Monday, December 22, 2014

A Better Way

Last week, the CBS news show, 60 minutes, in its normally breathless, muckraking manner, aired a segment entitled “Denied” which highlighted the review of psychiatric admissions by the insurance industry. It started with the statement, “When insurance companies deny the mentally ill the treatment their doctors prescribe, seriously ill people are often discharged, and can be a danger to themselves or others.” In the words of Scott Pelley, “The insurance industry aggressively reviews the cost of chronic cases.  Long term care is often denied by insurance company doctors who never see the patient.  As a result some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.”  The segment goes on to tell the stories of people who have either died or come close to death due to these decisions.  It also reviewed the process of making these denial decisions and presents them as cavalier and potentially uncaring. 

I have worked within Anthem as a medical director, albeit not one who was making those types of denial decisions, and have known wonderful doctors and nurses within that particular insurance plan, as well as in other insurance plans, whose main goal in performing case review is to ensure that patients are receiving care in keeping with best practice guidelines.  In many ways, their job is an impossible one.  It is almost impossible to uphold the fiduciary responsibility of the insurance carrier that requires that payment only be made for care that is absolutely necessary while also giving doctors free reign to practice in ways that may not be best for anyone concerned.  The normal way to meet this responsibility is by this type of regulatory approach which approves and denies payment in the sort of manner that is reported on by CBS News. 

The fact is that whenever you attempt to review cases from afar, and base determinations on either claims data or even on medical record information, you miss a big part of the story.  Even when you are able to speak with treating physicians, they may be poor at communicating the issues in a way that satisfies the black and white of insurance medical policies so that decisions are made that may not be in the best interests of either the patient, or even the insurance company. 

Recent work and recent writings have shown that medical narratives; the communications that really take place between doctors, nurses and patients are often not as cut and dry and may not fit into the nice algorithms of an evidence based medical policy.  Those narratives and the life context that clinical decisions occur in are not seen in claims data, in certification reviews, and often not even in the medical records or the quick telephone communication between a treating physician and the insurance company health professional.  Nowhere is this more true than in those who are in need of mental health treatment.  In the case of mental health care, the sickest patients can often be the most in need of an approach that is more nuanced and more in need of understanding that there may be facts that are not seen in the typical insurance review.

But there are other ways to impact care in order to decrease the care that is not necessary, protect the patient from potentially inappropriate care, and also respect the joint patient doctor decision-making process.  In my career, I have worked to build techniques that attempt to impact that decision making between a doctor and a patient in ways that do not require the type of micromanagement and approval and denial from afar that is depicted in the ‘Denied” report.  I know it can work. 

Early in my career, I was involved in starting a program that, in dealing with what looked like inappropriately long hospital stays, rather than deny payment, would deliver “Get Well” cards to people when they were admitted to the hospitals.  The cards said that we, the insurance company, hoped they would get well soon and that if all went well, based on best practice standards, we expect that they would only need to be in the hospital for 3 days (as an example).  The card went on to say that if more time in the hospital was needed, their insurance would cover the additional time so they should not worry.  This simple card decreased our length of stay average because it changed the conversation between the doctor and the patient.  It created a dynamic in which if the doctor wanted to keep the person in longer, the patient would ask why. That conversation was healthy, and moved people more towards a model of shared decision making and also fulfilled the fiduciary responsibility to hold costs to only those services which were necessary.  It used communication and positive influence rather than policing and regulation.  

It was one example of attempting to help influence people towards making their own best decisions in partnership with their doctors and nurses.  It did try to positively influence the conversations to help the joint decision making improve, but did not attempt to police the ultimate decision made. 
At Accolade, we have built a model which decreases unnecessary care, decreases admissions to the hospital, and decreases readmissions while never needing to say “no” to care.  We accomplish this even in mental health care where our data show that we increase outpatient visits, decrease hospitalizations, and lower overall costs.  We do this by using trust and positive influence, and by recognizing and addressing the impact that heightened emotions, which almost always accompany illness, have when doctors and patients attempt to make good decisions for themselves and the people they love.  We do this by forming a trust bond between that person in need and their Health Assistant and then educating him or her to the medical options available.  In this way, the right knowledge is available at the right time.  That leads to better shared decision-making.    

Our goal is always to improve the decision making but not to make the decisions for the doctor and the patient.  Our goal is to help people through the confusion of illness and not to police them and to tell them what to do.  We never want to hear anyone say, as the mother of a young woman who died from an eating disorder after being discharged from the hospital said on 60 Minutes, “the insurance company overruled the doctor.”
Insurance companies must maintain their duty to make sure that insurance premium dollars, whether they are paid by individuals, corporations, or government are used wisely, but that does not have to be done by second guessing difficult individual decisions made by a doctor and a patient and subsequently denying payment for the sickest patients.  There is a better way.  

Thursday, December 4, 2014

Engagement, Overconfidence and Healthcare Decision Making

At the risk of repeating my stories, something that my children always accuse me of doing, in December 2013 I wrote a blog post which mentioned by own history, some thirty-seven years ago, of going to the Emergency Room when I was an intern in Chicago, with my self-diagnosed appendicitis which really turned out to be a kidney stone attack.  I was confident in my analysis, was able to back it up with my history, was able to convince the medical staff, and was totally wrong.  I was also an engaged patient, working with a medical and nursing personnel who knew me and treated me as a full partner in my care, and was still wrong. 

My personal story came to mind as I read two apparently unrelated articles.  The first is from ImproveDX, the newsletter of the Society to Improve Diagnosis in Medicine.  It is entitled, “Overconfidence, Humility,and Diagnostic Error” and it reports on a paper presented by John D. Banja PhD at the 7th annual Diagnostic Error in Medicine conference.  As reported in the newsletter, Dr. Banja’s view is that “the current medical culture promotes narcissistic behaviors: being self-oriented, self-enhancing, and defensive.”  The newsletter goes on to say that physicians have this narcissistic view because their sense of self-esteem is tied into their confidence and is, in our current environment, under “constant threat.”  Dr. Banja clarifies that he is not accusing physicians of being narcissists but rather of showing that type of behavior in response to our system and our culture.  The point is well taken.  Physicians especially, but all health professionals, tend to treat their own anxiety about diagnosis with a healthy dose of hubris even when uncertain.  They can have an overly confident view of their own judgment, and may have trouble admitting when their initial diagnosis is wrong.  This leads to diagnostic errors which the article points out can be clinically devastating. 

While the fact that doctors need a healthy dose of humility is hardly news, the other article forces one to keep a sense of perspective about that reality.  Writing in JAMA, in an article entitled, “Engaging to No Avail”, Irene Wielawski, a medical journalist writes about her own bout of appendicitis.  In her case, as an empowered patient, she delayed calling her doctor despite her severe pain, and when she finally called, it was only because she wanted to sleep and the pain would not let her sleep.  When she spoke to the medical professionals, they listened to her but did not obey her request for sleeping medication.  In the light of day, she realized that their ability to ignore her request saved her.  “But determined as I was to run this show, my insights and utterances really were quite worthless – except as evidence of the addling effect of bacteria overload.”  She goes on to say,

“But it was competence in my case, not arrogance that led everyone to ignore my wishes.  First up was the nurse practitioner on call at the medical group.  She listened to what I had to say, but her trained ear picked up far more important information, namely the thready voice, pauses, and repetitive phrasings of someone seriously ill. ” 

As the second article demonstrates, narcissistic behavior and maintaining a sense of self-esteem is not limited to doctors but also applies to patients!  The principles of shared decision-making and patient engagement should be endorsed wholeheartedly however respect for expertise that only comes with training, skills, and experience honed by caring for patients should be given equal weight.  To care for patients, one must listen to them and take their concerns into account.  However that can never take the place of a professional’s knowledge of health and illness. 

Doctors are human, and their judgment can include an unhealthy dose of self-importance however if I am in a crisis situation, give me a good, arrogant doctor any day over one who is humble and incompetent.  When I choose a doctor, I try my best to have someone who has both skill sets however if I am the victim of major trauma, or am in the midst of a major heart attack, I care much less about the personality defects of a skilled trauma surgeon or an interventional cardiologist. 

The fact is that all health professionals must learn to listen empathetically and to think and assess what they are hearing critically.  They must be attuned to hearing and assessing what is said and also attuned to how it is said.  The doctor or nurse who, in the mode of true “shared decision making” only follows the patient without the critical assessment skills needed to decide what needs to be done medically will make errors just as frequently as the doctor who arrogantly decides on a course and whose inability to admit an error, follows that course into disaster. 

Health professionals have to find the right balance between being attentive to patient’s desires, while also leading the patient where they need to be taken to achieve cure.   That is part of what makes medicine, nursing and other health professions more than jobs.  That professionalism must be encouraged and any catchphrase, such as “engagement” or “evidence based medicine” must never take the place of the education, skill and experience that good health professionals bring to their patients every day.