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E-CareManagement News

June 1, 1999




Patient-Centered 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 Foundation's "Chronic Care in America:  A 21st Century Challenge" is a classic study that details the clinical and financial issues involved.

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?

1) Disease-centered
2) Technology-centered
3) Drug-centered
4) Bed-centered
5) Procedure-centered

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 cheaper."

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 there?
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
followed.
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 and treated.
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 MRS. JONES

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:

MRS. THOMPSON                       
Husband and family                  
Ranch House                         
Independent in daily activities     
Walks unaided                       
No incontinence                     
Happy                               
Loves her BMW                       
Occasionally overindulges           
$12,000/mo. Income                  
MRS. JONES
Widow
2nd floor, no elevator
Needs help eating & bathing
Uses a cane
Incontinent weekly
Depressed
Does not drive
Doesn't drink
$500/mo. Income

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 CogniMed, a 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.

SUMMING UP

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 and families.



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”.  This e-newsletter is brought to you by Better Health Technologies, LLC (http://www.bhtinfo.com) .  BHT provides consulting and business development services relating to disease management, demand management, and patient health information technologies.

You may copy, reprint or forward this newsletter to friends, colleagues or customers, as long as the use is not for resale or profit and the following copyright notice is included intact. Copyright © 1999, Better Health Technologies, LLC. All rights reserved.





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