Can the patient be the focus of managed care?

For physicians who work in HMOs concerned with quality, the distinction between caring for individuals--patients one at a time--and populations of patients is central to success. The very evolution of HMOs began with definitions that included the term "enrolled population." This population-centered idea has proven to be a very powerful tool for defining what it is we do as a health care system, and it has given us a way to begin to take reasonable accountability for our results.

Process-oriented, population-based medical care provides a means for including a broad-based, community-focused approach to prevention that is integral to other medical processes rather than their step-child. Quality measurement and CQI start with assessments of populations and lead to innovations that can produce population health improvements. As CQI, in the hands of HMOs, sees patient satisfaction as a valid assessment of medical care, the orientation of MCOs to the patients, collective wishes becomes explicit.

As a psychiatrist training in the post-Freudian world of psychodynamic psychotherapy, my mentors gave me two pieces of advice: the only goal for a first meeting with a patient was to be sure there was a second one, and the customer is always wrong. Have I unfairly parodied their message? Of course. I know that they meant that trust is important in medical relationships and that acute symptoms often do not tell the whole story. But their teaching was about individuals only, not about whole populations. And their teaching could afford to neglect its own biases toward paternalistic, more-is-better medicine.

One of the greatest challenges for all of medicine

There's no question that translating high-quality care for a population to high-quality care for individuals is still one of the greatest challenges for all of medicine, particularly for managed care, and for all of society. And while we don't have a satisfying answer on how to do it--we may never-we can point to three important continuing developments that have resulted from guality improvement and its process and the population-centered approach. 1. "Primary care" has more importance and

more status than ever before. Primary

care physicians still tend, in my view, to

suffer from residual low self-esteem, but

even that is changing. The effect of

transformed health care delivery on

health professionals and the educational

system that produces them was very elegantly

described in a recent paper sponsored

by the Pew Health Professions

Commission., 2. The importance of health

processes has produced

real clinical innovations

directed toward changes

in population health status.

Take breast cancer as

an example. A health plan

can put a program in

place designed to make

sure every woman who

sees a physician there

receives appropriate education

and screening. But

even if that program

results in virtually perfect

care, it has no impact at

all on the women who are

not coming in to see a

physician, the rest of the

relevant population. So in

order to meet the needs of

the population (call it the

community, if you like),

as well as the individuals,

the health plan creates an

outreach program. It

might involve community groups, direct

mail, TV ads, and it might reach beyond

the plan's membership. And a plan with

a "defined population" will be able to

be accountable for its results-in

screening, in stage-at-biopsy, and ultimately

in morbidity. 3. The importance of "clinical integration"

has provided a rational basis for linking

medical fiefdoms. Clinical integration

has received a lot of attention lately, as

vertical and horizontal mergers sweep

the landscape.[2] There is an idea that population-based

care plus clinical integration

will produce patient-centered care.

That may prove true in the longer run,

but until clinical integration has moved

beyond the organizational level to consider

how it might improve the care of

individuals and sub-populations, as well

as the cost and quality of larger populations,

that hope will not be realized.

The triangle and the need for real collaboration

The conflicts inherent in population-based integration and individually delivered care bytes need recognition. Most managed care, which means most care today, is a triangular relationship. There are three customers-patients, physicians, employers (or payers)-and they are all related to one another. They are a triangle. If you don't nurture all three of the legs according to their different needs, everybody gets messed up. So we have to look at what everyone wants from everyone else. Health care can't be centered only on individual patients, if that means excluding payers. Meeting a population's screening needs does not make care "patient-centered." And meeting an individual patient's needs isn't necessarily the same thing as meeting their desires-satisfying them.

Successful collaboration between some payers and HMOs has become the leading example of market-based health care reform. That's because it has been real collaboration, in which all parties learn, and has not been a collusive partnership. Harvard Community Health Plan's (HCHP) relationship with Digital Equipment Corporation is an excellent example of a partnership that has been responsible for significant savings for Digital and a clear focus of measurable results for HCHP. Clarity of mission was important to this partnership from the beginning.

One lesson from the failure of revolutionary federal health care reform was the importance of having a basic, shared notion of what this kind of triangular, potentially distorted relationship among physicians, payers, and patients is meant to be. Sabin and Daniels, in their paper "Determining `Medical Necessity" in Mental Health Practice,"[3] have described a range of possible first principles. They describe three models for understanding medical necessity: the normal function model, the personal capability model, and the welfare model. While the context concerned mental health, the alternatives work for most of medical care. Xerox Corporation, thinking about its mental health benefit offerings, seeks care according to the normal function model:

"...the central purpose of health care is to maintain, restore, or compensate for the restricted opportunity and loss of function caused by disease and disability. Successful health care restores people to the range of capabilities they would have had without the pathological condition or prevents further deterioration."

Meeting patients' desires in HMOs

When such collaboration works, companies like Xerox, GTE, and GE have included their own employees, evaluations of HMOs in their ongoing decisions about the population-based quality priorities they set in their negotiations. These evaluations are extensive and include the four classical dimensions or categories of patient satisfaction with an HMO: (1) Cost and value, (2) service, (3) convenience and choice, and (4) quality of care. Remembering that in each of these areas meeting patients, needs is not the same as meeting their desires--satisfying them.

Patients, needs and satisfactions in each of these categories depend on where they find themselves in the continuum of health and illness. We value the bonding with patients that comes when they are sick and need our guidance. That bonding and the intensity of that experience are things that we as physicians fear losing. We know, too, that much of what patients want from their doctors these clays is much less intense and that they have other needs that come to the fore. Patients know and understand being "patients." They do not like being called clients, customers, members, enrollees, or covered lives.(4) Yet it would be a major error to assume that patients should not be treated as customers, members, or even covered lives--times and in context.

When it comes to cost, a patient who is well might expect value in health care to be demonstrated in preventive care, information, and discounts at health clubs. A really sick person might see value in how decisions are made about-what kind of care is ordered, what tests are done, and which specialists (from which hospital) are used.

Good service for a patient who's not ill could mean reminder cards about screening, a new ID card, easy parking, hours of operation that meet the patient's schedule, and a telephone system that works effectively. It's because I am a veteran of managing a large delivery system that I know how hard these things are to produce day after day. For a sick patient, good service will mean that the referrals are coordinated-that the paperwork gets to the specialist's of fice before the patient does.

This kind of service isn't just being friendly. Customer service means making the patient's needs the focus of what we do. One example is Service Based Planning, an approach used in many places, including the HCHP Laboratory. "Service" is not a "place" and its form follows its function, directed by its customers. This approach, in a world changed by the information superhighway, says that there is a time-value to information. That time-value gives respect to a patient's time and a physician's time.

Creating patient-centered systems of care

Zapka and others5 in their article, "Relationships of Patient Satisfaction with Experience of System Performance and Health Status" looked at some of the factors that may be at work in producing patient-centered care in an environment with the multiple dimensions that are visible in modern managed care settings. They note the "...strong incentive to improve systems where failure in performance is associated with dissatisfaction among patients because patient dissatisfaction is known to correlate with increased disenrollment." Clearly, the full story of the relationships between what doctors, teams of doctors, and their systems of care do and the responses of their patients is not yet as rich as it will be in the near future. Here are a few interesting findings from this paper: 1. Cross-correlating different questions

about patient satisfaction and dissatisfaction

suggests that almost three-quarters

of those who see their care as

"excellent" also agree that "things could

be improved." Both patients with higher

levels of (perceived) health status and

patients reporting chronic illness were

less likely to express dissatisfaction. But

the more contact with the care system,

the more they saw that things could be

improved. 2. Three problems in "system performance"

were associated with the sense that

improvement was needed ("things could

be better"): (1) Receiving confusing

information; (2) Finding their caregivers

were not aware of results; and (3)

Experiencing delays in follow-up care.

These seem to me to be precisely the

areas of coordination and integration

that are the hallmarks of effectively integrated

systems of care. 3. Health status, by itself, correlates positively

with "satisfaction" with medical

care. But this association is independent

of the appreciation of the need for quality

improvements. This means that the

capacity of patients to understand and

contribute to the improvements in their

complex medical care system should

never be underestimated. In fact, this is

just what national organizations concerned

with evaluating quality (NCQA,

AAHP) have begun to learn from focus

groups. 4. There is one aspect of scholarly discussion

at the conclusion of the paper

which struck me. The authors put it this

way: "Some critics have noted that

patient ratings have more to do with

patient characteristics than with health

system characteristics...." I guess this is

an academic reference to the old idea we

physicians have that we are doing just

fine and giving them just what they

should have, and if the patients can't see

it, then it's because of something wrong

with them.

The focus is on health processes

In the old world of traditional medical care, the patient's relationship was-with the doctor, and the doctor mapped the patient's illness. The emphasis on quality and the cost of medical1 care have led to a focus on clinically integrated care, and a new relationship has emerged. Now the patient and the health care system are supposed to continuously collaborate with one another. The focus is not just illness and doesn't even start there. It's on "health process."

Patient-centered care is not a new concept: it is simply a new phrase, spawned in a market-driven world where patients have new power to demand quality. Not just quality as the professionals define it, but quality as they define it. And as they redefine it as part of a partnership in learning. One of the challenges for each of us in that partnership is to re-examine quality in a way that includes in its definition, care for populations and care for individuals. The difficulty of this task is the source of our uncertainty about patient care and managed care.

Listen, for example, to the words of one of our board members at HCHP. When I asked him to define quality, he said in his mind it means HCHP must be "above average" because "it's impossible to maintain a superior environment" all the time, in all the services, in all the locations that our plan has. But, speaking as a patient, he didn't hesitate to define quality this way: "I want the best: The best treatment, the best doctor, the best care." How do we reconcile these two viewpoints? Where dO we begin? Y

References

[1.] Tresolini, Carol P., et al., "Health Professions Education and Managed Care: Challenges and Necessary Responses," Report of the Advisory Panel on Health Professions Education and Managed Care for the Pew Health Professions Committee, 1995. [2.] Goldsmith, Jeff C., "Managed Care Comes of Age," Healthcare Forum Journal, September/October 1995, pages 14-24. [3.] Sabin, lames E., and Norman Daniels, "Determining ,Medical Necessity, in Mental Health Practice," Hastings Cent`>r Report, November/December 1994, pages 5-13. [4.] American Association of Health Plans, Market Research, 1994-95. [5.] Zapka, Jane G. et al., "Relationship of Patient Satisfaction with Experience of System Performance and Health Status," Journal of Ambulatory Care Management, 1995, 18(1), pages 73-23.

RELATED ARTICLE: The New Practice of Preventive Medicine 

When a person feels healthy, convenience in health care might mean wellness, exercise, stress reduction programs at the workplace or at school for children. And this convenience means the program will fit the needs, the language, the realities of the patient, as well as the place and time. For the sick patient, convenience might mean home health care telemetry, or the ability to use a nearby hospital for some care and a tertiary care center for other care.

What about the quality of care that's been given? For well patients, high-quality care means regular checkups and appropriate screening. This is the preventive care process in action. But for the sick patient, high-quality care means integrated, appropriate, respectful care with clear communication and information. This is the new practice of preventive medicine: practice synonymous with prevention, prevention at every point. Here's a story from my HMO:

A mom feels a small but prominent lump on the back of her six-year old son's head. Neither of them can recall an injury that might have caused it. She calls her HMO pediatrician's office and gets a same-day appointment. The doctor feels the lump, and says that since he can't seem to move it, he thinks it may be a deposit on the bone, rather than a cyst. He says it should be X-rayed, but he doesn't want the boy to have a complete skull series; he wants only a very specific view. He says he'll check with radiology in the building to see if they can do it. If they can't, he says he'll refer the boy to Children's Hospital for the X-ray.

Before he makes the call, however, he consults with one of his partners in the pediatrics department. She feels the lump and says she can move it. They confer, they palpate, they manipulate, and they concur that it does in fact feel like a cyst. They tell the mom it will disappear on its own in three to four weeks, and they offer her a referral to dermatology if she wants a second, or actually a third, opinion. She declines. She feel comfortable. She'll call if there is any change that concerns her, and bring the boy back in three weeks regardless.

This patient got high-quality care: a same-day appointment for a problem that was not obviously urgent; a pediatrician who intended to identify the best, least harmful radiology option; on-the-spot collaboration between colleagues who comfortably reached consensus; an offer of a specialty consult; advice about follow-up. All under one roof. In about half an hour.

What makes this care patient-centered, system-based, and service-oriented? The physicians' skill and teamwork involved their professional expertise and included the child and mother in the deliberation. No time was lost, and cost was not spared. Continuity and relationship were both personal and site-based.

This article was taken from a recent presentation by John M. Ludden, MD, FACPE, to the Mayo Clinic staff in Rochester, Minnesota, Dr. Ludden is Senior Vice President of Medical Affairs at Harvard Pilgrim Health care in Brookline, Massachusetts. He can be reached at 617/739-7850.