Monday, January 25, 2016

The Cost of Care When Nothing is Wrong

For many years, healthcare management has focused on the small percentage of people who drive very high costs.   I admit that I have never been comfortable with that formulation.  I could never get past the reality that people who are spending the most money in health care are really sick.  They are having surgeries and being hospitalized – taking very expensive biological agents and chemotherapy, and have diseases such as cancer and sepsis, strokes and myocardial infarctions.  They are the exact people who should have the most money spent on them.  While focusing only on that small percentage of people who are the sickest is perhaps administratively less costly and helpful to those individuals, as it gives those people the coordination they require which does save some money, it targets those with the lowest percentage of unnecessary care.  It ignores the much larger number of patients, with the larger percentage of unnecessary care, representing the bulk of those who seek care.
In my years of professional practice in the field of gastroenterology, more than half of my patients had pain and symptoms with no disease that could be found by testing.  They were people with belly pain, constipation, and diarrhea who were suffering, but had normal blood tests, normal x-rays and normal endoscopes.  They often spent large amounts of health care dollars as they bounced around the medical system, getting repeat tests, going on more visits to different specialists,and trying to find ways to cure their ills.  I was fairly successful treating those people because I understood, in the words of Francis Peabody spoken in 1925, that “The secret of the care of the patient is caring for the patient.”  I would see these types of people, talk to them about the issues in their lives that were causing them distress, and often instruct them to drink more water (I became famous for my water cure.)  Most importantly, I would tell them to come back and tell me how that worked because I was interested in how they felt. I asked them about their life and how their pain was affecting their work, family and finance.  Being attuned to the life context of patients has now been shown in controlled studies to have tremendous impact on the quality and cost of care by Saul Weiner and Alan Schwartz. Only rarely did I end up referring them to psychiatrists or psychologists, as I knew that the minute they perceived that I was telling them that there was nothing physically wrong, that it was “all psychological,” was the minute I would lose their trust.  I took these lessons with me as I entered the world of health policy and care management.  
In my health policy career, I studied populations and reviewed data and learned that while these types of patients may have been over 50% of my practice, they were an even larger percentage of primary care practices. Much of primary care is actually the art of following Voltaire’s dictum that “the role of the physician is to entertain the patient while nature cures the disease.” That is to say: finding ways to help people for whom there are no answers by lab and imaging and whose problems will abate over time. From a population health point of view, these people do not fit neatly into the high cost cohorts that we try to target.  Yet, these are people in pain and distress coming to the doctor to relieve that pain.  Sometimes they are people with chronic diseases however often their immediate pain is not related to their battles to manage their diabetes or heart disease.  They are in the health care system, spending money as a measure of hope, and a significant percentage of those dollars spent are unnecessary.  That gets to the heart of the best way to save money in health care….focusing on the unnecessary care that is often directed towards those who are the most difficult to treat and manage, because their problems do not fit neatly into the boxes that we in medicine want to create.  
A recent review in the Harvard Review of Psychiatry provocatively entitled, “Medically Unexplained Symptoms: Barriers to Effective Treatment When Nothing Is the Matter” By Lipsitt, Joseph, Meyer and Notman discusses the problem and suggests principles around how best to treat such patients. It starts out by describing a composite model patient who has belly pain and is afraid of having ovarian cancer, as her aunt had recently died of ovarian cancer.  The authors describe a cycle of having evaluation after evaluation with nothing found, and the physician referring her to psychiatric care.  As they state, “She feels misunderstood, rejected, disappointed, and angry.  She decides to find another doctor.  The cycle repeats for several months.”  They point out in the article, “These patients pose a significant burden to practicing physicians and the health care system, with estimates of nine times the cost of general medical care per patient.”  
The article suggests that the way to treat these people is to make the relationship paramount, and to focus on care versus cure.  This approach creates a clear path for health policy and care management in which the ability to build trust with these types of people is critical to accomplishing lower costs and higher quality for the population, as these are the patients who  make up the majority of all physician visits, and have the highest percentage of unnecessary care .  It is not as low cost administratively as focusing on small numbers of expensive patients; however it is a more effective way towards effective cost reduction and quality improvement.  

The model of care management we have built at Accolade allows these people to build a trusting relationship with Health Assistants who care for them as people while we allow the physicians and nurses who are evaluating and treating them to find the cures. The small number of people who become high cost patients are parenthetically better managed because they have formed trust with an assistant before the coordination they require is necessary.  It is an approach that assumes physicians practicing good medicine and assumes rational but emotional patients who need a trusted, caring person to be on the healthcare journey with them.  It follows Peabody’s dictum while achieving lower costs, as it is about caring rather than curing, regardless of the disease label, or lack of a disease label.  While such an approach may modestly increase administrative costs, it dramatically lowers total costs by addressing unnecessary care. Simply put, relationships are cheaper than tests and hospitalizations, and eliminating unnecessary costs by cultivating purposeful relationships will bring us closer to our health care goals.