with enough data to be actuarially credible, there have been quite definite improvements in ten measures such as costs per member per month, number of emergency visits, admissions per 1000 members, length of stay, cost per admission, and readmissions within 30 days after discharge, etc. while maintaining or improving quality measures. Not all panels of PCPs were as successful as others and those that were tended to be successful in each of the three years in the program. At the end of the third year, about 60% of the panels were granted an incentive award for beating their projected global budget. The successful panels tended to be those in small private practices and, interestingly, had sicker patients under care yet they maintained higher quality scores. Another important finding was that some specialists tended to much higher utilization (and therefore costs) than others despite similar patient problems. PCPs who tended to refer to high utilization specialists were much less likely to achieve an end of year incentive payment. 

Of course, there are some questions to raise. If the PCP is spending more time with these patients but still has the same total size practice, then where is the time coming from? Does it mean less time for other patients? PCPs have now learned which specialists expend more dollars per patient than others. Will their referrals gravitate to these specialists regardless of known or perceived quality? Patients will likely in the future be offered incentives for choosing the PCPs that are most effective with this program; is that appropriate? And what about those PCPs who have converted their practices to direct primary care? They are actually saving the insurer considerably, probably much more than the incented PCPs in this program. The insurer should consider paying all or part of the DPC fee for their insureds since the insurer is benefiting substantially yet at no cost to itself. 

Perhaps the most important outcome, from my perspective, is the recognition by a major insurer that it is possible to create a new incentive-based approach to reimbursement – in this case within the old fee-for-service model – which actually costs more for primary care (up from about 5% of total costs to about 7-8% of total costs) yet significantly reduced those total costs of care while improving quality. 

Note: I talked to CareFirst's CEO, the former chairman of the board and a vice president about the program but I have no financial relationship; this program is used for illustrative purposes only and is not meant to be an endorsement.

 

 

Employer-Sponsored Comprehensive Primary Care

Patients need doctors that take time to listen which means a limited number of patients under care. Employers need programs that reduce costs and ideally improve the health of their staff. These apparently disparate needs can come together in a new model for effective company-sponsored primary care programs.

Those of you who have followed this series know that I am an advocate for PCPs finding ways to have a smaller patient panel so that each patient can receive more time for comprehensive primary care. When properly designed, company-sponsored primary care clinics can do just that.

Some employers are turning to outside firms such as QuadMed to initiate care models that can serve both smaller patient panels yet reduce their total costs toward healthcare. Although there are many such firms (or local practices) that will take on the role, real success hinges on a program that is well organized and allocates adequate time for the PCP to give truly comprehensive primary care. It also means that the employer has accepted the concept that it is no longer just trying to hold the line on healthcare costs but is actually looking at employee health as a strategic business imperative.

Successful programs tend to include not only PCPs, NPs, nurses and other providers but, if the employee base is large enough, a pharmacy, laboratory, and radiology suite. Other key resources are health coaches and nutritionists to maintain wellness and reduce risk factors. The typical employer in these arrangements is generally self-insured, has a large enough employee base to justify the clinic resources and is committed to employee health and wellness while wanting to reduce its total costs of health care.

A full service primary care clinic is funded by the company at or very near to the employer’s site of business. Services include routine episodic care but also extensive preventive care, intense management of those with chronic illnesses and care coordination when a patient does need to visit a specialist and sufficient time with the provider that trust can develop; in other words, this is comprehensive primary care not just limited function urgent care centers.

Employees are informed that they are welcome but not required to utilize the clinic and do so at no cost or perhaps a modest fee per visit. Some but not all employers make the clinics available to family members. Each participating individual is assigned a primary care physician (PCP) or in some cases a nurse practitioner or physician assistant. The PCP/NP/PA is paid by salary by the vendor company, not fee-for-service. In the programs that truly develop comprehensive primary care, the PCP/NP/PA has a limited number of patients in his or her panel, does a full initial evaluation usually lasting 60 minutes or more and then sees the individual thereafter as often as necessary for as long as necessary.

The expectation is that the patient and PCP/NP/PA will develop a long term trusting relationship just as they would in a private office setting. Individuals can schedule appointments often on the same or next day and there may be extensive use of mobile technologies, an electronic medical record, telemedicine and other advanced techniques. For those individuals with a chronic illness, the clinic nurses often work with the PCP to coordinate care and (often and hopefully always) the PCP communicates directly with any specialist before referring and after the visit.

The clinic manages wellness and preventive programs with health coaching and lifestyle behavior management. This might include but is not limited to nutrition counseling, fitness counseling, stress management and smoking cessation. It depends on the provider company selected to develop and manage the clinic, but if the employer already has an effective wellness program ongoing with another provider, the primary care company may agree to partner with that wellness provider to create seamless programs. It can thus be an employer wellness program and a comprehensive primary care program rolled into one. It may even be population health to the extent that the PCP and the team proactively interact with each participant to address risk factor and incipient chronic illnesses rather than waiting for an employee/patient to call or visit with a problem. To repeat, a very key ingredient is assigning no more than a reasonable number of employees and family members to each PCP/NP/PA. What is “reasonable”? – it depends – on average age, whether many individuals have chronic illnesses, etc.

Some provider companies such as WeCare TLC call their model “medical risk management,” a term generally thought of in medicine as programs and policies to reduce the potential for malpractice claims. Here however it has a completely different meaning. It is called medical risk management because the driving principle is identification and management of ongoing medical problems while at the same time addressing potential health risks for the future. It is really an employer-sponsored (although not directly involved) companywide approach to population health management. It is taken from the concept of enterprise risk management which seeks to identify and mitigate corporate risk as a strategic advantage. It is management of risk not just from a downside perspective but from an upside or positive perspective as well. The employer therefore needs to be thinking about health risk management as a strategic perspective, not just as a tactical effort. In other words, a healthy workforce is available to be productive and a healthy workforce creates a very substantial savings in medical costs for both the company and the employee.

Note that it is not just “episodic” visits but rather comprehensive primary care in a medical home type model with proactive population health concepts.

The provider company and the employer usually agree up front to a set of performance measures such as utilization/penetration of the clinic (are employees actually using it), patient satisfaction (do they like what they get), quality outcomes (standard measures used nationally such as blood pressure control, diabetic control, immunizations up to date, etc.) and of course functioning within budget and a return on the employer’s investment at a pre-agreed level. Companies that engage in these clinics, provided that the services are actually comprehensive in nature as described, tend to find that their return on investment very good.

Since in these models of comprehensive primary care where the employer fully pays for the primary care services, there can be a significant savings for the employee (patient) and family members.  Importantly, the employer pays the bills, perhaps offers incentives for participating but is otherwise kept at a distance. The PCP and other staff members work for the provider company, not for the employer, and cannot be expected to share patient information. The employee gets quality healthcare with a strong emphasis on maintaining wellness, active prevention and on chronic illness early detection, management and care coordination. The result is a healthier workforce leading to greater productivity, greater workforce satisfaction, reduced or no employee costs for primary care and reduced or at least limited health insurance cost increases for both employers and employees.  Definitely a triple win.

But there are potential downsides to consider. Some KevinMD readers will certainly comment that it is best to keep the employer completely out of healthcare. Another downside would be if the employer wanted to be intrusive and learn medical information about individuals. A third would be the loss of a trusted PCP when a person leaves the company for other employment. So in the end, each person offered the option needs to make an informed decision.

Note: I have interviewed principals at both QuadMed and WeCare but have no financial or arrangements with either. They are used as examples only; their use does not represent an endorsement.

Primary Care Physicians Can Greatly Reduce The Costs Of Care, Especially For Chronic Diseases

In an earlier post I described the problem of excessive and inappropriate drug prescribing when a patient with multiple chronic illnesses did not have good care coordination by a single primary care physician. In this post I will relate the story of a lady who had an excellent primary care physician but the communication system broke down when she went elsewhere for a single visit. In her case the problem was the recommendation of an inappropriate medical technology for her chronic condition.

Ellen is an elderly lady who had been going to the same primary care physician (PCP) for over twenty years. On nearly every visit she said that she felt “tired.” Repeated history and exam revealed no cause nor did logical tests such as those for anemia or hypothyroidism. She then developed syncopal episodes – times she would black out and fall to the floor, once bruising her head when she fell against the stove, and then waking up in a few minutes. Evaluation showed that she had intermittent episodes of bradycardia, or very slow heart rate, resulting in the drop attacks. In consultation with a cardiologist, it was decided to insert a single lead pacemaker. The pacemaker senses the electrical action in the heart and when the rate drops below a set level, it immediately begins to send out an electrical stimulus – on demand - to the heart muscle so that it will contract at a normal rate. The pacemaker is expensive and the procedure to place it is expensive as well. But it worked perfectly and she no longer had the attacks that were not only scary and medically dangerous but seriously impacting her quality of life. A good return on investment.

A few months later during a visit to her daughter, she went to that daughter’s internist for an unrelated reason; he urged her to see a cardiologist colleague. Both the internist and the new cardiologist heard the usual complaint of “being tired” and assumed it related to her cardiac status. This cardiologist in turn recommended that she needed a “dual lead” pacemaker instead of the single lead one she had. [It has been found that having more than one lead can sometimes improve the heart’s output for very carefully selected patients with heart failure.] When the PCP much later received the cardiologist’s mailed consult report, he disagreed, noting she did not have heart failure, just syncopal attacks – an electrical not a mechanical problem in her heart. Further, the current pacemaker was only needed about 10% of the time meaning that her heart beat at a normal rate at least 90% time, so the pacemaker was not even active most of the day. This lady did not need the proposed new, even more highly expensive pacemaker. No pacemaker, no procedure, no risk of insertion, no risk of post operative infection or bleeding. A lot of money could be saved and the patient could be spared a straight forward yet somewhat risky procedure – which she did not need. The fundamental problem was the lack of care coordination. One would like to believe that had her medical record been easily available digitally, the newly involved internist would have never even suggested the need for a cardiologist opinion and even if sent on, the cardiologist would have rapidly recognized the lack of need for the new device.
The lesson is one doctor needs to be the orchestrator of all of the patient’s care. A good PCP, like this one, coordinates the care of his or her patients with chronic illnesses and in so doing avoids excess referrals, tests, procedures and hospitalizations along with unneeded drugs or devices – all the elements that drive up the total cost of care – and in the process assures quality care, safer care and a close doctor-patient relationship. But sometimes a patient is elsewhere, sees a new physician and the medical history is not readily available. All too often as in this case, the patient ends up getting tests, images or procedures that he or she just does not need.
One of the most effective ways to reduce medical care costs is with good coordination of the care of individuals with chronic illnesses. As the story of Ellen above and of Henry from the earlier post exemplify, there is a strong tendency today for patients with chronic illnesses to either be referred to various specialists or else to go on their own. When this occurs without coordination, the visits add up, the number of tests and images ordered go up, the number of drugs prescribed rises rapidly and the number of procedures and even hospitalizations climb. Unfortunately, many of these are simply not needed – excessive and wasteful, not the best quality and obviously very costly. The value of a good digital medical record in both of these patients is obvious because communication among providers is critical to optimal care.

The primary care physician is in the best position to coordinate care. He or she knows the patient, the patient’s family and socio-economic situation and of course the patient’s various illnesses. Ellen did not need to see a second cardiologist and did not need the dual lead pacemaker. The PCP knew that “tired” was just her normal statement at every visit; not a reason to do more tests, add a drug or do a new procedure. It was unfortunate, indefensible but not at all uncommon that the new cardiologist did not make the effort to call the long time PCP. It would have been quickly determined that Ellen did not need a very expensive new pacemaker.

Henry suffered because he did not have a PCP. Instead he had four doctors, each one dealing with all of his problems and none communicating with the others. Once he had a single PCP, his prescriptions plummeted from 23 to seven, he felt better, had fewer drug-induced side effects and both he and his insurers were saving a lot of money.

Care coordination is critical; it improves the quality of care; it reduces risk; it reduces the costs of care; and it ultimately improves patient satisfaction. A good PCP (or occasionally a specialist) is needed to the orchestrator of that coordination. The electronic medical record has an integral part to play in robust care coordination.
Why, with all of these attendant advantages, do not all PCPs engage in excellent care coordination? I believe it is twofold – dollars and lack of training.

My new book, “The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You,” from which this post is adapted, will be published in February, 2012 by Potomac Books

Care Coordination Is Critical For Those With Chronic Conditions Like Diabetes or Osteoarthritis

This is the fourth post in a series on care coordination; this time focusing on other examples of team-based care. Patients with diabetes not only have to deal with the diabetes itself and its management, such as insulin and drugs, but they have to deal with nutrition, weight and exercise. They need to cope with potential side effects of the diabetes, such as damage to their eyes or kidneys or the blood vessels running into the lower legs that can lead to ulcerations, infections and even amputations. The current approach is for an internist to be the patient’s primary care physician and then to send the patient on to a specialist whenever a problem arises. A much better approach is the one developed by the Joslin Clinic in Boston, which has now been “franchised” across the country. The internist refers the patients to a Joslin Center for consultation. There the patient has a nurse as their coordinator and advocate, an endocrinologist to work out the specifics of their diabetic drugs and insulin, an exercise physiologist to help them with an exercise plan, a nutritionist to review their dietary needs, an on-site ophthalmologist expert in diabetic complications of the eye, and a podiatrist to deal with foot issues. The point is that all of these professionals are available in a single location. The patient comes to one place and one place only and from there can go to individual adjacent offices to see whomever they need to see. Whenever they come back to see, say, the exercise physiologist, if there is an issue or problem they immediately can be referred across the hall to the appropriate specialist. They key is that these healthcare providers are all working as a team and bring to bear all of the different disciplines necessary to the treatment of this complex and complicated disease for this individual patient. And by using an electronic medical record, the data is all present all of the time as the patient goes from one provider to another within the Center but also back home with his or her primary care physician. The result is better care, more coordinated care and a much more satisfied patient. It also costs much less because there is less duplication, less unnecessary testing or X-rays, and fewer hospitalizations because the patient is better cared for.


So as time goes on, more and more of these disease-based programs will emerge for the care of complex, chronic diseases. To some degree this may seem to threaten the primary care physician in the community. But it is really a benefit and an adjunct to both the physician and the patient. The primary care physician still sees the patient for the bulk of their individual care but knows that he or she and the patient have an expert team available to help either occasionally or more often as necessary.

Here is an example of team based care in orthopedics. Marshall Steele, III, MD is an orthopedic surgeon in Annapolis, Maryland who did a lot of knee and hip replacements. He was frustrated that the system just was not efficient nor was it patient or provider friendly or convenient. So he and some collaborators worked with their hospital, Anne Arundel Medical Center, leadership to devise a totally new approach to total joint replacement. Briefly, it works like this. A unit of the hospital was set aside solely for total joint replacement patients with its own dedicated staff. A single leader who had full responsibility but also the needed authority was placed in charge, eliminating the traditional silos that exist in most hospital management systems. Instead of being focused entirely on the inputs which dominates organizations structured in departments, this new model focuses first on the outputs (outcomes) of their work from the perspective of all stakeholders. All patients for the week are brought in the week before to meet each other, meet the staff, tour the facility and attend a class taught by a nurse navigator or coordinator of what will transpire during their stay. They are then all brought to the hospital for surgery the same day, necessitating that extra ORs be available for the orthopedists. After surgery the patients are put into a wellness environment outside of their hospital room. There they are brought together for some meals each day and for beginning physical therapy. They even return as outpatients for physical therapy together.

These steps plus many others have markedly improved physician, nurse and physical therapist coordination and satisfaction while working as a multi-disciplinary team, each with their own expertise unleashed for the care of these patients. The patients are much more satisfied and work together as a support group. At a formal luncheon one month later, patient and family input is sought and programs changed to respond to their needs and those of their families. Length of stay is down and complications have been reduced. Important hospital reported metrics are collected and shared with the team on easy to understand electronic dashboards. Patient reported metrics are collected on how effective the procedure was in reducing pain and return to desired activities. As word got around, more and more patients, many from great distances, sought out the team. Hospital revenues rose and the orthopedists became very busy. Other hospitals have tried to emulate this approach. But many fail. Why? Because, as Dr Steele points out, what is needed is a transformational change but most physicians, hospital staff and hospital managements are only able to muster incremental change. Incrementalism where transformation is needed just doesn’t work.

As medicine becomes more and more disease/patient-oriented, the traditional departments of medicine and surgery within a hospital will tend to be de-emphasized and in their place will come centers for cardiac care, cancer care, diabetes care, stroke care, joint replacement and the like. A multidisciplinary team approach to care will become much more common. Just as with the primary care physician, this shift will appear to many practicing specialists to be a “threat” to their autonomy and certainly to their long-held practice patterns. To be effective they must have an effective electronic medical record system. Moreover, insurers do not like to pay for a team to see a patient. Their approach is to pay one physician for one consult or one patient visit. To pay for three doctors to see one breast cancer patient all at once is anathema, and, in general, they may refuse payment. Hospital managers, like physicians, are “conservative” and traditional, with functions organized in a format that was effective many years ago but which is no longer. But change is difficult and as pointed out in the story above on joint replacement, the change needed is transformational, not incremental. The electronic medical record, critical to success of these arrangements, must be part of the transformational change. Change will not come easily; but it must occur and so it will, but not quickly. But the hospitals who figure this out first will have a competitive advantage.

These stories raise the question as to why it is so difficult for physicians and hospitals to change their ways when the new approach can be shown to be so much more effective in delivering improved quality of care at a reduced cost?

My new book, “The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You,” from which this post is adapted, will be published February 28, 2012 by Potomac Books. You can find it now at Amazon at http://tinyurl.com/

Lack of Care Coordination Leads to Patient Frustration and Poor Care

This is the third post in a series on care coordination and the importance of the electronic medical record to effect that coordination.

Medical images such as CT scans, MRI and pathology specimens are largely all digitized today so they can be transmitted to any location in an instant. This means that the most experienced physician at a distant institution can be called upon to review, say, a mammogram that has raised questions for the initial local reviewers or for a pathology specimen which is of an unusual type. It also means that when a patient goes for a specialty visit, his records could go simply and instantly and be available for the specialist(s.) This obviously will save time and improve patient care at limited increased cost. But it is largely not what happens today. Here is an example of what actually happens now.

A gentleman, I will call him Otto, who lives in a remote area in northern Pennsylvania developed a chronic cough. He went to his primary care physician, who diagnosed bronchitis and gave him a prescription for an antibiotic. But the doctor was clearly concerned and told Otto to “come back in two weeks if the cough is not gone.” Two weeks later, the patient returned unchanged. He was sent to the closest hospital, about an hour away, for a CT scan of his lungs. The result was not good; it looked like lung cancer. To definitively confirm the diagnosis he was told to come back in four weeks [!] for a biopsy to be done by inserting a needle into his chest. Why four weeks? Because the specialist at that rural hospital only did these biopsies every other Friday and he was booked up until a month later. So Otto had to be “patient” and came back as scheduled. The biopsy, sent to another hospital a hundred miles away for review, confirmed lung cancer. Now he was referred to a surgical specialist in yet another distant city, an academic medical center. That took a few weeks to arrange and, when he met the doctor, he was told that to make a good plan for treatment it would be necessary to get a PET scan. “OK,” he said, and it was arranged for two weeks later – the PET center just down the hall being booked up until then. So he drove home and then back two weeks later. Once the scan was done, a call came from the surgeon’s office that his return appointment had to be postponed for a month since the surgeon would be out of town. His wife, protesting that that was too long to wait, arranged for a visit to be “fit in” in two weeks rather than four.

By chance we happened to visit them that day and heard his story. I called my former University of Maryland Greenebaum Cancer Center colleagues and was told that he could be seen concurrently by a team of surgeon, radiation oncologist, medical oncologist and nurse practioneer in just three days time. But he would need to bring his medical record, his CT scan, the PET scan and the pathology report. So he had to call and then drive to each of the hospitals and pick up the materials. What he picked up were not pictures or films but CDs of his CT and PET scans and his pathology report; in other words they were already in digital format. Too bad these hospitals were not yet capable of just sending them via the Internet to the cancer center in the third city. This is supposed to be a story about the problems of getting information from one physician or hospital to another, but you will have also realized that it was about remarkably less than good care for him – waiting weeks to get the biopsy, more weeks to get the PET scan and then the absurdity of being told he could not be seen by the surgeon for another four weeks. What Otto needed was a well-coordinated, team-based approach to care, which he eventually got – but which he certainly should have gotten long before. This happens all too often in American medicine today.

This is the typical way most patients get treated for cancer (and most other chronic illnesses.) Go to one doctor and then once he or she is done with his/her recommendation, get shunted off to the next physician, and then the next, etc. The patient may be sent to another physician for a “second opinion” but never do the doctors actually sit down together and talk through the issues. When a team jointly discusses the patient’s situation, jointly listens to the patient’s (and family’s) needs and then jointly offers a plan, you can bet that the plan will be far superior – and there is not second guessing later. And as treatment progresses, the team can monitor progress and make course corrections as necessary. The multidisciplinary care coordination approach is not just better, it is far superior. If you develop a chronic illness and your doctor wants to refer you to a specialist, insist on a team-based approach.

Sharing information is a critical element of this approach. Today hospitals (and doctors) do not share medical information among themselves readily, such as when a patient is discharged from one hospital but then ends up in the emergency room of another hospital days or weeks later. Similarly, if a patient has a test at one hospital but then is referred to another for a procedure, it is nearly impossible, as we have seen in the story above, to electronically send that data from hospital to hospital. Instead, the patient usually has to act like “Federal Express” and pick up the information and hand deliver it to the other location, just like Otto. Not a good arrangement – it takes time and it only adds to the patent’s sense of anxiety when the systems should be working to reduce patient angst. Once the electronic medical record is available on a universal basis this difficulty should be abated. Meanwhile hospitals that determine how to share information now will find that they are benefiting patients and in the end benefiting their institution. They will be recognized as providing better care and be rewarded with patient referrals.
But this story raises the question as to why with the information in digital format and the Internet ubiquitous that records like Otto’s cannot readily be transmitted today?

Taking 23 Drugs From 4 Different Doctors – Lousy But Expensive Care

Lack of Care Coordination of Chronic Illnesses Leads to Excess Prescriptions, Suboptimal Care and High Expenses

Henry is a 69-year-old living alone in a small town about 60 miles from the nearest metropolitan area. He has healthcare coverage via Medicare, Medigap, and Medicare Part D. He had recently been discharged from the hospital after an ICU stay for a urinary tract infection and called to ask for some advice. He was taking twenty-three -- yes, 23 -- different prescription drugs; some once, some twice and some three times per day along with one by shot monthly. He was not certain why many of them had been prescribed and stated that despite them he did not feel well. Here is a partial list: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate and one for depression.

I asked him who his primary care physician was and learned that he did not have one but rather went to four different doctors, each of whom treated different issues and none of whom shared all of his information and none of whom used electronic medial records. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage. He told me that when he went to the local drug store and checked his blood pressure, it was always normal.

Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues. The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, one of the doctors had given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result he had developed an infection that had almost killed him. And all these drugs were expensive, both to him and to his Medicare Part D insurance plan.

Heart failure and diabetes together consume more than 50% of our healthcare dollars and here is a person whose care is not being adequately monitored; rather he is getting one drug after another without attention to what else is going on. This lack of care coordination is a prime reason why the costs are so high yet quality so low.

My first suggestion was that Henry needed a primary care physician, one to call his own. He found one who had just started his practice, had the time and inclination to coordinate his care and had installed an electronic medical record system. A few months later Henry called and told me that he was now taking just seven medicines and felt much better!

Henry still has four serious chronic conditions. But with a single physician serving as orchestrator rather than just intervener, one who uses an electronic medical record and who actually pays attention to Henry’s medical plus social and home life, Henry has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap and Medicare Part D’s money. In short good care coordination is a win-win for all concerned.

And yet, care coordination is not appreciated for its importance by most physicians, insurers nor patients. Why is that?

Complex, Chronic Illnesses Last a Lifetime and Consume 70% of the Healthcare Dollar

Medical care is organized to treat acute conditions but the need today is to prevent, diagnose and treat chronic illnesses. Unfortunately, we are sorely lacking in a good chronic care management system. this will be the first in a series of six posts on this issue.

Our medical care system has developed over decades and even centuries around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gives an antibiotic for the pneumonia and the patient gets better. The surgeon cuts out the gall bladder or the appendix and the patient is cured. One patient; one doctor. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that once developed usually remain with the individual for life. These patients with chronic illnesses need a different approach to care. They need long term care, not episodic care. They need a multi-disciplinary, team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers along with all of the tests and procedures to allow for a unified, coordinated care management approach. Not only are these diseases likely to last a lifetime, they are difficult to manage, have an adverse impact of both quality of life and mortality, and they are usually quite expensive to treat. Today 70% of our medical care expenditures go toward their treatment. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs and this will require high quality health information technology.

However, it is valuable to first understand the implications of chronic disease. Most of us are just not aware that their incidence is rising - and rapidly. The Milken Institute (http://bit.ly/lGHFqP ) quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes [presumably type 2], hypertension, stroke, heart disease, pulmonary conditions and mental disorders. Here are some of the key findings:

• “More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases.

• The total impact of these diseases on the economy is $1.3 trillion annually.

• Of this amount, lost productivity totals $1.1 trillion per year, while another $277 billion is spent annually on treatment.

• On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases.

• $4.2 trillion in treatment costs and lost economic output.

• Under a more optimistic scenario, assuming modest improvements in preventing and treating disease, we find that in 2023 we could avoid 40 million cases of chronic disease.

• We could reduce the economic impact of disease by 27 percent, or $1.1 trillion annually; we could increase the nation's GDP by $905 billion linked to productivity gains; we could also decrease treatment costs by $218 billion per year.

• Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year.”

To me the most telling and important finding is that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.” Restated, we as individuals need to take responsibility for our own health. Not every chronic illness is preventable, but most are. It is up to us to eat a nutritious diet in moderation, exercise our bodies, seek ways to reduce chronic stress and avoid tobacco. These four steps will make a huge difference in our health and our lives. Adding in dental hygiene, avoiding sexually transmitted diseases, using seat belts and not drinking and driving will further prevent many illnesses. Many do not appreciate either that following a more appropriate lifestyle will actually slow the normal aging process that ultimately leads to many of these chronic illnesses.

Meanwhile, when chronic illness does strike, it is imperative to have a single care provider take responsibility for care coordination. Someone to not only recommend tests, procedures, images and specialist visits but who will actively ensure that each provider is properly attuned to the patient’s needs and that all of the information is collected and aggregated in a meaningful manner. When this is done the quality of care rises markedly, many fewer adverse events occur, the patient is more satisfied and the costs of care are dramatically reduced. In most cases, a primary care physician is the appropriate one to coordinate care although sometimes a specialist is better equipped for this role (e.g., a very complex cancer treatment plan). To be effective, the PCP or specialist needs to have not only the willingness and interest but also the time available to actually do the care coordination – time that is not available for most PCPs today. This coupled with limited digitized health information leads to today’s inadequate care of many individuals with chronic illnesses. In future posts I will describe today’s problems with lack of care coordination and how it can be corrected.

I wonder what others think abut why the problem of chronic illnesses and the need for care coordination is just not well recognized?

Leadership In Medicine – New Expectations

What should we expect of a physician leader today? I believe it should be something much different than what leaders do now.

Today, a hospital physician CEO might be expected to develop new or improved clinical programs, in part by recruiting the best and the brightest, by building new wings, and by purchasing new technologies. The measure of success would be improved finances as a result of added admissions. A dean might be expected to develop new research programs by building new facilities and recruiting the needed scientists. The success measure would be rising on the NIH rankings of total research dollars awarded. A pharmaceutical company physician leader might be expected to find new drugs that will be “blockbusters.” His measure of success will undoubtedly be financial as well. A similar picture extends to the CEO of a health insurer.

Are these the right measures? Are our medical leaders really leading? Or at least leading toward truly valuable goals?

Leadership is all about success in three sequential activities, as outlined by John Kotter at the Harvard Business School. The first is generating a vision for what needs to be done. Perhaps it will be the clinical program, new research activities or a new drug. The second step in leadership is to convince others that the goal is worthy. Aligning everyone involved with the desired outcome can be difficult but without alignment there will be no action. And the third, often overlooked, is to get the needed individuals to actually help to achieve the goal, the vision. These are difficult steps, especially in or university setting where lines of authority are diffuse and responsibilities overlapping or in a community hospital where the physicians are mostly in private practice and not hospital employees.

But the question is what should be the vision and what should be the measure of success in achieving that vision?

An article in the Journal of the American Medical Association by Dr Robert Brook [July 28, 2010, pages 465-6] got me to thinking about this issue.

We know that despite spending more per capita on medical care, we still have far from the best care. We do not lead in infant mortality or total life expectancy. We do poorly at coordinating the care of those with chronic illnesses, such as diabetes and heart failure, and the result is less than adequate care and care that is much more expensive than it needs to be. As a society, we have rampant adverse behaviors such as overeating and lack of exercise plus many of us still smoke, all leading to more chronic illnesses, increasingly occurring at an earlier age.

I would suggest, echoing Dr Brook, that real medical leadership today needs to focus on the important outcomes, not the ones that just improve our organization’s financial successes [not withstanding that strong finances are critical in order to accomplish a valuable end – “No money, no mission.”] This means that medical leaders must begin to accept the responsibility for aligning the various constituencies and power brokers both within and without of medicine toward real healthcare progress. Unless medical leaders accept this challenge, it will increasingly be done by others, and done without serious input from physicians and others in the field.

What then are the important issues and outcomes?

I would suggest that we must find a way to first markedly improve prevention of illness. Within medical care itself, this means assuring that primary care physicians are trained and have the incentives to do basic screening, administer vaccines, and give sound advice. It means actually advising about diet and exercise for the person with high cholesterol, not just giving out a routine prescription for a statin. And medical leaders need to take the initiative to change government policy regarding food and nutrition. For example, it makes little sense that the beef with the most saturated fat is marked “prime” by government inspectors or that food processors can label a cereal “healthy” because they have added some vitamins to what is manufactured from non whole grains plus sugar and salt.

Second is to develop methods to assure that every patient who has a chronic illness gets intensive care coordination among all of the providers involved. This means the development of multi-disciplinary teams of physicians, nurses, pharmacists and others who actually work collaboratively and with the patient’s interest foremost. There can be various models but among them is the creation of “centers” (cancer centers, heart centers, trauma centers) at academic medical centers and at community hospitals, developed with real authority to function effectively. Another is to use bundled payments or “capitation” to reward coordination. And most importantly is to have one physician, usually the primary care physician, serve as the coordinator – the orchestrator.

Third, medical leaders need to address the need for care delivery to be customer focused with the recognition that the customer is the patient and the patient’s family. Too often we develop programs or actions that continue the current provider-oriented approach rather than a patient/customer-oriented approach. If medical leaders do not address this now, a rising tide of consumerism will force the issue later. Eventually, patients will hold the physician directly accountable and will expect to pay only if the care is patient-focused.

Having addressed these basics, medical leaders then need to turn to the more global health issues, health not only of the individuals under their care or their institutions’ care but the care of the community, the population at large. This is critical if all Americans are to have a healthy life regardless of social or economic status.

To accomplish this will mean that hospital, insurance company and pharmaceutical company boards of directors and university boards of regents will need to give out new, different and clarified directions to their CEOs, presidents and deans, holding them accountable with new measures that reflect realistic progress toward these goals. Otherwise, although there will be various medical breakthroughs of great value for treating disease, American medicine will continue to stumble along, as it has, without making any real progress in what is truly important.

Care Coordination in a Retirement Community – Better Care at Lower Costs

Older individuals tend to have more complex chronic illnesses and they need lots of preventive care. The Erickson Retirement Communities determined to learn if attentive primary care would lead to better quality care, better quality of life and yet lower costs overall. By way of background, their basic goal was to improve the quality of life for their residents – good marketing. So they built in nutrition, exercise and other programs for the residents who live in a campus-like setting. Yet they found that their biggest failure from the retirees’ perspective was medical management. The Community hired a physician who initially spent about thirty minutes with each patient’s visit. The word got around and more and more residents signed up for his care. Once that happened he had to cut back until he was seeing each patient for about ten to twelve minutes per visit. And so the residents were again not satisfied. So the Community hired additional full time primary care physicians and paid them enough in salary over what Medicare paid so that they could afford to take the needed time with each patient. It quickly became apparent that the residents liked this approach but it meant only about 400 or so patients per physician rather than the national average of about 1500+ for a primary care doctor. It was more expensive up front but Erickson found that the number of hospitalizations for this group declined by about 50% suggesting that good coordination of care was effective in not only increasing satisfaction and quality but also in reducing costs. Of course, the reduction benefited Medicare but Erickson still had the extra expense of the added physicians to make the program work. Erickson then went to Medicare and petitioned for a demonstration project. To date over four thousand retirees in multiple retirement communities joined this Medicare Advantage program. The results again confirmed the value of good care coordination, the value of a computerized medical record and orchestration of chronic care by a primary care physician who could spend adequate time with each patient. At one retirement center, inpatient hospital days dropped from a national average of 2096 per 1000 Medicare enrollees per year to less than 500. And since these retirement communities generally have older residents, age adjusting the data meant that it was equivalent to only about 200 hospital days per enrolled resident. Another key metric is an unplanned return to the hospital shortly after discharge. The national rate for Medicare recipients is near 25% but the Erickson plan has kept these to less than 10%.They found that one key to success was having the primary care physician be the “orchestrator” among all of the patient’s specialists, being sure that the patient’s medications were appropriate, not mutually adverse, and in the correct dosage for a geriatric person. The primary care physician attends the resident when hospitalized, bringing the patient’s electronic medical record to the hospital on the doctor’s laptop. [They found that if the patients were cared for only by the hospital-based hospitalist, the tendency was for the acute problem to be well managed but for other issues to get out of control leading to longer lengths of stay and various complications.] As a result, they can assure that the individual continues to get appropriate care for all of their needs, not just the one problem that sent them to the hospital this time. Care coordinators are used as well but in tandem with the primary care physician who has the needed time with each patient. They conduct regularly scheduled programs of health management. There are behavior modification courses as in employer-based wellness programs but also specific programs for monitoring, coaching and prevention for specific high risk diseases. To reiterate, the program provides what a typical primary care physician either does not or cannot provide today [although most would like to provide.] It includes the behavior modification programs, plus the monitoring and coaching for patients with cardiac, chronic lung, diabetes and other diseases found in wellness programs sponsored by employers. To this is added aggressive management of these complex chronic diseases with close care coordination from their very beginning rather than when they become problematic later on. There is extensive use of non-physician providers which helps to keep the costs down but the contact level high. In short it is a wellness program, a care management program and a disease management program all rolled into one.

Disease Prevention For All And Care Coordination For Those With Catastrophic Illness

The care coordination described in the previous post is a major part of the new CareFirst Blue Cross Blue Shield plan. But there are three other important components.

First, the PCP will receive increased compensation for all of his or her CF-insured patients, not just those with complex chronic illness. Hopefully, this will be enough to assure that every patient gets the time and attention needed for the best possible care. It also means, hopefully, that the PCP will be less inclined to quickly refer to a specialist rather than taking the time needed to sort out the patient’s problem [This happens a lot today and drives ever more specialist visits.] By the same logic, it is anticipated that the physician will do a more complete history and physical exam, negating the need for more tests and procedures. The result is better care for the patient, a more satisfied patient since the doctor will not be in a “rush” and a more satisfied physician. Better care at lower total cost.

Second, CareFirst recognizes that over 90% of their clients remain with them year after year so it is financially logical to try to assure good preventive care. This will cost more today but should pay off in the years to come with lower costs because the patient will remain healthy. So in this new practice arrangement, CareFirst will pay for any preventive/ screening program/ test that is well defined by evidence. This might include cholesterol measurements, mammography and colonoscopy and it might include dietary consultation, or a smoking cessation program. As an added incentive to get this type of preventive care done, CF will waive any co-pays or deductibles that the patient might have to otherwise pay.

Finally, it is recognized that some small percentage of patients will develop a truly catastrophic condition such that the PCP can no longer easily coordinate the care. These are the 5% of patients that consume a very large portion of the healthcare dollar. This is the patient that must be referred to a specialty center or an academic medical center, have major surgery or perhaps receive an organ transplant. My own observations over the years demonstrate that these are the types of patients who get less than the best possible care because the hand offs and referrals among providers are less than satisfactory. This is where quality breaks down, where safety issues arise, and where all too often excess tests and procedures get done. And since no one is orchestrating the entire care program, the patient is left with well intentioned caregivers but less than the best care.
In this situation, CareFirst will develop an incentive-based relationship with the specialty provider – probably a hospital system – to assure care coordination. The hospital system will assign a “navigator” to each such patient. The navigator will have the responsibility to be sure that the care of the patient within the system is well coordinated, just as the PCP does in the community setting. This navigator will work the interface among the myriad specialists, departments, even hospitals and centers that the patient must utilize for his or her care. The result could be much better care quality yet at a substantially reduced total cost.

The whole concept here is to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It will mean a real change in how the primary care physician functions – a change from being an intervener to be an orchestrator. And a major change for the hospital system in that it will need to become an orchestrator as well, not just a place for specialty care. And it is a change for the insurer, one that accepts that care coordination and disease prevention costs money but recognizes that the end result is better care at a lower cost. This plan uses various incentives to align needs – we could say that it gives rights but with corresponding responsibility.

Putting It Together To Bring Down Costs

President Obama is working hard to address the issues surrounding health care in the USA. Two days ago he hosted a group representing many of the major providers such as physicians, hospitals and pharmaceutical companies. They promised to work to reduce the rate of rise of costs of care over the coming ten years. No specifics were given out. Here is what I would suggest as the first steps.

If we take the comments from my last few blogs and put them together, we see that a few critical forces have come together to push up the costs of care. To be sure, there are other reasons for the rising cost of care and I will address them in later blogs. But these few are they key ones and are the ones to aggressively address now if we are ever to slow the rise of expenditures much less actually bring them down. Here they are:

Our population is aging – simply stated, “old parts wear out.” We have bad behaviors – poor nutrition, overweight, lack of exercise, stress and tobacco with many of these starting in childhood. Both age and behaviors are leading to the development of complex, chronic diseases [heart failure, diabetes with complications, cancer, etc]. This is much different that the acute illnesses that we generally think of such as appendicitis or pneumonia. In those cases a single physician can treat them and the result is a cure. But these chronic illnesses once developed persist for life and they require the expertise of many providers.

These chronic diseases are expensive to treat – today they consume about 70% of all US health care expenditures although this care is going to only about 10% of the population.
But our care system is poorly coordinated and this results in far too many doctor visits, procedures, test and even hospitalizations. That is the reason for the excess costs and these could be brought down with resulting improved quality of care, safer care and more satisfied patients.

What is needed, more than anything else, is a cadre of primary care physicians [or sometimes specialist a physician] to carefully coordinate the care of those with chronic illnesses. Without question, this approach will bring down costs.

Sounds simple and is in concept but the reality turns out to be not so easy

Lack of Care Coordination

The switch from acute to complex chronic diseases and the wide variation in care patterns are closely related. It is the complex chronic diseases that need the most attention and hence are most expensive to treat. But as a country we have long had the tradition of the independent, autonomous practioneer in the community taking care of us. This was fine for acute illnesses. The physician could either treat you him or herself or else would refer you to a particular specialist for needed care. Maybe to the surgeon to remove your appendix or gallbladder. Once the surgery was done, the problem was “cured.” Not so with chronic illnesses. Often the patients need multiple physicians, each with different skills and expertise such as the cancer patient would need a surgeon, a radiation oncologist and medical oncologist. But these three and the primary care physician are not likely to be well coordinated. They may have offices in different parts of town and possibly use different hospitals for some of their work. Communication is weak and the PCP often does not feel able to serve as the coordinator or quarterback. And, since these chronic illnesses often occur in older individuals, there is a good likelihood that other illnesses will develop concurrently. Maybe high blood pressure, heart failure or diabetes with complications. And so off to more specialists who do not communicate well and who do not understand the implications of the other illnesses, the other medications, etc. the result is often extra doctor visits, extra procedures, tests and X-rays and even extra hospitalizations than would have been necessary with well coordinated care. Unfortunately, this is the way medicine is practiced today and it is a real problem. It means that care is not as good as it should be or could be, not as safe as it should or could be, not as customer [patient] friendly as it should be or could be, and it means that it costs far too much.