Tuesday, October 28, 2014

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way Part 4 – Impacting Emotions

“The good physician treats the disease; the great physician treats the patient who has the disease”
Dr. William Osler

We are all emotional beings.  Emotions are necessary and part of the human condition and are associated with illness of all types.  This is so self-apparent that people who lack certain components of emotions are considered to have a disease.  Whether someone lacks fear and tends to put themselves in danger or lacks empathy and tends to put others in danger, they are seen to be at a significant disadvantage in life.  Thus it is no surprise that people have emotional responses when they are in pain and when their body is overcome by changes due to disease.  These normal emotional responses to disease are actually helpful as we adjust in order to effectively deal with the challenge of being sick.  But while small doses of fear, anger, sadness, and other emotions are helpful, so too can they be destructive when they move into the realm of full blown depression, anxiety and denial that can signify a need for active treatment.  Even when the emotions do not reach that level of distress, they still must be acknowledged and addressed so that they do not lead to bad decision making when accessing care.  A person who is frightened can rush to an Emergency Room when waiting a day to see a primary care physician can be a better decision.  A person in denial can avoid needed immediate care and end up with severe consequences.  While neither situation may raise to the level of full blown emotional illness, they can adversely impact care. 

The interplay between medical illness and emotions has always been a part of medicine.  In recent years, with the emphasis on efficiency and adherence to disease protocols, the emotional aspect of treating illness has sometimes not garnered the attention it deserves when one visits a doctor or a hospital.  But a number of researchers have continued to look at the interplay between emotional illness and medical illness.   A classic article published in the New England Journal of Medicine in 2010 by Dr. Wayne Katon and his group showed that by combining support of chronic medical illnesses such as diabetes and heart disease with better treatment of depression and other behavioral diseases, clinical results were vastly improved.
Dr. Katon, with his work, coined the phrase “collaborative care” to describe a combined medical emotional approach to treating patients with illness and described three needed components to good collaborative care; a population approach driven by standard metrics for both the behavioral and the medical problems, monitoring of adherence by patients, and the use of “stepped care” or intensification of therapy if patients are not responding to therapy even when they are adhering to their treatment.  While poor adherence is often an issue in poor outcomes, a lack of proper monitoring and an inability to intensify therapy as needed are more likely to cause failures of treatment. 
At Accolade, we have made the use of collaborative emotional and medical support a cornerstone of all that we do to assist our clients.  In a commentary written in 2012 in the American Journal of Preventive Medicine, Dr. Katon cited the use of multi-condition managers to enhance quality of care.  At Accolade, we have used this type of model since we started helping people more than five years ago.  To quote his commentary:

“Several studies have expanded the concept of collaborative depression care by training care managers to enhance quality of care for depression and common comorbid conditions such as hypertension, diabetes, and coronary heart disease.  These new multicondition collaborative care models may provide economies of scale to treat multiple common primary care conditions.  Rather than primary care systems needing a separate care manager for each illness, which may be prohibitively expensive, multicondition care managers can provide enhanced quality of care for the most common medical conditions in a cost-effective manner.”

The key for us at Accolade is to expand that concept even further and recognize the patient as a person with medical, emotional, financial, spiritual and social needs.  We help the person address all those needs in a dynamic, ongoing way.  The data that shows that adherence and stepped-care are both important means that a relationship based case management approach is needed to remind about adherence and to maintain a patient’s trust so that if treatment is not effective, he or she can be coached and helped to return to the care giver in order to be properly assessed for intensified therapy.
While this results in improved care, the question is whether it saves money.  An article from the American Journal of Preventive Medicine by a group at the CDC suggest that the savings from this type of collaborative care approach can be significant.  By performing an in depth analysis of previous studies, they found that savings per person could reach levels of from $1,000 per person to $4,000 per person.  Their conclusion was that collaborative care provides good economic value. 

Saving money in health care paradoxically often means doing more, not less.  In the case of emotional reactions to illness, the need to proactively identify, monitor and treat the depression, anxiety and even the fear that is part of being sick results in higher quality and lower cost interventions.  This is one more example of Osler’s dictum that the great physician, and in our case the great health assistant, treats the person who has the disease.  This results in saving money in health care the right way.