June 1, 1999
Care: Motherhood and Apple Pie?
Seventy percent of health care costs in the U.S. are spent on people
who have one or more chronic condition. The Robert Wood Johnson
"Chronic Care in America: A 21st Century Challenge"
is a classic study that details the clinical and financial issues
A new term in the vocabulary of health care and managed care is
"patient-centered" care. In short, it refers to care focused on
the needs and preferences of an individual patient (more below).
Patient-centered care for people with chronic conditions is akin to
motherhood and apple pie. Everyone says they're for it. Nobody
says they're against it. But let's look a little deeper.
IF NOT PATIENT-CENTERED, WHAT ELSE IS THERE?
So if everybody is for patient-centered care and nobody is against it,
what else is there? Can you recognize any of these?
These approaches all rely on specialized TOOLS to assist patients.
You've probably heard the saying "When the only tool you have is a
hammer, the whole world looks like a nail." Specialized disease
knowledge, technology, drugs, hospital stays, and procedures are
invaluable TOOLS in caring for patients.
The danger lies in over-reliance on tools.
We are observing tool-oriented approaches migrating to
patient-centered business and clinical models of care. Our commentary:
1) Disease-centered: Almost all disease management (DM)
companies started with carve-out approaches for one disease. "We
specialize in taking care of patients with ______(congestive heart
failure, diabetes, asthma, etc). Therefore we do it better and
The single disease companies started by picking the low hanging
fruit--patients with one disease. In fact, many patients have two or
more chronic conditions and/or have complicating social factors. This
will increase as baby boomers get older. The single disease program or
company is quickly beginning to fall by the wayside. Companies are
establishing programs to deal with the opportunities and risks
associated with patients who have multiple comorbid conditions.
2) Technology-centered: "We've got great technology to manage
patient care. We've set up a telephone call center with IVR and
CTI and have centralized the nurses in one location."
Here's a true story. A colleague of ours told us about
disease management programs being sponsored by his father's health
plan. His father, who has four chronic conditions, was receiving
routine calls from different nurses with four call center programs.
There was no coordination or sharing of information among the four
different programs nor sharing with local care providers. Does
that make sense?
3) Drug-centered: Pharmaceutical companies initiated the disease
management movement back around 1993. Many of them established
independent DM subsidiaries. Almost all of them have closed shop for
lack of customers. What happened? Almost everyone perceived that
the pharma companies were more interested in selling drugs than in
managing patients' diseases. Our interpretation: The pharma companies
assumed they were "the dog wagging the tail", i.e., that they could
independently drive DM approaches. WRONG. Today, they are
discovering that they have a critical role in SUPPORTING care
management, and that a byproduct is the selling of more drugs.
4) Bed-centered: Ever heard of a hospital administrator
preoccupied with keeping beds full? Today, hospitals are
recognizing that they must care for patients across a continuum of
services; they are just starting to build systems to do this.
5) Procedure-centered: There are many specialized facilities and
specialized clinicians. Much of this has been driven by reimbursement
available for procedures.
Is it possible to incorporate tool-focused approaches into
patient-centered care? Of course. The issue boils down to: is
the tool being used to ENABLE better patient care or to DRIVE patient
care (to a particular modality, location, etc.)?
DESCRIBING PATIENT-CENTERED CARE
We summarized "patient-centered" as care focused on the needs and
preferences of the individual patient. How does an organization get
Data must be organized across time and
around patients, not around organizational departments, sites of
care, or episodes of care.
Data must include key medical and
non-medical risk factors.
High cost and high risk patients must
be identified and
Care must be customized to the needs
and preferences of INDIVIDUAL patients. The tools we mention above
will be part of a larger tool box. Appropriate tools will be
used at appropriate times. Tools will be enablers of care,
not drivers. Many of the tools needed by patients will not
come from a "medical" tool set (e.g., the family needs "Meals on
Wheels" so that the caregiving spouse is relieved of some of the
burden of caring for the patient).
The highest cost and highest risk
patients should be monitored by case managers.
Comorbid conditions must be recognized
Patients and their families must be
given choices and information. Many studies show that this results
in more conservative, lower cost treatments.
MRS. THOMPSON AND
Consider two women who have the same "medical" conditions. Both women
are 80 years old, have diabetes, and heart disease, and take 8
medications. But, they have differing health risk factors:
Husband and family
Independent in daily activities
Loves her BMW
2nd floor, no elevator
Needs help eating & bathing
Uses a cane
Does not drive
Mrs. T and Mrs. J will appear IDENTICAL in
a typical health plan claims data base. Health plan care managers will
not be aware of their differing physiology, function, and social
context. While these patients will be shown as having the same
"medical conditions", they do have very different elements of risk to
a health plan. (Thanks to John Haughton, MD, MS for this
insightful example. Dr. Haughton is President of
population health and patient care management company.)
So what? First, without this information the health plan is far
less likely to identify Mrs. J's multiple risks and to offer
assistance to her and her medical providers. Second, without this
information Mrs. J is far less likely to receive the types of
assistance she needs; while her medical providers are watching her
"medical" conditions (diabetes, heart disease, medications), they are
less equipped to address some of her non-medical needs (e.g.,
assistance with daily living activities, social support).
A care system that is truly patient-centered will address Mrs. J's
medical AND non-medical needs.
Patients with chronic conditions are stretching the boundaries of
medicine. The next layer of value is being created with
patient-centered care approaches. This results in clinical outcome
improvements, reductions in care costs, and more satisfied patients
AN EXAMPLE OF
WHAT WE DO
Could your group benefit from a clearer understanding of "The
Transition from Managing Cost to Managing Care"? Better Health
Technologies can educate and inspire your audience on this critical
topic. We can customize presentations for your market and your
audience (Board, management team, medical staff, investors).
HOT OFF THE
PRESS: HEALTHCARE AND THE INTERNET
"The eHealth Industry: The Future of Healthcare is
On (the) Line," Wit Capital, May 26, 1999. Wit Capital
initiates research on the Internet/Healthcare sector. (Answering the
first two questions links you to their report.)
"Internet Update--Health Care/Pharmaceuticals,"
Manhattan Research, May 1999. An imperfect first offering from
another company starting to follow the healthcare/internet area.
Contains many useful tidbits, if not a comprehensive synthesis. Worth
monitoring for now.
"A Superpower Emerges in Online Health Care. The merger
of Healtheon and WebMD will create a firm worth some $20 billion."
E-CareManagement News is an
e-newsletter that tracks a major change in health care and managed
care—the paradigm shift from “managing cost” to “managing care”.
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management, and patient health information technologies.
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