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.  

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.  

Surgery, Family and Post-Operative Care

In the eyes of parents, children are always children, even when they are grown.  So when our youngest son, 20 years old and a junior in college, needed sinus surgery, my wife and I drove the 7 hours to see him through the surgery and take care of him.  That is what parents and families do.  As a physician and as someone who routinely searches for best physicians and facilities as part of my job, I had investigated the surgeon and the facility and had decided that he should have his care in the city where he goes to school. 

The surgeon was perfect.  Caring, skilled and communicative.  The facility and the health system was excellent.  The surgery was less straightforward than we had hoped, as his obstructed sinus was profoundly infected with abscess formation.  The skill of the surgeon and the operating team was a blessing as operating on infected tissue is always more difficult.  Thus the one hour surgery turned out to take three hours.  Our son came out of surgery and after a few hours in the recovery room and in the extended care area, we took him back to our hotel, as we thought we could better care for him post-operatively there than in his student apartment. 

We walked him into the hotel, supporting him on either side.  He was shaky on his feet as one would expect after hours of anesthesia.  He had been intubated (had a breathing tube inserted into his trachea) during the surgery so his throat was sore and his voice very weak.  No surprise there.  In the hotel room, we were busy changing the dressing under his nose (a so-called “moustache” dressing) which was catching the bloody discharge from his nose, and also helping him deal with some difficulty with urination, also no surprise after anesthesia and surgery.  We were helping him stay on top of his proper pain medication dosage and anti-nausea medication.  We gave him the antibiotics he needed at the proper time intervals.  And then it hit us.  My wife and I are doctors.  We are used to these issues and feel very well equipped to provide post op care and post op monitoring.  But what if we had no background in medicine?  What if we were accountants or store clerks, or engineers or bus drivers who suddenly had to be thrust into this role?  Would we feel as confident and comfortable?  What if the patient had no one to help them, with a friend driving them home and then leaving them alone for the rest of the evening, night and days to recover?

We were keeping him hydrated, pushing fluids.  We were watching him to make sure the bloody discharge did not suddenly turn into bleeding that would be much more serious – even potentially life threatening.  We suddenly understood emotionally the truth of the adage that people in our modern era were discharged from hospitals “quicker and sicker”.  We intellectually knew that people, who had day surgery, were sent home from the hospital often in need of care, even if they were not in need of hospitalization.  The norm today is for that care and monitoring to be provided by family and friends with little training and support in those often critical first 12 to 48 hours after surgery.  Rarely do medical facilities, no matter how good, review the adequacy of that caregiver as they discharge the post-operative patient to home.  

The facility where he had the surgery had done everything in a world class way.  The instructions given to us upon discharge were thorough and clear.  The surgeon had given us good explanations and instructions and had personally called our son the first day post operatively to check on how he was feeling.  Everything was done the way it is supposed to be done.  The problem from our prospective – from a family prospective – is the profound emphasis on efficiency by the rules of the payment systems and the minimizing of the human element of families caring for loved ones. 

Thorough instructions do not take the place of experience and training.  The care of someone with dressings, with pain management, and with all of the issues related to bodily functions are no longer seen as being efficient when done in the hospital.  Those activities do not reach the level of care that meets criteria for skilled home care.  But at the same time, patient and family fears and uncertainties are not taken into consideration.  The risk of being alone is not addressed.  Instead, the families are forced to take on roles for which they have no training and no skills.  Patients are believed to have the ability to monitor themselves.  It is believed that providing reassurance around wound drainage, expected post-operative pain, and family’s worries that the healing process may not be progressing as normal, is just not efficient. 

My belief is that from a cost point of view, this responsibility given to patients and families leads to unnecessary ER visits and unnecessary readmissions as the caregivers often do not know how to deal with a loved one, having just gone under the knife, who complains of pain and other symptoms.  Even though on paper, criteria may make sense, when they don’t take into account the experience, knowledge, and fears of the family caregivers or the lack of any caregivers, they are not adequate and can lead to poor clinical outcomes and ironically higher cost.

Our son is now doing fine, and I feel great gratitude and admiration for the surgeon and his team.  On a broader scale, I worry about whether our push for efficiency in health care has actually hurt our quality of care and paradoxically increased costs.  I worry that we may be minimizing the caring, understanding and empathy that are necessary components of health care.  I worry that we may not be paying enough attention to the informal and untrained and unpaid caregivers who now must do so much of the monitoring and care.  I worry that even as we improve the quality of care inside facilities; we ignore the fact that patients go home and are still sick and need care and monitoring.  I hope and pray that we find ways to address my worries in an increasingly population based medical care system.  

Biology and Culture in the Treatment of Ebola

We are starting to make progress against Ebola.  But those who believe it is because we have developed new treatments or vaccines, would be wrong.  We are still struggling to find the right treatments, and still doing research on an accelerated time table to try and find vaccines for this rapidly mutating virus.  Rather, we are making progress because we are fighting the disease using basic principles of public health while paying closer attention to the cultural aspects involved in both the spread and the control of the disease.  In a study done in “Emerging Infectious Disease” in October of 2003, during an earlier Ebola outbreak, Barry Hewlett and Richard Amola explained how the local population in Northern Uganda both explained and treated Ebola using local beliefs and customs and the wisdom of traditional healers.  Contrary to Western biases, the authors found a great deal of pragmatism and flexibility in the local healer’s approach and found that local cultural and religious norms could have a positive effect on the control of an outbreak.  The local healers led efforts, which appear to pre-date Western influence in Uganda that are very much in keeping with modern methods of infection control.

“When an illness has been identified and categorized as a killer epidemic (gemo), the family is advised to do the following: 1) Quarantine or isolate the patient in a house at least 100 m from all other houses, with no visitors allowed. 2) A survivor of the epidemic should feed and care for the patient. If no survivors are available, an elderly woman or man should be the caregiver. 3) Houses with ill patients should be identified with two long poles of elephant grass, one on each side of the door. 4) Villages and households with ill patients should place two long poles with a pole across them to notify those approaching. 5) Everyone should limit their movements, that is, stay within their household and not move between villages. 6) No food from outsiders should be eaten. 7) Pregnant women and children should be especially careful to avoid patients. 8) Harmony should be increased within the household, that is, there should be no harsh words or conflicts within the family. 9) Sexual relations are to be avoided. 10) Dancing is not allowed. 11) Rotten or smoked meat may not be eaten, only eat fresh cattle meat. 12) Once the patient no longer has symptoms, he or she should remain in isolation for one full lunar cycle before moving freely in the village. 13) If the person dies, a person who has survived gemo or has taken care of several sick persons and not become ill, should bury the persons; the burial should take place at the edge of the village.”

Yet during that earlier outbreak in 2003, the traditional healers’ approaches to disease control was assumed to be destructive to the enlightened Western approaches.  It was assumed that the local traditions contributed to the spread and that those local beliefs and approaches had to be challenged and discarded. 

In the current outbreak, the same cultural arrogance, and belief in the Western approach being the only acceptable approach, may have initially hindered early progress on disease control.  As an example, one of the factors that is believed to have contributed to the spread of Ebola has been the local burial practices.  Muslim burials in West Africa, are traditional and involve a ritual washing of the dead, a practice that Muslims and Jews have in common (as is true for many practices of Muslims and Jews).  In addition in some cultures of West Africa, during the funeral, touching the face of the dead is also done as a way of showing their love.  Yet research has also shown that people are willing and ready to modify those burial practices if the changes are done with respect for beliefs and the involvement of local religious leaders. 

A new protocol that has been instituted by the World Health Organization addresses these burial practices but does so in a way that respects the cultural and religious beliefs of the mainly Muslim and Christian communities that are now being affected so severely by the disease.  As reported in the New York Times,

“The new protocol emphasized that burials needed to be safe, but also dignified, taking account of religious and cultural sensitivities to build trust in communities where some people have accused burial teams of spreading the disease. Inviting the bereaved to be involved in digging the graves of relatives and offering Muslim families an alternative to ritual washing of the dead, a practice that could involve lethal exposure to the virus, “will make a significant difference in curbing Ebola transmission,” the W.H.O. said.”

Alpha Kamara, a journalist who lives in Sierra Leone in a piece published in USA Today describes this interface between religious faith and medical care quite eloquently from a Christian prospective quoting the book of Joshua.  He states:

“Joshua 1:9 reminded me that although God can be everywhere, Ebola cannot.  God can command.  Ebola cannot……. Ebola is a virus.  We react to it.  But we can control our reactions.”

He goes on to states his thanks to OXFAM, the World Health Organization, UNICEF, and Doctors without Borders who have done so much for the people of Sierra Leone.  Those organizations are at the forefront of caring for people in both a scientific and a culturally and religiously sensitive way.

Without the trust built through protocols that respect beliefs, and the attention to the cultural issues in health care, the work of worldwide health organizations and protocols such as this new protocol for burial practices would not be as successful and would not be able to decrease the spread of the disease as it appears to be doing.  Without the blending of science, faith and culture, we could not vanquish this virus.  If this were a pure biologic approach that did not incorporate local religions and cultures while respecting local leaders it would not have the kind of success that is needed. 

Medicine, wherever it is practiced, must start with trust and respect for the patients and their beliefs.  That includes understanding and respecting their cultural and their spiritual selves as well as their biology.  Without that starting point, the best biologic research and treatment in the world, will never be as successful as it can be. 

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.  

Bias, Fear, and Health Care

Dr. Leana Wen is a wonderful physician and author (as well as a member of the Accolade Medical Advisory Board) who is a recognized expert on the role of communication in medical care.  In a talk she gave in May of this year at TedX Foggy Bottom, she spoke, for the first time, about her own experience as a stutterer and the paralyzing impact of the shame and fear that the stuttering caused.  Stuttering, for Dr. Wen, is just as important to her identity as her being Asian-American, being a woman, and being a physician.  It is part of the complex tapestry of who she is as a person and how she is seen by others and how she sees herself.  Each one of us is an amalgam of   traits, beliefs, attitudes and histories that defines us for the rest of the world and shapes our own perception of how we interact with the world.  This complex dynamic of the world’s perception of a person combined with a person’s own perception of what makes them unique can dramatically affect every aspect of our lives, including our health care.  In the latest issue of Health Affairs Dr. Wen builds upon her TedX talk and tells a story of a patient who is also a stutterer who initially receives sub-optimal care for chest pain due to his stuttering.  When the care is transferred to Dr. Wen who recognizes the trait and adjusts the evaluation and treatment accordingly he receives the right care. 

The way others see us and the way we see ourselves can create barriers to receiving the right care at the right time.  In the case that Dr. Wen describes, the first ER doctor saw the intelligent lawyer who stuttered, as someone who was slow, possibly even mentally impaired, and that created a risk that the care to be rendered could be misguided and wasteful.  Dr. Wen was called in to obtain blood tests and x-rays to evaluate the patient’s chest pain however when she was able to communicate with the patient in a trusting, caring way, he needed neither as the problem was not what it initially seemed to be.  Rather he had found himself in the ER with a diagnosis of chest pain due to his being in a situation in which his fear of stuttering created a panic attack.  The blood tests and x-rays were unnecessary and after his evaluation, he was able to go home.  It would have been no different if the issue was a language barrier, a manner of dress, or even someone’s race giving rise to bias. 

While bias in health professionals is a problem, it is only part of the problem.  Each of us also has a trait, belief, or other feature that cause us to feel fear and to block our ability to achieve all that we can achieve.  That fear can be related to race, family background, or physical disability.  It can be based in personal or historical reality or just be a perception that has no basis in anything overt or obvious.   I am a Jewish child of immigrants and while I take pride in that pedigree, when I was growing up, it also elicited a certain fear in me and led me, to sometimes feel as an outsider in the medical circles in which I worked and lived.  When I started medical school I had to get past the feeling that every one of my classmates was tall, with blond hair, had parents who were alumni physicians and had gone to Yale (since over 20 people in my class of about 150 at Columbia had gone to Yale it had a bit of a basis in reality).  Externally, when I was growing up, I faced some overt anti-Semitism and while not enough to be material, when combined with my family history of uncles and aunts being killed in the hell of Auschwitz, the fear that it elicited was very real.  My father, my hero, lived with a certain amount of fear that was founded on the reality he lived with when he was in Europe helping others escape from Germany and he passed some of that on to me.  He also passed along the bravery to stand up to the fear and take the kind of risks only an immigrant coming to a foreign land with nothing could take.  While that may seem disconnected from the stuttering that Dr. Wen describes, the fear that was part of my family history was a self-perception that sometimes caused me to be treated differently and to hold back when I should have been assertive.  It was my stuttering.  In a critical illness situation, that can be dangerous.

In health care, which is so personal, the external reality of bias for any reason, and the internal feelings of fear, can lead to care that is bad, dangerous and often more costly than it should be.  In May 2013, I wrote a blog post about my son’s hospitalization for a unknown illness, and the perception of the staff that his illness was not serious, or was somehow his own fault (the illness actually turned out to be secondary to an unusual disease totally missed by the staff at the teaching hospital).  The bias that they developed, just based on their assumption of who they thought he was hurt his care.  Happily, his own self-perception was strong enough, that he could overcome that barrier to get the right care at a different health system after discharge and be treated successfully.

 

The combination of health professionals who put a “label” on anyone, for any reason and the fear brought on by a self-label can be deadly, but they both can be fought.  A person, who recognizes the bias in a health professional, even if inadvertent, can point it out to the doctor, nurse or therapist and in most cases, the professional will probably apologize.  Thus the “disease” of bias, which affects care, can be countered, just as it was in the case related by Dr. Wen in the Health Affairs article.  If that doesn't work, then quietly demanding to be treated as an individual and not as a perception or a label may be needed.  Often the harder job is attempting to overcome the internal self-images that tell you, in a soft voice, that you cannot succeed so you don’t even try.  In those instances, just as Dr. Wen uses that self-image of being a stutterer to help her succeed, so others can be coached and supported to embrace who they are and to turn the fear into a strength.   In a person’s journey through illness, both the health professional and the patient have to be ready to face their own biases and their own perceptions head on to obtain the best care.  

Communication as a Valued Skill in Patient Care: The Need for a New Profession.

The Curse of Knowledge.  We tend to think of knowledge as a positive attribute, and we are right, however every positive attribute has within it the challenge of the attribute being used correctly and sensitively.  In a recent commentary in the Wall Street Journal entitled “The Source of Bad Writing” Steve Pinker describes this curse, defined as a “difficulty in imagining what it is like for someone else not to know something that you know” as a source of much of the bad writing that we see.  He wrote:

“Anyone who wants to lift the curse of knowledge must first appreciate what a devilish curse it is. Like a drunk who is too impaired to realize that he is too impaired to drive, we do not notice the curse because the curse prevents us from noticing it….. I go to a website for a trusted-traveler program and have to decide whether to click on GOES, Nexus, GlobalEntry, Sentri, Flux or FAST—bureaucratic terms that mean nothing to me. My apartment is cluttered with gadgets that I can never remember how to use because of inscrutable buttons which may have to be held down for one, two or four seconds, sometimes two at a time, and which often do different things depending on invisible "modes" toggled by still other buttons. I'm sure it was perfectly clear to the engineers who designed it.”

While his message is about writing, it also applies to medicine and to the communication that is critical to good quality medical care.  Medicine is a field of endeavor in which sensitive topics require strong communication, however, the curse of knowledge has infected medicine through policies, regulations, economics and medical education. Medical professionals are trained to learn a highly specific language and we don't give doctors the time, training, and incentives to communicate. We also seem to be stuck in a destructive cycle in which the cost of giving physicians and other health professionals the time and tools they would need is assumed to be too expensive in our resource stretched world, so the problem keeps getting worse. However, while we act otherwise, it may actually be less expensive to give health professionals more time with patients because we often substitute tests, drugs, and procedures for communication.  Many of the concierge medical programs and the direct primary care approaches are starting to prove that the most expensive part of the health care bill is not necessarily the increased time per office visit. 

Giving doctors, nurses and therapists more money for more time, as the only solution, will not solve the problem.  I worry about the challenge of retraining doctors who have been taught that the communication aspect of treating patients is not important.  The current system is driven by an almost religious belief in science alone and dedicated to the precision of scientific language which is often incomprehensible to those who are not in medicine. We must try to change the culture in medicine and in medical teaching environments that lauds the medical scientist as the final arbiter of all that is high quality in medicine. That being said, the science is critical, and we should not be compelled in this cultural change to devalue the science. But we must regard the caring and the communication as being of equal value to the science.

I know this will be challenging. It is extremely difficult to change the culture of medical education in which physicians huddle outside patient rooms around computer screens, discussing among themselves the diagnostic dilemmas and the therapeutic challenges that the pathology, not the person, presents. It is also extremely difficult to change the insurance rules and payment systems and the culture of insurance, government and health policy which speaks in the language of "incentives" and "codes" and "adjudication", rather than the language of “caring” and “understanding.”  It is virtually impossible to change a medical science and industry infrastructure that looks for a complex medication or a new technology or a new payment methodology rather than looking for a better way to relate to people as people.

Yet we will not improve care and caring for people unless we start to focus as much on changing this culture of purist medical science to one that values communication, story telling, and the social and psychological aspects of people's lives.  We can learn lessons from Pinker’s message and from literature in general about communicating with people’s spirits as well as their minds.

Dr. Daniel Sulmasy, a Franciscan monk, physician, author and expert on medical ethics, has written extensively on the need to see the experience of illness as distinct from the disease pathology.  He wrote:

“Illness is a spiritual event. Illness grasps persons by the soul as well as by the body and disturbs both. Illness ineluctably raises troubling questions of a transcendent nature-questions about meaning, value, and relationship. These questions are spiritual. How health care professionals answer these questions for themselves will affect the way they help their patients struggle with these questions.”

It is spiritual, it is literary, it is story-telling and of course it is scientific. Health care touches people as people and not only as patients.  As such, we must find solutions that fosters the caring, the communication, and the literary and spiritual aspects of care as well as the purely medical science aspects. 

My solution is somewhat radical but also keeping with the tradition of medicine in human history.   A new health professional dedicated to hearing people's stories, relating the stories people tell to professionals in ways that influence the care they receive, and helping those people in need by translating the jargon of insurance, care delivery and medicine, into understandable and actionable prose that reflects their lives, their challenges, their values, and their fears. A profession that recognizes the spiritual nature of illness as well as the scientific aspects of disease.  We, at Accolade call the professional who has this communication expertise the Health Assistant and lest this blog seem too much like a shameless commercial, our goal is to create this new profession in addition to growing Accolade as a company. Of course I want to see the success of my company, but more as a vehicle for changing the landscape of medicine than as a purely commercial endeavor.  Our patients need and deserve this. We all, as people, need to be approached with a dedication to true communication that matches the dedication to medical science.

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 3: Physician Incentives

As patients, we all want our doctors to be smart and caring, and to focus all of their attentions on helping us as we struggle with illness.  We want our primary care doctors to take their time with us, allowing us to tell our stories and to fulfill their role as our trusted advisor and advocate as we traverse the health care system.  We want them to be clinically aware of all the implications of what we say, to be able to assess us with their skilled physical examination and to be able to choose the right tests and therapies to treat us.  We want them to help us access the right specialty expertise when that is warranted. 

We want our specialists to have in depth knowledge and skills so that if we put our lives in their hands, we will be confident that we will come out of our interaction with them better and healthier than when we started.  We want their technical expertise to be excellent and their judgment to be impeccable when our lives are on the line.  We want our surgeons to have gifted hands and gifted minds to go with those hands.  We want our cardiologists, our endocrinologists, our pulmonologists and our gastroenterologists to be able to assess and treat our illnesses when those illnesses fall into their areas of expertise and we want them to have the wisdom to know when our problems are not in their areas. 

We as patients want our clinicians to follow the advice of Dr. Daniel Sulmasy who states  in his book, “The Rebirth of the Clinic” that our clinicians should “concentrate on the basics, becoming again who we always have known we should be – physician, surgeons, nurses and others who are full of care; humble, sincere, compassionate, and competent.”  

But it must be acknowledged that the costs involved are real and impact other family needs from housing costs, to food, to the ability to care for families.  So costs cannot be ignored.  As I stated in part 2 of this series on saving money in health care, costs are generated when a patient meets a health professional and decisions are made which generate claims and bills and ultimately costs.  The smallest part of the costs generated by a visit to a doctor are the fees that are charged for seeing the physician.  The testing, the therapies, the surgeries, the imaging and the facility charges make up the bulk of the services that costs all of us so much.  Payors need to better understand that dynamic and try to pay physicians and other health care professionals in ways that foster what patients want, which is for clinicians to use their knowledge and skills to help make decisions that best help the patient.  Does the reality of our payment and incentive system actually match our desired outcome when a patient sees a physician? 

Many years ago, I used to speak on the topic of how to pay and incent physicians.  With my tongue firmly in my cheek, I would always say that there are three ways to pay a physician.  One is to do less, one is to do more, and one is to leave at 5 PM.  When you pay a doctor a fixed fee per patient, whether the patient is seen or not, often called “capitation”, you are paying them to do less.  When you pay them a fee per service, and allow individual services, such as ECG reading, blood drawing, and physical exam to be separate services and therefore billed separately, then you are paying them to do more.  When you pay them a salary you are paying them to leave at 5 PM.  The point I was attempting to make when I would say this was that doctors are people and we need to acknowledge that they work towards incentives just as all people do. 

At the same time, patients (and we are all patients at times) often don’t want doctors and health professionals to be ordinary people.  We, as patients want them to be more.  We want them to fulfill a calling and to understand their standing in our society as occupying a position of trust that is a both a privilege and a responsibility.  It may be a bit overwhelming to try and think of developing an incentive system that recognizes and encourages that sense of professionalism that leads to the calling being fulfilled; however we must try.  Our current incentives do not succeed at fostering this sense of professionalism. 

The language used to describe clinicians has changed and incentives are driven by the language.  They are no longer doctors and nurses caring for those in need.  They are no longer clinicians but “providers” and patients are not patients but “consumers”.  The language of caring and healing has gone by the wayside to be replaced by the language of economics.  Society has allowed the MBAs (and I say that as a physician with an MBA who takes great pride in that degree) and the economists to suck the professionalism out of health care professionals by allowing the financial people to claim the language. 

By lumping all clinicians into the bucket of “providers”, the payers first tell them that their training, knowledge, education and expertise is merely a set of information “content” that can be replicated, at a much lower cost, by advanced computer systems, by lower level personnel using expert systems, and by technical advances that make their professionalism primitive and even quaint.  The clinicians are told that they must precertify their decisions as the payers don’t really trust how they are applying their knowledge, and must assume that they will be doing the wrong thing for the patient and for society.   The actions of payers and regulators, are based on the assumption that clinicians are likely to make mistakes and to overcharge.  That is hardly a way to incent what we, as patients, appear to want.  Our payment system is now geared towards the false efficiency of having doctors see more patients in less time, and in having more work leveraged to other personnel who are lower cost.  This may actually work against us.  For nurses it is no different.  The skilled nurse of the past, who had a patient who she (and it was usually a “she” in the past) felt personally responsible for has been replaced with the nurse manager who triages the work to the lower cost nurse’s aide and other support personnel.  The interest in knowing the person behind the patient has come to be seen as just too expensive.

 

I admit to being a lover of irony and paradox.  Thus I have spent much of my career designing and building programs that encourage more time to be spent with patients by the people most knowledgeable and proving that the irony rests in the fact that the more expensive, more highly trained people, spending more time, not less, with patients, actually saves money.  Many years ago, I was involved in a program to try and lower the costs of mental health care.  We set up a program, for people who were in a psychiatric crisis.  They were usually in an Emergency Room or in a local police station and we would send a PhD level Clinical Psychologist to the patient, wherever they were, to assess and stay with the patient for however long they needed to.  Patients and psychologists often spent 3 or 4 hours together and then saw each other daily for the next few days.  With this approach, paying the psychologist for their time generously, we saved huge sums of money by avoiding unnecessary mental health hospitalizations, and we saved society from the costs of incarcerating people who were acting out because of their mental health crisis.  We theorized that the time these skilled professionals spent with people in need would easily pay for itself and we proved that.  In follow up studies, we also found that the care rendered was far superior to the usual care as measured by recurrence rates which were a fraction of the usual recurrence rates for this type of population. 

Currently, at Accolade, we have built a system which trains a new type of professional, one we call a Health Assistant, who telephonically stays with people in need, for however long they need: someone who forms relationships in ways that are considered too costly in today’s world.  Yet using that relationship as the backbone of a person’s use of the health care system, improves care and saves money.  The paradox that spending more time supporting, educating, and helping people through the trauma of illness and difficulty saves money is real. 

What does my Accolade experience and my experience with the psychiatric crisis intervention program teach me about incentives for physicians?  It says to me that incentive systems should first respect clinicians and not attempt to get in the way of active patient care.  Programs that require pre-review and pre-approval of treatment are demeaning and ultimately counterproductive.  That includes pre-certification, step therapy, and pre-approval of imaging exams and lab tests.  I do not believe that the decisions by clinicians are always correct, only that the programs that try to ensure that they are always correct are bound to get in the way of the trust between doctor and patient and not encourage the type of joint decision making that is needed.  These “mother may I” programs can have the perverse effect of making access to care more difficult.  We should review a doctor’s patterns and records and pay him or her based on the quality of the care as evidenced in those retrospective reviews as long as the reviews include the clinicians ability to form trust relationships with the patient, and to understand the context of the patient’s life. 

Physicians should be reimbursed in ways that encourage them to spend time getting to know patients, and in ways that encourage a direct deep relationship between the doctor and the patient.  For that reason, in primary care, I look on the movement towards direct contract primary care as a good step towards doctor and patient working together with the doctor being paid to be the trusted advisor.  I also believe the open notes movement (the movement towards a medical record which is truly shared by the patient and the doctor) further encourages the type of trust that this relationship requires and incenting office practices to embrace open notes is likely to have a positive effect.  

My desire to incent proper relationships between doctors and patients makes me a bit nervous about the bundled payment movement as I fear it creates a new administrative barrier to the relationship between a doctor, a nurse and a patient.  The service “bundler” tends to be the health system and they have the most to lose financially when clinicians and patients think carefully about all options and how those options will affect a person’s overall life.

I want the incentives for surgeons and other specialists to include payment for talking to patients, with lower payments gong to those surgeons who see themselves purely as technical experts, doing the procedure and then never seeing the patient again, allowing all follow up care to be done by the physician extender.  I wonder if, for both primary care clinicians, and for specialty physicians, an hourly charge system could ultimately result in more thoughtful consultations and more effective joint decision making and a resultant lowering of costs. 

I expect that we will always need multiple payment and incentive systems that understand the variety of people and cultures in our society.  For some doctors and patients, an integrated system that salaries physicians may be best and for others, a more direct financial relationship between doctor and patient may be best.  Whatever the system, it must properly reward what, Warfield T. Longcope, Professor of Medicine at the Johns Hopkins University School of Medicine once wrote when he stated, “even though a clinician has science, art, and craftsmanship, unless he is intensely interested in human beings, he is not likely to be a good doctor.”  All solutions for paying and incenting physicians must encourage and not discourage the professionalism that leads them to ever increasing interest in the human beings they help on a daily basis.  

Old Doctors in a New a Health Care World

My friend and colleague, Dr Jeff Rubin, will be speaking at the Stanford Medicine X conference on September 7^th. Jeff and I are both in our early 60s, which does look younger and younger to me every day. However, we have both been in health care for well over thirty-five years and during those thirty-five years have been in clinical practice and in the world of care management and building health care systems. So when Jeff takes the podium on September 7^th in Palo Alto, he will be old among the medicine Gen Xers.  In many ways, his message will help remind people that no matter how technology driven medicine is becoming, certain tenets of care must always hold true.

Jeff is a Clinical Psychologist, who in addition to being part of leadership at Accolade, still sees patients one day a week.  He and I and others helped found Accolade in order to use technology to foster relationships rather than to replace relationships. He is appearing before these medical entrepreneurs, many of whom believe that the future of medicine is a future of apps, self service medical protocols, and sophisticated data mining to give a message that says “yes” to those cutting edge tools but only when they are used in the context of a trusting, healing relationship between a health professional and a person in need. He will speak of the danger of believing so much in the tools, that issues of fear, sadness, and social isolation are not given the attention they deserve.

I have been to many such conferences over the past few years and I am always struck by the earnestness and energy of these young people who believe in their solutions’ abilities to solve the ills of our health care system. Many of their creative solutions will contribute a great deal to our health care needs and one can't help but share their enthusiasm when at these meetings. At the same time, people like me and Jeff know that all of these solutions must always be tested against the standard of how they impact the care of an individual in need. They must always be evaluated by how much they help the entire person and the entire family unit. They must understand that while physiology and pathology are the same across people, their experience of illness is dramatically different based on their culture, their family concerns, their finances, their emotional state, and their competing life priorities.

At Accolade, we have developed the new profession of Health Assistant and have used technology to give that patient and their Health Assistant access to the tools needed for them, as a social unit, to make the best decisions in health care. The decisions always rest with the patient and their family based on their values and their beliefs, informed by the best information and supported by the coordination, and the caring of their personal Health Assistant. It works and results in higher satisfaction in health care decisions, better quality of decision making, and lower costs. The technology is important but not as important as the patient-Health Assistant relationship.

I know that the message Jeff gives will be the most important message at the meeting. It will be to use technology as a tool but never to forget the need for a true human to human connection. Patients are people, and they are complex, interesting and different and deserve to be helped in ways that respect the unique aspects of each and every one of them. It takes more than apps, data and protocols to do that well.  It takes caring humanity.  

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 2: The Doctor Patient Dance

Costs are generated when a patient, meets a health professional, (usually a doctor but in our modern world, increasingly a nurse-clinician, a physician assistant or a non-MD therapist), and decisions are made which generate claims and bills and ultimately costs.  An old saying in medical management is that the most expensive medical instrument is the pen, because doctors write orders with pens.  While today it may be the keyboard instead of the pen, the saying is still true.   This may appear obvious on its face however when we think and write of health policies driving either savings or increased costs, we must think about what happens between the patient and the doctor.  This joint decision making may be thought of as an intricate dance that if performed well, results in a sacred trust relationship.  I fear that this dance that doctors and patients take part in is changing and not necessarily for the better.

I have a wonderful primary care physician, who is very smart, and very caring and who was taught to be more attuned to the population trends than I was taught to be, even though I have spent the last thirty years of my life focused on just those population needs.  Needless to say he is significantly younger than I am.  More than a week ago, I fell ill.  I am fortunate because I have medical knowledge, and I am married to the smartest physician I know.  The first few days of the illness, I treated myself, with my wife’s advice.  After five days, my wife convinced me to call my PCP with an eye towards getting an exam and some blood tests because we were both  starting to get worried.  I called my physician and he quite rightly told me that I most likely had something that would get better on its own, and that the best action at that time was  to wait.  On that basis, he said, I probably did not need to be seen and did not need blood tests.  Because we have a close relationship, I kept in touch by phone and a few days later he saw me in his office as I was still sick.  On exam he noted abnormal physical findings and blood tests were found to be abnormal. We both saw that while waiting had not hurt me, it was perhaps not the best approach in this instance as it delayed treatment.  It was, however the right way to proceed from a statistical evidence based,  population health point of view.   I have to wonder if someone who did not have as trusting a relationship with his or her doctor, would have stayed in as close touch with the doctor as I did.  If not, they likely would have ended up with a more serious and more costly medical condition.

The fact is, that even with my sophistication or perhaps because of it, I needed that trusted, objective and knowledgable confidant.  I needed my doctor to examine me and really hear my symptoms and my fears.  I was scared and thinking the worst.  No matter what, I felt better that I was being cared for once I saw my doctor and was able to directly see his concern for me and his thoughtfulness about my problem.  He has a concierge type of practice, together with three other physicians (although they all function as solo practitioners with their own nurse) and their practice fits into what is today considered to be a small medical practice. 

In a study just published on line in Health Affairs, Lawrence Casalino and his associates at Cornell Medical College found that, while it is assumed that large practices, often with team based medical homes and quality of care controls in place,  provide better care, smaller practices of fewer than 9 physicians, had 27% fewer preventable hospital admissions with practices of 1 to 3 physicians having 33% fewer preventable admissions.  Physician owned practices also had fewer preventable hospital admissions.  The authors postulated that this was perhaps due to easier access to the doctor who was part of smaller practices.  My theory is that smaller, more personalized medical practices create more trust.  When your doctor tells you to wait, you tend to trust your doctor and wait rather than run to the Emergency Room and end up admitted unnecessarily.  While waiting, a person cared for in a smaller practice will tend to stay in closer touch, knowing that a call will allow one to speak to your trusted doctor or nurse rather than be triaged by the nurse or doctor on call. 

In our impatient society, one of the hidden secrets of medicine is how time-based it is.  Illnesses tend to follow, what is often called in medicine, a natural history, and throughout much of the history of medicine, the role of the physician was to know the natural history in order to predict, for the patient and the family, what was likely to happen as the physician’s ability to impact what was going to happen was limited.  In our medically sophisticated world in which there appears to be a drug and a procedure and a surgery for every ache and pain, that physician’s art of prediction – of knowing the natural history and thus being able to counsel a patient about not only what should be done, but also if and when it should be done, is critical and is based on trust. 

It is this trust that makes one not only a physician but a healer.  I trust my doctor and for me, his judgment and his caring are critical to the decisions I make.  I still make my own decisions, but his advice is necessary for me to make good decisions. Trust is the key to the ability to time care appropriately which saves money and more importantly, helps people avoid the risks of unnecessary care and the risks of necessary care delayed.    

In an unpublished work (privately shared), Drs Saul Weiner and Simon Auster wrote about the need for physicians to have healing relationships with their patients, in order to engender the type of trust needed for medical care to be successful (and in case anyone has not noticed – successful care is less expensive than unsuccessful care unless of course the unsuccessful care results in very quick and efficient death).  They speak of the need for the doctor and the patient to become one social unit, and the requirement that this relationship happen over time with both the doctor and the patient sharing parts of themselves in ways that creates vulnerabilities.  They describe four characteristics of the healing relationship.

1. It cannot be scripted
2. It evolves with a relationship over time
3. The individuality of the physician, like the patient’s, is central to the direction the relationship takes
4. It depends on trust or, in the initial phases, on the expectation of trust

This of course beings me back to the dance between doctor and patient and the health care cost equation.  The equation, just as a reminder is

Total Population Costs = Volume of Services X Unit Cost of Service

The only way to decrease the volume of services is to build relationships between health professionals and patients that meet the four characteristics outlined by Weiner and Auster.  When I was in medical school, I was taught that my only focus should be the good of the patient whose care was entrusted to me.  The building and maintanence of that  sacred trust relationship was a major part of the education that made me a doctor.  In today’s world, we ask physicians to also think about the health of populations and the reduction of the per capita costs of health care as defined by the triple aim I spoke about in part 1 of this series.  My fear is that in trying to make physicians more aware of the societal needs, we may inadvertently be changing that focus and undermining the trust necessary to save money in health care the right way.

 

I worry that our desire to refocus physicians toward societal goals, and our push to make them focus on the use of technology  may paradoxically work against the goal of lowering costs. As we try to leverage and even replace doctors and nurses with protocols, apps, and systems, do we end up eroding the trusting relationships that are at the heart of medical care?  While the technology and the systems offer many benefits, our challenge is to use them to foster and strengthen relationships and not to try replace relationships in the name of efficiency

Robin Williams and Preventing Suicide

Five years ago this past week, my company Accolade first started helping people through the health care system by opening our Health Assistant Center.  This came only after spending two years developing the new profession of Health Assistant and the systems to support those Health Assistants.  A Health Assistant is a professional trained to form long term relationships in order to help people and their families through the health care decision making process, including  those decisions related to insurance coverage, physician selection, care options, personal health behaviors and all of the life issues which impact and are impacted by health, wellness and illness.  There were many surprises and lessons learned as we improved our ability to form human relationships with people as they were about to enter the health care system and help them along the way. 

One of the biggest surprises that first week was when our youngest Health Assistant, a very bright young woman who is now a leader in our company, took our first call from a person at risk for suicide.  The person was calling for a totally mundane reason, having to do with her benefits when she made a vague suicidal reference that upon assessment by our in house clinical psychologist, turned out to be hallucinations commanding her to kill herself.  This was a first psychotic break for this woman and for the next hour, we stayed on the phone with her, called the Emergency Medical Response team, contacted her sister to come and stay with her in person and had her evaluated and admitted to a hospital.  Following her hospitalization, that same young Health Assistant and our Clinical Psychologist helped that woman get the continuing care she needed.  Five years later, while our Health Assistant is now a leader in our company, she still maintains the relationship with that woman whose life she likely saved that day.  The person has had one relapse which did not need hospitalization and she continues to live a full life.

That was our first experience with helping prevent a potential suicide.  We have found this to be much more common than we would have predicted and now as we help about half a million people who have access to a Health Assistant, we speak with people on the verge of suicide on an average of once a day.  They often start with a benign call.  One stands out in my mind as we were helping a person through an open enrollment process.  Her boss had told her to call her Accolade Health Assistant because the open enrollment period was ending and it was required that she take part in that process.  On a Friday afternoon, this patient called and the Health Assistant first asked about what health care she might need the following year as that would help decide on the best plan for her.  The conversation continued with the person finally telling the Health Assistant that she was not sure that she would be around the following week let alone the following year!  She admitted to severe depression and told of her plan to kill herself.  Our mental health expert immediately joined the call.  On that Friday afternoon, the Health Assistant and our mental health expert stayed with her and made sure that she received the care she needed including admission to the right facility to start her therapy. 

I know that we are not always successful but we do know that suicide, if you are fortunate enough to catch someone at the right time and have the right skills to best assess and engage with these people, can be prevented.  The timing is key and while these telephone conversations cannot achieve 100% success, they are often our best hope.  The assessment often starts by simply listening to the person on the phone.  A clinical “pearl” I learned in medical school was that one should be suspicious of depression if, when you talk to someone, you start feeling depressed yourself.  While the natural reaction when a person feels depressed talking to another is to turn away, we know that is the precise time to stay with that person in need.  We do know that a phone call can be lifesaving when the professional on the phone recognizes the risk of a potential suicide and has the tools and skills needed to facilitate the right interventions. 

In some ways, as I reflect on our experience at Accolade and on the tragedy of a man who gave so much joy to so many deciding to take his own life, I realize that the challenges of treating that creative, quick mind of Mr. Williams may have been too much for any single phone call or any intervention to avoid the newspaper headlines we are now faced with.  I am also reminded of a senior psychiatrist who once told the story of a person he treated for twenty-five years who then committed suicide.  He asked the question of whether his treatment was a failure and answered that his assessment was that he helped that person avoid suicide for those twenty five years so the therapy, while incomplete, could not be called a failure.  I for one will not second guess the health professionals who, presumably, tried to help Robin Williams with his addiction and depression over the years.

But we always must try to intervene, and a simple phone call, as the suicide prevention hotlines around the country and we at Accolade have proved, can be successful in helping people through the depth of despair at the right point in time.  There is a country western song written by Matt Kennon (and I admit to believing that country songs have great truth embedded in them) that may best reflect the power of a phone call to avoid tragedy. 

Today was gonna be the day
He'd already wrote the note
And parked that Chevrolet
At the end of that dead end road
Had his finger on the trigger; just about to end everything
He was taking one last long breathe; when he heard his cell phone ring

And his best friends say man where you been?
We're headed down to the lake this weekend
You better not miss it 'cause buddy I swear
It won't be the same If you ain't there
And I told that girl that you like so much
You were coming along and her eyes lit up
I better let you go man I really hope I didn't catch you in the middle of anything

He said you kinda did but I don't mind at all
I'm glad you called

I have seen over and over, the right phone call at the right time prevent tragedy and I only hope and pray that all who are suffering and alone, make or receive that phone call at the right time to prevent the horror of suicide, for themselves of course but also for all those who care about them.  

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 1

In May 2008, Donald Berwick and his colleagues wrote about the triple aim of the US health care system.  They wrote, “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing the per capita costs of health care.”  Today that triple aim remains the goal of those of us in the trenches trying to improve care and access for all Americans.  This is difficult and some would say impossible without real constraints on individual’s decision making.  In that same article, the authors say “Pursuit of the Triple Aim is an exercise in balance and will be subject to specified policy constraints, such as decisions about how much to spend on health care or what coverage to provide and to whom.”   For Berwick and his colleagues, the most important of the constraints is “the promise of equity; the gain in health in one subpopulation ought not to be achieved at the expense of another subpopulation.”  While I agree with that statement I do not consider it the most important constraint.  For me, the most important constraint is that the pursuit of the triple aim must never compromise the individual’s right, working with the health professional, to obtain care in a way that matches their values and their goals. 

I say that because in my thirty years trying to impact this difficult equation, I have seen many well-meaning, and intellectually elegant solutions, that pass the “equity” test however they fail in maintaining individual autonomy and dignity in a way that fosters trust which is a necessary precursor for the best care. 

Ultimately, the value of care, which is inherent in “improving the experience of care” which is the first of the Triple Aim, must be in the eyes of the patient and their family.  If good individual decisions are made by patients and doctors working together the population’s health in aggregate will improve and costs will lower.  We first have to acknowledge, that the Triple Aim as addressed in our society thus far, has focused more on reducing the per capita costs of health care than either of the other two goals as defined.  Lowering costs is extremely important as that allows more people more access to care and best allows for the equity in the system that Dr. Berwick speaks of. 

My starting equation to achieve the cost aim of the Triple Aim is:

Total Population Costs = Volume of Services X Unit Cost of Service

However, I have tried to develop answers and approaches that give equal, if not more importance to the aims of improving the experience of care and improving the health of the population.  That requires obeying the following rules:

1. Maintaining trust between health professionals, patients and families must always be paramount.  Any system that impairs, in any way the trust relationships will make policy solutions unsuccessful.  Ultimately, medical care involves a person putting their life in the hands of another and trust is a necessary pre-requisite.
2. Never lower volume of services across all services, but rather lower unnecessary services.  In other words, lowering health care cost should focus on the cost of avoidable unnecessary care, rather than total cost and care.  While this may seem obvious, our solutions today often take the view that all health care cost is bad. 
3. In order to lower unnecessary services, always understand the real needs of the individual and find the necessary services that best address those needs from their point of view. These are often not related to biology but to emotions, culture, family, finances, time constraints, and competing life requirements. 
4. Do not lower unit costs by devaluing the contribution of trained professionals.  Trying to pay physicians less per service often leads to less personalized, more hurried care, which impairs trust and careful evaluation. 
5. Instead lower unit costs by having the right professionals, working in the right collaborative environment maximize the talent needed for the individual’s issues.  For many problems, for example, that may mean a social worker instead of a physician, or it may mean a community health aid instead of a social worker. 
6. As we optimize unit costs by using the right professional at the right time, never allow any person in need to feel as though they are being “handed off” and always foster the type of coordination and trust that continuously communicates that the patient’s needs and values are paramount. 

In future blog posts, I will attempt to talk about how to potentially succeed at this three dimensional chess game but will also acknowledge that this is no game.  This is people’s lives and families and thus any answers need to be implemented carefully and with study.  My own belief is that as strive for the Triple Aim, as long as we measure everything we do, against the primary “constraint” of maintaining and fostering individuals’ dignity and autonomy, we will succeed.  

Care and Medical Intervention: Are They the Same?

People occasionally need care, and people occasionally need medical intervention.  We often confuse the two.  No one is 100% healthy and we all carry risk of disease, and often live with minor or major symptoms that modern medicine is not equipped to impact.  Many of us live with the label of having a chronic disease.  Despite this, our American culture fosters the myth that all illness and even death is optional, and can be overcome just by our own actions or the right medical interventions. The myth would be funny if the results were not so tragic – both for individuals and for society.  All of us live with the genetic material that our parents gave us; with the risks inherent in where and how we live, and with the realities that life is a fatal illness.  We also all deal with the challenges of living; supporting ourselves and our families, and making our way in an often hard, cruel, and still beautiful world on our personal journeys through life.  What this means is that medical interventions and interactions with health care professionals are unlikely to solve all the problems and life challenges that we often, unrealistically, look to medicine to solve. 

One of the real challenges in medicine is the attempt to tell the difference between a medical problem that can be solved by medical professionals and a problem manifested by physical symptoms that is really a life challenge that must be addressed by means other than medical tests, surgeries, and the latest in pharmaceuticals.  In many ways, the most difficult job in medicine is still the job of “triage” which in its broadest sense, is the ability to assess, or diagnose a person to determine if their symptoms can be helped by the tools and skills that medicine offers.  Since sickness and health are a continuum and there are often few clear lines as to where disease starts and ends the starting point is always the “eye of the beholder” or the belief that the patient in need brings to the appointment with the health professional. 

That belief usually is communicated as a problem presented by the patient, and referred to as the “chief complaint” with the plaintive question to the doctor of “what’s wrong?” and the expectation that the doctor will either wisely give an answer and a medication to fix “what’s wrong” or order tests to determine “what’s wrong’.  The unsatisfying, but often true answers, which doctors rarely give is “you are lonely” or “you are sad” or “you are fearful” or “you are overwhelmed by the problems in your life”.  Instead tests are ordered, a possible “virus” or other medical illness is referenced and a medication is prescribed. 

The fact that the mind and the body are connected and that both mind and body are intertwined with our own personal life environment (mind/body/environment connection) is not given enough attention.  People who present to their doctor, in pain, need care – they may or may not need medical intervention.  They may need care that is more directed towards their emotions and to the true life problems that are presenting as medical illness.  A single mother who has a young child in need of cardiac surgery and who also has three other children to take care of, feed, pick up from school and do all that needs to be done, in addition to needing to showing up at work, needs care when she presents with chest pain and muscle aches.  Chances are, the pain she has is more of a manifestation of her stress and her real human problems than of an impending heart attack.  But how do we know? 

Recently, much has been written about the doctor shortage and a recent blog commented by pointing out that more care does not necessarily mean more doctors.  The article points out how technology and the use of nurse practitioners and physician assistants will change the medical model and create new solutions to the doctor shortage.  While I agree with that assessment, I admit to worrying about the ability to use all these new models, and leverage other health professionals in ways that maximize the skills needed on that front end to determine if the problem is amenable to medical intervention.  I also am concerned that the resultant fragmentation from multiple professionals and multiple communication channels may impair the trust needed to help people in ways that truly address the mind/body/environment elements that are all necessary to care for people.  I worry about team based approaches devolving into bureaucratic confusion for the patient and a “pass the buck” mentality that is already seen in the interface between health benefits, access to care, primary care and specialty care in certain systems. 

Every patient should be assessed and treated with the following elements in mind:

1. Assess and diagnose both the medical and the contextual (social and psychological) issues contributing to the problem
2. If a medical intervention is needed, define a diagnosis plan and a treatment plan in partnership with the patient and consistent with the patient’s values and beliefs
3. Define a care plan distinct from the medical intervention but coordinated with the medical intervention consistent with the patient’s values and beliefs, whether or not it is a medical disease which needs a medical intervention
4. Define an action plan to ensure that both the medical intervention plan and the overall care plan are followed.
5.  Identify the right professional with the right skills to implement the medical plan, whether that means surgery, a procedure, or medication management. 
6. Identify the right professional to provide the needed encouragement and coordination needed to implement both the medical intervention plan and the care plan.
7. Follow through relentlessly on both the medical intervention and the overall care plan as the bumps in the road can easily derail both.

To effectively accomplish these steps, you need skilled professionals and you need to gain and maintain the person’s trust that the medical treatment plan and the care plan as developed will help.  You need physician skills, nursing skills, social work skills, mental health skills and even insurance and benefits skills.  You need diagnostic acumen, cultural competency, communication skills, coordination skills and the skill to build and maintain a relationship.  While in the past, a physician was expected to have all of those skills, we now know that these skills are often best done by those with a myriad of different training, and can be facilitated with technology.  The real challenge, is how to put all this together, in a very simple way that fosters trust and involvement for all those in need of care.   The high level opinions on the need to leverage professional talent and technology must address exactly how this is accomplished so the person at the center of all this effort, actually benefits. 

As we think through all the pieces of this complex puzzle, let’s make sure that we focus on building trust, understanding an individual’s values, culture and beliefs, and accurately assessing their medical and their care needs.  We need to think through the best way to accomplish that in ways that are both effective and efficient.  We also need to think carefully about how to combine all the skills and professionals in a seamless, simple way.  Until we understand all that, I will continue to maintain my very traditional strong relationship with my primary care physician and pray that I stay healthy.