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.