The Emerging Role of Physicians in Disease Management Programs

David Sobel, MD, JD Rushika Fernandopulle, MD, MPPEmmi Solutions, LLC Renaissance HealthChicago, IL Cambridge, MA

Who am I?

 Recovering Attorney:- University of Michigan Law School (1992)- Paul, Weiss, Rifkind, Wharton & Garrison (1992-96)

 Urological Surgeon:- University of Illinois Medical School (2000)- Rush University Medical Center (2000-2005)

 Chief Medical Officer & founder of Emmi Solutions, LLC

Historical Context

“Life is short, the Art long, Opportunity fleeting, Experiment treacherous, Judgment difficult. The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals.” [emphasis added]

-Hippocrates

Historical Context

Only section of the Hippocratic Corpus that addresses doctor-patient communication:

-“[p]erform [your duties] calmly and adroitly, concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity, turning his attention away from what is being done to him; sometimes reprove sharply and emphatically, and sometimes comfort with solicitude and attention, revealing nothing of the patient’s future or present condition.” [emphasis added]

“In our country, patients are the most under-utilized resource, and they have the most at stake.  They want to be involved and they can be involved.  Their participation will lead to better medical outcomes at lower costs with dramatically higher patient /customer satisfaction.”

Charles Safran, M.D.President, American Medical Informatics Association

From his Testimony Before the Subcommittee on Healthof the House Committee on Ways and Means

New Paradigm

Evolution

 Disease Management

 Care Management

 Population Management

New Paradigm

 Medical Home Model:- Ongoing relationship between a provider and patient

- Around the clock access

- Respect for the patient/family’s cultural and religious beliefs

- Comprehensive approach to care

- Coordination of care through providers and community services

- AAMC

American College of Physicians’ Definition

 Best quality care is provided through:- Patient-centered, physician guided

- Cost-efficient and longitudinal

- Encompasses and values the art and science of medicine

 Attributes of Medical Home include:- Promotion of a continuous healing relationship

- Through delivery of care in a variety of care settings

- According to the needs of the patient and skills of the medical provider

Consistent Themes

 Patient Centric  “Wellness”

 Physician Driven  Enhanced Access

Even Better

 Engaged Patients  Leveraged Physicians

Redefining the Physician’s Role

 Doctor walks into a bar . . .-Pain-Misery-Suffering YOU

TOO

Wednesday May 14, 2008

 18 Patients in the AM:- 8:30 -10:00- 8:30 -10:10- 8:40 -10:20- 8:50 -10:20- 9:00 -10:30- 9:10 -10:40- 9:20 -11:00- 9:30 -11:15- 9:40- 9:50

 21 Patients in PM- 1:00 -2:30 -4:00- 1:10 -2:40- 1:20 -2:50- 1:30 -3:00- 1:40 -3:10- 1:50 -3:20- 1:50 -3:20- 2:00 -3:30- 2:10 -3:40- 2:20 -3:50

How to spot a physician?

Can you spot the caregiver? Which one manages disease?

Redefining the Physician’s Role

 CV:- AOA graduate from Emory University

Medical School- Internal Medicine Resident – voted best

resident by peers- Invited for Chief Residency position

 How he described his patients:- “20 semi-strangers who do nothing but

complain.”

 How he described his day:- “It’s like suffering through Thanksgiving

everyday of the week.”

Redefining the Physician’s Role

 Medical Home Model demands that the physician be:

- All knowing This requires technology to assemble virtual teams of people and resources as needed based on patient needs

- Always present This requires technology such as IVR, web coaching, and web visits to automate routine communications

- Service with a smile This requires training and technology to help physicians communicate with empathy and clarity

Conversation is the Key

 Communication isn’t a message sent; it’s a message received- We need to be better listeners

 People don’t always say what they mean- We need to actively listen

- Position: demand or assertion often expressed with strong feeling

- Interest: the underlying concern that generated the position

 Communication isn’t always verbal

The Power of Conversation

 12 Angry Patients:- No one is a doctor

- Everyone is a patient

- “I know how to talk to patients”

Can you catch cancer? Can you catch cancer?

 EXTEND The Conversation

Low Tech

“We are sorry! We always try to meet your scheduled appointment time. Sometimes we run late and we apologize. A patient’s visit sometimes takes longer than we anticipate. Sometimes that patient is you.”

James W. Saxton, Esq., The Satisfied Patient, 2003

Leverage Technology

Literature review of computer-based patient education (1970-2001):

- Majority of studies showed significant gains in knowledge acquisition- Also:

• Increased prevalence of self-care behaviors• Improved health outlook• Increased adherence to health management regimens• Increased patient satisfaction• Positively impacted several different clinical outcome measures.

• Lewis, D. Computers in Patient Education. Comput, Informat, Nurs 2003

“The Disease of Familiarity”

Interactive computer programs were as effective or even more effective than instruction provided by staff educators

Krishna, Santosh, Balas, E. Andrew, Francisco, Benjamin D., Konig, Peter, Graff, Gavin R., Madsen, Richard W., Internet-Enabled Interactive Multimedia Asthma Education Program: A Randomized Trial. Pediatrics, 00314005, Mar2003

Green, MJ, et al, Effect of Computer-based Decision Aid on Knowledge, Perceptions, and Intentions about Genetic Testing for Breast Cancer Susceptibility. J Am Med, 2004

Jenny, NYY, et al, Evaluating the Effectiveness of an Interactive Multimedia Computer-based Patient Education Program in Cardiac Rehabilitation. Occup Ther J Res, 2001

Jones, RB, et al. Randomized Trial of Personalized Computer-based Education for Patients with Schizophrenia. Br Med J, 2001

Martin, JT, et al. NPs vs. IT for Effective Colposcopy Patient Education. Nurse Pract Am J Prim Health Care, 2005

Miller, DP, et al. Using a Computer to Teach Patients about Fecal Occult Blood Screening – A Randomized Trial. J Gen Intern Med, 2005

Evans, AE, et al, Computer-assisted Instruction: An Effective Instructional Method for HIV Prevention Education?, J Adolesc Health, 2000

Best Practices

VisualsCreating programs that rely on simple graphics and animation to illustrate key concepts makes the program

easier to follow for most people, but is critical for those patients with diminished reading skills. (1)

EmpathyStudies have found that consumers “seemed more willing to confide in computers than in human interviewers, possibly because the computers were perceived as nonjudgmental or evoked less embarrassment on sensitive

subjects.” (2)

Plain LanguageNearly half of all American adults have difficulty understanding and using health information Higher rate of hospitalization and emergency services when patient’s have limited health literacy. (3)

1) Sechrest, R.C. & D.J. Henry. Computer-based patient education: observations on effective communication in the clinical setting

2) Mantone, Joseph. (August 8, 2005). Reading, writing and relating. Modern Healthcare.

3) Health Literacy: A Prescription to End Confusion, IOM April 2004

Best Practices

Visuals - show it, don’t say it.

Empathy - say it, don’t write it.

Plain Language - write it. But, write it well.

Unlike people with type 1 diabetes, people with type 2 diabetes produce insulin; however, the insulin their pancreas secretes is either not enough or the body is unable to recognize the insulin and use it properly. This is called insulin-resistance. When there isn't enough insulin or the insulin is not used as it should be, glucose (sugar) can't get into the body's cells. When glucose builds up in the blood instead of going into cells, the body's cells are not able to function properly. Other problems associated with the buildup of glucose in the blood include: Dehydration. The buildup of sugar in the blood can cause an increase in urination (to try to clear the sugar from the body). When the kidneys lose the glucose through the urine, a large amount of water is also lost, causing dehydration. Diabetic Coma (Hyperosmolar nonketotic diabetic coma). When a person with type 2 diabetes becomes severely dehydrated and is not able to drink enough fluids to make up for the fluid losses, they may develop this life-threatening complication. Damage to the body. Over time, the high glucose levels in the blood may damage the nerves and small blood vessels of the eyes, kidneys, and heart and predispose a person to atherosclerosis (hardening) of the large arteries that can cause heart attack and stroke. Anyone can get type 2 diabetes. However, those at highest risk for the disease are those who are obese or overweight, women who have had gestational diabetes, people with family members who have type 2 diabetes and people who have metabolic syndrome (a cluster of problems that include high cholesterol, high triglycerides, low good 'HDL' cholesterol and a high bad 'LDL' cholesterol and high blood pressure). In addition, older people are more susceptible to developing the disease since aging makes the body less tolerant of sugars. Although it is more common than type 1 diabetes, the causes of type 2 diabetes are less well understood. It is likely caused by multiple

When “Prescribed” by a Physician

• 89% watched program from start to finish• 87% of patients experienced increased confidence

in their doctor• 96% of patients reported improved understanding

– No $ incentives– No free iPods– No rewards or threats

Rushika Fernandopulle, M.D., M.P.P.

Renaissance Health

Cambridge, MA, USA

May, 2008

Putting the Physician Back into Disease

Management

Start with the Sickest Patients

Source: Large West-coast self-insured employer PPO data, 2005. n=147K

Healthy- 50-100%ile- 5% costs

Acute illnesses- 20-50%ile- 15% costs

Complex- 0-10%ile- 65% costs

Simple Chronic- 10-20%ile- 15% costs

The most leveraged target for redesign are what we call Complex patients- those with multiple chronic conditions who end up costing up to 2/3 of all health care dollars, and are poorest served by the current system.

Average spending for percentile groups

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

0% 20% 40% 60% 80% 100% 120%

A new model from the ground-up

New Principles

•Meet the needs of our patients and focus on experience

•We cannot manage our patients’ health; they must, and we can provide tools and resources

•Continually innovate and improve

New Processes

•Jointly created strategic health plans

•In depth education and coaching from RN/CHWs

•Unfettered access to help

•Proactive management

•Remote monitoring

•Integrated mental health

•Specialists as consultants

New Structures

•Different staffing and true team care

•Robust Information Technology Platform

•Physical Design

•Business model

•Culture

The RenHealth Complex Care ModelRe-imagining the entire care system for complex patients

Early Pilots of the Model (and Variants)

Part of a larger movement

•AAFP- Transfor-med (36 sites)

•ACP- Patient Centered Medical Home

•IMP- Ideal Micro Practices

•CMS- Case Management for high cost Beneficiaries Demonstration

Legacy Sites- Active before 2006

Sites in Implementation Phase

Sites in Planning Phase

Variant 1: Working with existing Medical Groups

• Boeing is a leading aerospace company headquartered in Chicago, but with >150K employees in 70 countries

• Annual revenue 2006 US$61.5 billion• Self insured, large, stable, geographically concentrated

workforce; >US$2b in medical costs• High and rising health costs put them at a competitive

disadvantage with their major competitor (Airbus)

• Focus on Puget Sound, WA market • Two major plants to assemble commercial

airliners, may other sites; total of >150K lives• Partnering with three well respected,

progressive providers to build A-ICU model for 700 predicted high cost employees and dependents

Linking payment change with clinical redesign

• Patients selected through predictive modeling, invited by their doctors to participate

• Provide RN Health coaches to work within medical groups to help manage patients

• Practice are staffed by high performing MD, RN “health coach”, other help• Shared care plan, access, proactive care all implemented• No benefit changes, so sites continue to bill Fee-for-service for MD visits• Sites get paid a case rate pmpm (roughly 2.5% of total spending) to cover

non-traditional services• In subsequent years will consider sharing savings with sites

Variant 2: “Workplace” Clinic for Complex Patients

Atlantic City, NJ

• HEREIU Fund- Large multi-employee trust fund for service workers- hotel, restaurant and casino

• Focus on Atlantic City, NJ with approx 25K lives• Partner with a large not-for-profit integrated

delivery system (IDS)- Atlanticare to build a new clinic for predicted high cost employees and dependents

• Patients are given incentives (through waived copayments for visits and pharmaceuticals) to seek care at the Special Care Center

• Globally budgeted, costs shared by Fund and Health System

A redesigned care space, team, and system

Anecdotally Making a difference

• “I look forward to seeing IOCP patients on my schedule. I can see what’s happening with patients whom I have generally struggled with for years. The light bulbs are turning on, they are engaged and motivated.”

• “Patients respond positively to their relationship with their care manager. It’s like the whole tenor of the visit is changing from one of resignation that nothing is likely to change, to one of improved results, optimism, and hope.”

• “I have been helped more in the last six months than years of seeing multiple doctors.”

• “Being a patient in the IOCP has been a life-changing event for me. I have learned to change the way I live and think. I finally stopped smoking. Somebody actually listens to me and is giving me the help I need.”

• “My BP is now normal after being high for many years. I am getting good advice about my prescriptions. I am able to take walks and hope to be swimming again soon. I am feeling positive now, I once felt doomed. I feel like a new person.”

Physician Feedback Patient Feedback

Goals tracked across multiple vectors

Health Costs

Reduce net total health care spending trend for

target population vs. control group in 1-2

yearsFunctional status

Improve self reported functional scores (SF-12)

and improve productivity in the

workplace

Patient Experience

Improve patient’s experience of care

across all dimensions in a standard survey (ACES/CG-CAHPS)

Quality

Improve performance on chronic disease

measures, both claims based and ones based

on clinical data

Staff SatisfactionCreate an excellent work

environment for physicians and staff

Advantages Over Traditional DM

• Much higher engagement rates• Able to manage with clinical as well as claims data• In person relationship and transference from MD

helps with behavior change• Effector arm to change care if needed• Spillover effects of collaboration between payer and

provider

Renaissance HealthOne Broadway, 14th floorCambridge, MA 02142P: 617.682.3669F: 617.475.6027W :www.renhealth.netE: rf@renhealth.net

“Insanity is doing the same thing over and over and expecting different results”

-Albert Einstein