Shared Decision Making, Screening Mammograms and Quality Care

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals & Managing Partner at Quo Magis Partners
  Issues in medicine typically evade grouping into “necessary” versus “unnecessary” or “good” or “bad” categories. Such is the case with the topic of screening mammography, perhaps, when viewed from the perspective of a patient or family member trying to make the most of a shrinking dollar while maximizing their health as they get older. For example, few would have argued that early diagnosis and treatment improves outcomes in most cancers.

The federal government, in fact, has endorsed screening mammograms in its 5 Star program, by paying Medicare Advantage plans explicitly for maximizing the percentage of female members between 40 and 69 who receive them every 2 years. Recently, a study in Lancet was published that concluded that for every life saved by mammography screening, 3 women will be “over-diagnosed” and ultimately treated for a cancer that may never have caused the trouble for a given person. The article suggests that screening “reduces breast cancer mortality but that some overdiagnosis occurs.”

In his book, “Overdiagnosed: Making People Sick in the Pursuit of Health”, Dr. H. Gilbert Welch, refers to some cancers as “incidentalomas” which are discovered as part of the screening we can now do enabled with-ever-more-sensitive technologies.

While I am not going to take a position on this topic, the point that I want to make is that it is confusing, at best, to the average patient. Certainly, what we “know” as indisputable fact today will be contradicted or clarified at some point in the future.

The best thing that can be done, then, for the average patient is to provide supportive guidance that stops short of being dogmatic about the use of such tests. While the quality indicators that are now driving Medicare Advantage Star ratings don’t take such nuances into account and carry real financial consequences for the plans if the member does NOT have the mammogram, the clinical and personal realities for a patient are shaded with elements that are not population-based, but very individualized. The things that motivate or demotivate a patient to receive that mammogram: fear of pain of the test or results that come from it, personal time and money, perceptions about the benefit versus the risk, and a variety of other factors. These are the real reasons a person will decide to have or not have a mammogram. And the quality question---may remain open for debate.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61216-1/fulltext

Terri is the founder of Cambria Health Advisory Professionals and a Managing Partner at Quo Magis Partners. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders. a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to IMS Health in late 2007. She has both a BS and a PharmD in Pharmacy and an MBA.

Shared Decision Making, Waste, & Progress

Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals & Managing Partner at Quo Magis Partners

The good news:  there continues to be progress in the arena of shared decision making (SDM), which I believe will be one of the most important tools to achieve optimal health care outcomes and medical economics. SDM represents a deeper dialogue involving clinicians, academics, health plans, patients and family members regarding how resources are best used and expectations of care are met.  If accomplished effectively, SDM will result in a more rational use of resources. More importantly, it will enable higher satisfaction on the part of all parties, but especially the patient.

The process of sharing the decision making has become its own medical expertise, representing a new field of greater study, complete with an evolving body of literature.  It is the place where science, technology, social, and economic factors converge; a place where the imbalance of power between who decides and who must live with the decision meet; a place where the one who pays the bills and the one who pays the consequences must deal with the nuances.  Does the decision at hand involve a clear path with easily understood risks and benefits or is it one that is fraught with vague and unknowable consequences, consuming both the patient’s limited financial resources and the system’s allocated spend, without meeting anyone’s expectations?   

As I have written before, perhaps the single greatest driver of health care cost is under the umbrella of “waste”.  Under this ignoble category, the labs have been ordered, prescriptions dispensed, and procedures done when the patient either did not want or comply with them, may not have understood the need or was disappointed in the results.  Perhaps the whole process yielded little benefit to them personally; and the use of the system’s resources may be categorized as “wasteful”.  Perhaps the physician who ordered these services did so because they were necessary; perhaps it was to cover the medical-legal checkbox.  Experts comment frequently on how the elimination of “fraud” will return billions of dollars back into the system.   But my take on it (without any statistics to back me up because I don’t believe there is an accurate way to measure either fraud or waste) is this: waste outweighs fraud by a factor of a hundred-fold. 

One article recently caught my eye which addresses the expansion of SDM as a method of better understanding decisions and consequences, each with different points.

The first article references the differences between the physician and the patient in terms of expectations of breast cancer treatment, citing the physician’s greater sense of “reality” as compared to the patient.  The study investigated “differences between patients and physicians with regard to the required efficacy of treatment and the factors influencing patients' and physicians' willingness to accept different therapeutic options.”  Clearly, the patient is not on the same “reality plane” as the clinician.  The study was published in Breast Cancer Res Treat. (2012 Aug 30), by FC Thiel et al, “Shared decision-making in breast cancer: discrepancy between the treatment efficacy required by patients and by physicians.”

What is most interesting to me is the last statement in the abstract which demonstrates what I believe:  that each patient has unique desires and expectations, even if they have the exact same disease state, with the same odds.  The uniqueness is where the opportunity for real SDM (or potential waste) comes into play.  This is fruit for new dialogue and new study, and I am anxious to participate in the discussion! 

(Available at the link below); “Approximately one-fifth of the patients were willing to accept treatment regimens even with marginal anticipated benefits, whereas one-third required unrealistic treatment benefits. Several influencing factors that were significantly associated with the quality rating of treatment regimens in the groups of breast cancer patients and physicians were also identified. In contrast to physicians, many breast cancer patients required treatment benefits beyond what was realistically possible, although a large group of patients were also satisfied with minimal benefits. Individual factors were also identified in both groups that significantly influence thresholds for accepting adjuvant treatment, independently of risk estimates and therapy guidelines.”

http://www.ncbi.nlm.nih.gov/pubmed/22933029

Terri is the founder of Cambria Health Advisory Professionals and a Managing Partner at Quo Magis Partners. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders, a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to IMS Health in late 2007.  She has both a BS and a PharmD in Pharmacy and an MBA.

As Rx Coupon Debate Goes On, Massachusetts Reverses Stance

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals & Managing Partner at Quo Magis Partners

I have written a number of times on the potential benefit that drug coupon programs can afford all parties in the health care exchange, but also recognize that this is a very controversial subject. Specifically, coupons programs can benefit the manufacturer who seeks to penetrate a market, a patient who is looking for a financial benefit for a drug that the physician believes is necessary, and, if done in collaboration, can help a payer manage high-cost drugs.

Recently, Massachusetts announced that it is officially lifting its long-standing (since 1988) ban on prescription drug coupon programs. Massachusetts was the last state in the country with such a ban. Certainly, the controversial methods which make these programs very attractive to the consumer continue to stir heated debate in PBM, plan, pharmaceutical manufacturer, and regulatory circles. And those parties who hope to eliminate them have to jump a significant public relations hurdle.

You can tell from the tone of the attached article that the lifting of this ban is popular with consumers. (See link: http://www.wcvb.com/health/Massachusetts-lifts-long-standing-ban-on-prescription-drug-coupons/-/9848730/15929808/-/a3k66g/-/index.html  ) But coupons are an important and beneficial tool as health care reform gets underway and costs are shifted to the consumer, who will continue to act in his /her own perceived self-interest.

Case in point: The application of coupons in health care is not only about drug manufacturer but is also applied to provider services. In an article by Judy Wang Mayer, “Health Care Providers’ Use Of Groupon Stirs Up Controversy” on August 10, 2012, the author warns health care providers (dentists, physicians, surgeons) to be careful with social coupon websites. She says that although no providers have yet been disciplined by state licensing boards, it is “only a matter of time before most state boards of licensure and national professional associations take a position on the legality of these types of promotions. Until then, health care providers should be cautious and consult an attorney before signing up with a daily deal website like Groupon or Living Social.” (See link: http://www.mondaq.com/unitedstates/x/191090/Healthcare/Health+Care+Providers+Use+Of+Groupon+Stirs+Up+Controversy)  

A few links that are a little older that describe some of the controversy are included for the reader.

1. A number of employers/unions (County and Municipal Employees District Council 37, American Federation of State, the Sergeants Benevolent Association, the Plumbers and Pipefitters Local 572, and the New England Carpenters) have sued pharmaceutical manufacturers in federal court over the presumed legality of these programs (March, 2012, see link: http://www.insurelane.com/insurance/blog/health/2012/03/08/Drug-Companies-Sued-By-Insurance-Plans-Over-Coupons.html)   
2. Adam Fein, PhD, of Pembroke Consulting has written considerably on this topic and is a good source of the overall topic, including this Drug Channels article from November of 2011: http://www.drugchannels.net/2011/11/pbms-launch-new-attack-on-copay-cards.html   
3. In the article, “Co-pay coupons: Good deal for consumers, headache for health insurance companies” by Mary Kay Jay, the author makes the case for the fact that the consumer wins while the insurance company is left to pay for a product that is many times more expensive than the generic drug they'd prefer to see be used.  http://www.netquote.com/health-insurance/news/co-pay-coupons.aspx#ixzz23SMuKDYC  

Terri is the founder of Cambria Health Advisory Professionals and a Managing Partner at Quo Magis Partners. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders. a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.

Does Recent UK Physicians’ Strike Carry an Important Message for the US?

---Anna Shepherd, Health & Personal Finance Professional - Cambria Health Advisory Professionals

For this blog, I generally try to find news that raises prescient questions about healthcare and economics in our current climate. This article (link below) goes a little outside of that but I find it important nonetheless to keep in back of my mind as a guidepost of sorts. It details a recent strike effort by General Practitioner’s in England’s National Health Services (NHS) over a pension dispute with the government. The government has requested that the doctors contribute more to their pension plans as well as raise the retirement age in order to ease the burden on other health care workers such as nurses or porters (patient transporter). The story reports that this strike was small, affecting about 24% of practices, but was still effective due to the tumult the system saw from canceled surgeries, closed clinics and rescheduled appointments. What I find interesting about this article is the insight into NHS functions, and how we’ve experienced similar issues in the US, and what it meant to the patients. http://www.dailymail.co.uk/news/article-2162242/Doctors-strike-affects-10-patients.html

This illustrates a key inefficiency in the NHS: the doctors are not beholden to the consumers. The chairman of the doctor’s union even used the phrase ‘the fight is with the government’, implying that they are not trying to hurt their patients. But who gets hurt when their scheduled surgery, (an appointment that is often difficult to come by in the first place) has to be rescheduled? The power of the purse is in full display in this instance. In the US, we’ve created a society that engenders pride in the success of doctors. We want our doctors to be highly competent, well compensated, and esteemed for their efforts. Bumping them down a peg to the status of ‘cog in the machine’ will certainly not lead to better outcomes. 

We have had similar issues in the US with government employees. You may recall the air traffic controller strike of the 1980’s or rows in individual states over pay and pensions, such as the recent recall election of Scott Walker in Wisconsin. The very idea of public employee unions has been in dispute even going back to the FDR administration. In a letter to a Federal union he wrote,

• “All Government employees should realize that the process of collective bargaining, as usually understood, cannot be transplanted into the public service. It has its distinct and insurmountable limitations when applied to public personnel management. The very nature and purposes of Government make it impossible for administrative officials to represent fully or to bind the employer in mutual discussions with Government employee organizations.”

This seems pertinent still today, given that after the recent Supreme Court decision upholding the ACA, several commentators in the healthcare industry have been predicting the eventual unionization of doctors; if Britain serves as an example, it is not one we should be clamoring to follow. Here’s a link to a very good article on the effects doctors may see in the coming months: (http://news.heartland.org/newspaper-article/obamacare-expected-increase-loss-doctor-owned-practices)

Now to bring the focus back to the most important driver of healthcare: the patient. A problem lingers with the whole premise of having a doctor’s union. I can only ask the question---- because after much thought, I realized that my solutions got very murky, political, emotional, and ultimately led to naught (at least for the purposes of this blog):

What do you do when your doctor is in a union and you no longer trust him/her to put your best interests first? It seems far-fetched for the United States, given the culture I described above, but it’s all too real for thousands of patients in Britain right now.

Read more at the American Presidency Project: Franklin D. Roosevelt: Letter on the Resolution of Federation of Federal Employees Against Strikes in Federal Service   http://www.presidency.ucsb.edu/ws/index.php?pid=15445#ixzz1zbinKpWE

Feds Grant Millions to the “Shared Decisions” Endeavor

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals

The proud announcement about more federal funds ($36.1 million in funding, part of a $1 billion “Innovation Grant”) being “won” by a handful of large, integrated health systems exudes optimism as it explains the use of these funds is “primarily to hire and train an estimated 48 patient and family activators over three years to help with shared decision-making (SDM) related to hip, knee or spine surgery, and for patients with diabetes or congestive heart failure.” (By my math, that is $750,000 per “activator” or $250,000 per activator per year, to help what can only amount to a handful of patients.)

While I could comment on the wisdom of bleeding these funds on a speculative project at a time when we are in pretty dire economic circumstances, I won’t indulge that instinct. And those who read my blogs or know me personally know that I am passionately enthused with the concept of “shared decision making” in health care. SDM can be the primary means to improve patient satisfaction and optimize results ----which reaps (only as a by-product) REAL cost-savings based on a reduction in resource waste due to non-compliance or over utilization. http://www.ama-assn.org/amednews/2012/07/02/bisd0703.htm  

My larger concerns in this article and with this approach is described at the end of the article: that a physician can prescribe a “video” for the patient to watch which will result in a “shared decision” for the patient to have (or not have, gasp!) a surgery. SDM is more than “tools”----it is a process that requires time and deliberation. The article quotes Dr. Goldbach, the Chief Medical Officer of HealthDialog as saying, “It can be a matter of a physician “prescribing” a video for a patient deciding whether or not to get knee surgery.”

HealthDialog is a “private, wholly owned subsidiary of Bupa, a global health and care company of more than $12 billion in revenues headquartered in London, England. Health Dialog provides population analytics, interactive decision aids, and healthcare decision programs to over 17 million people around the world. Health Dialog provides population analytics, interactive decision aids, and healthcare decision programs to over 17 million people around the world.” Clearly, this private company is heavily linked to our health care reform initiatives in its relationships with CMS.  http://www.healthdialog.com/Utility/Company

 Shared decision making involves give and take between the clinician and the patient (and sometimes the family). It is as intimate as a confessional and is not something that can be slap-dashed together as part of a “program”.  It occurs in local surroundings and not in corporate offices, conducted by call-center personnel.  Shared decision making happens ONE patient, ONE situation at a time.

Terri is the founder of Cambria Health Advisory Professionals. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders, a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.

Overall Healthcare Spending Only Slated to Rise 7.5%

---Anna Shepherd, Health & Personal Finance Professional - Cambria Health Advisory Professionals


The following is an interesting press release of a recent research effort by the Health Research Institute of Price Waterhouse Cooper. It predicts 2013 healthcare spending based on recent trends and finds interestingly enough that overall spending is only slated to rise 7.5%. (Still above the posted rate for inflation, but not as bad as some had predicted.)  http://www.marketwatch.com/story/historically-low-growth-in-healthcare-spending-expected-in-2013-projects-pwc-health-research-institute-2012-05-31

The reasons for this slowed growth are quite heartening for the cause of business like Cambria Health Advisory Professionals, which holds as its mission the right of the individual to make his own health care decisions.  PWC’s article cites that in recent years, employers and industry professionals have made sincere efforts to reduce their own cost burdens; examples include such strategies as employees shouldering more of their medical costs, blockbuster drugs coming off patent, cost transparency, and employee participation in employer-sponsored wellness programs. Combined, this means that lowered costs could potentially be sustainable.

We continue to experience upward cost pressures stemming from the need for increased hiring and more sophisticated technology. With the baby-boom generation seeking retirement and getting ever-older, the healthcare industry is going to necessarily experience continued growth in costs due to greater utilization; the key will be assuring that resources are properly allocated (“not wasted”) to avoid negative impacts on the overall economy.

Certainly, Americans are demonstrating their interest in taking control over these decisions. For example, average enrollment in high deductible plans coupled with a Health Reimbursement Account has increased to 43.2 percent in 2012 from 34.2 percent in 2010.

The information showcased in this article represents, in my opinion, a great success for the free-market and individual decision-making. It legitimates a RAND study from the 1980’s that I frequently reference; the study demonstrated that people consume less health care when forced to pay higher co-pays. Numerous studies involving health savings accounts have corroborated what economists have always known: the more insulated people are from having to pay for something, the more of that thing they are willing to consume.

It seems to follow simple logic: if something is coming out of your pocket, you tend to pay attention. Obvious, right?

But allow me to make 2 additional points that this article brings to mind.

1. All of this progress can be undone if the Affordable Care Act is upheld as Constitutional. In our discussions on this blog, we try not to be too political in our commentary, but the fact remains that this piece of legislation is likely to fundamentally transform a sector of the economy that accounts for 17% of GDP. As employers unload employees onto government plans (which appears probable if recent polling is to be believed), the efficiency that we’ve seen when patients are accountable is likely to be erased. This was, and continues to be, my biggest objection to the legislation.
2. On a lighter note, if recent cost-controls keep pace, we’re on a better road. I believe that in addition to having consumption tied to the patient’s own wallet, the patient needs to be knowledgeable about their options and treatment courses. This will allow them to make more effective decisions, not simply financial ones. Instead of foregoing their yearly check-up just to save money, they may decide to forego an expensive drug and consider a generic instead. These types of informed trade-offs will add up for the industry as a whole as well as the individual patient.

The key may be helping the market find ways to create and attract more informed consumers who make more rational purchasing and health care usage decisions.

Can Solving Health Care Be As Simple as Just Doing What We’re Told?

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals

I don’t really think it’s this simple, of course, but since New York Mayor Bloomberg believes in the soundness of his recent decision to outlaw large soft drinks within the walls of his kingdom for the benefit of those (like me) without prudence or self-control, I thought it would be interesting to at least pose the question. Patient compliance with medications is frequently only around 50%; this is a well-documented fact. And the reasons for the non-compliance or non-adherence are as varied as the subjects of the study.


Do we forfeit our liberty to be willful and uncooperative (either by drinking Big Gulps or not getting our prescriptions filled) when others must contribute to the actual costs of our own health care? 
 
The article linked to this discussion recognizes the truth that people often don’t get their prescriptions filled. http://articles.sun-sentinel.com/2012-04-08/health/fl-hk-skipping-medicines-20120406_1_drug-costs-cvs-caremark-drugs-for-chronic-conditions  

There are a number of reasons that people do this---and it’s not just because they are obstinate rascals. They don’t get the prescription filled because a) they know it won’t work, b) don’t like the side effects c) don’t want to spend the money, d) they don’t have the money (different than option c), e) they already have a whole stock of that drug at home in the medicine cabinet that they didn’t take last time either, f) they don’t believe that the drug was necessary because their problem is going to resolve quickly and g) other reasons.

However, the system costs of medication non-compliance are well documented. The non-compliant patient is more likely to have costly medical complications. In addition to the obvious higher costs, there are some additional questions that this story raises:  

1. Buried in the story is this sentence: “Employers and insurers have grown so concerned about the costs of drug skipping that the credit-rating service FICO now offers a service to estimate the likelihood an employee or patient will take medicine correctly.” I think about whether I would want someone to rate my compliance in the same manner as my credit score. That seems a bit too “judgmental” and invasive. I wonder what others think about that. Here’s a link to that offering: http://www.fico.com/en/Products/Scoring/Pages/FICO-Medication-Adherence-Score.aspx
2. I wonder how the effects of “electronic-prescribing” “ERX” will change the dynamic of physicians sending a prescription which the patient will never have filled. If the doctor KNOWS that the patient does not get the prescription filled, will it change the patient’s behavior? How will the doctor react when he/she finds out the patient never picked it up or rejected it? One of the benefits of ERX in the professional literature is the fact that if it is electronically sent, it is much more likely to be dispensed. According to Surescripts, “Research shows that 20% of prescriptions never even make it to the pharmacy. A study conducted by Walgreens and Surescripts showed that once a practice starts e-prescribing, 11 percent more of their prescriptions get dispensed.” http://www.surescripts.com/about-e-prescribing/benefits-of-e-prescribing_for-pharmacies.aspx  
3. The FDA is looking (again) at designating some drugs as a third category, potentially available without a prescription. How will such a new category be impacted by this compliance concern/trend? What will their health coverage be? See well-written analysis here: http://www.fdalawblog.net/fda_law_blog_hyman_phelps/2012/02/on-again-off-again-third-category-of-drugs-is-on-again-at-fda-simultaneous-rx-and-otc-marketing-also.html  

Of course, I am just scribbling my thoughts and opinions on this matter in a blog posting. The questions are provocative and the answers are not necessarily clear-----it is my hope that we don’t let the discussion go by the wayside. The way in which we attack the problem of therapy compliance may have unintended consequences in terms of our freedoms and on care quality. We need to embark on the next steps with eyes wide open.

Terri is the founder of Cambria Health Advisory Professionals. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders, a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.

A Perspective on Waste in Healthcare: A Tale of Two Articles

---------By Anna Shepherd, Health and Personal Finance Professional

Two recent headlines tell a tale of two stories but offer me an opportunity to comment on a couple of interesting challenges we face in our health care system, across the country.

1. The first article lauds a $1.1 million federal grant awarded to a Berkeley clinic as part of the Affordable Care Act (http://www.mercurynews.com/breaking-news/ci_20713200/berkeley-clinic-lands-1-million-grant-educate-abouthttp://www.bellinghamherald.com/2012/05/23/2535431/feds-struggle-with-getting-elderly.html)  The funds were from a pool of $122 million in Health Care Innovation Awards given out recently to 26 recipients. The "Over 60 Health Clinic" of LifeLong Medical Care will hire 60 new employees as part of the grant. The goal? Educate patients and reduce costs associated with urgent care, while improving outcomes through the use of “Peer Educators”.
2. The second article (by Kaiser Health News) details the disappointing results of another federally funded program started in 2007: “Money Follows The Person” which anticipated saving significant Medicaid and assistance dollars, by moving elderly people out of nursing homes and back into community.  See (http://www.bellinghamherald.com/2012/05/23/2535431/feds-struggle-with-getting-elderly.html) 

The Berkeley clinic article seems to be an appropriate start to patient-based cost control. It cites that educating 750,000 patients about compliance and the nature of their disease could save the system $250 million. The cost of the program itself: $122 million. My immediate concerns have to do with the information available in the article and the nature of the problem itself.

This article doesn’t go into depth about what type of backgrounds the peer-educators have, which to me is really what the whole program hinges on. If these people are former clinicians, nurses, or medical psychologists, I could foresee a high success rate (though costly).  

However, if they are case workers, which is likely, I could see an outcome similar to the second article about the Money Follows the Person program; it has been promised $4 billion, received $1 billion, and performed it’s duties for 36% fewer people than promised.  

In California alone, the health agency responsible for implementation has to work with two dozen other local placement agencies and is finding the barriers significant. This is the type of waste endemic in trying to fix problems whose origins are misunderstood or even unattainable.  

I want to explore why these types of programs are ineffective. Is it just government bureaucracy run amok? Is the populace in question more at-risk than average, leading to skewed results? Are the advocates being employed the ones best-suited to help?  

The fact that much of the US population needs advice concerning their health is not in question; but who is providing it certainly is. Suggesting that former healthcare professionals need to be central to patient counseling is not intended to demean the role of social workers; they are a necessary resource to many who have limited options and means. However, I think that the people advising patients on issues of compliance and decision-making need to be steeped in the industry; someone who’s seen and treated it all can be an invaluable advocate.  

However, let it be clear that they must also be entirely uninvolved when it

comes to diagnosing or treating the patient once they turn the page on being a provider and become an advisor. Current payment schemes’ create inherent conflicts of interest for the provider and are certainly a contributor to waste and fraud. In my opinion, patients would also be much likelier to heed the words of an impartial professional, leading to increased success rates.

In regards to efficacy and cost of the counseling, the biggest obstacle remains patient involvement. Those who have self-selected to be involved in the Berkeley clinic have a higher likelihood of success and will make the program worthwhile (again, given appropriate counsel).  

The point of this whole website and subsequent venture (see Cambria Health Advisory Professionals at http://www.sharedhealthdecisions.com/ ) is about empowerment of the individual and illness prevention for patients within the private sector. In speaking with outsiders, I have been criticized for not understanding the plight of a poor or disabled patient and the needs they have when they are sick and on their own.  

I respond by saying that I do understand because I work personally with elderly patients on Medicaid. But empathy is not an effective solution, nor is more money or programs.  

What we believe is effective is to catch the individual well before they have entered the Medicare system. If someone is frequenting a health advisor in their 40’s, they can learn about all of their options before the hard decisions must be made and, more importantly, they can plan. Removing these proactive patients from the pool of those in need not only saves vast sums of money but also allows focus to be directed on the patients with a high likelihood of noncompliance or medical neediness, creating a win-win for all.

For Fear of Being “Difficult”, Will I Forego My Needs?

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals
A study by the Palo Alto (Calif.) Medical Foundation Research Institute published by Health Affairs this May describes what many of the “meek” already know. You don’t want to irritate your doctor with too many off-putting questions; you’d rather suck it up and trust that he/she will do the right thing. http://newsroom.pamf.org/2012/05/patients-fear-being-labeled-difficult/

Though not a random, large scale trial, the researchers confirmed something many of us who have taken care of patients already know: There is often something broken in the dialogue between physician and patient as it relates to “give and take”.  The patient often withholds information, lies, or deliberately remains quiet when the golden opportunity to ask questions, challenge, or probe for options comes up.  Think how hard it is to ask for a second opinion! 

 In December 2009, PAMF researchers interviewed 48 people broken into six distinct focus groups. The participants were randomly selected from the electronic health records of five primary-care physicians in the San Francisco area.  Maybe not suprisingly, most were white, well-educated and more than 50 years old, and 19 reported annual incomes of $100,000 or more, although the investigators believe the results apply across all demographics.


And I would tend to agree with them from my own anectdotal experience.
The researchers found that focus group participants feared to question a physician’s advice or recommendations, concerned that they would be perceived as a challenge to the doctor’s authority. Most of them wanted to avoid “displeasing” or “disappointing” their physician.

Patient-Doctor Relationships represent a fundamental imbalance in power;  some felt that their physicians perpetuated this authoritarian stereotype. To manage their care, then, many described “doing their own research about treatment options and bringing social support to medical consultations to make the best use of the limited time available.”

“Shared decision-making is a collaborative process that allows patients and their healthcare providers to make health care treatment decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences”: This requires two way exchange of information and implies accountability on both parties to actually be direct with regard to needs, wants and concerns.

It may mean that we should start early (perhaps in grade school) to encourage more effective means to encourage two-way dialogue with health care providers so that the charade of what is actually going on with a patient does not involve the patient withholding important factors or feelings (embarrassment, shame, unworthiness) that could impact care.

Terri is the founder of Cambria Health Advisory Professionals. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders. a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.

Waste Avoidance vs. Rationing: In the Eye of the Beholder

--By Anna Shepherd, Health & Personal Finance Professional

After musing over this must-read article written by Dr. Howard Brody, a few things come to mind. I absolutely agree that the type of waste the author describes is the elephant in the room that needs to be addressed before any realistic measures can be taken to rein in healthcare spending in the United States. 

See: Brody, Howard. “From an Ethics of Rationing to an Ethics of Waste Avoidance” NEJM 2012; 366:1949-1951. May 24, 2012. Taken from the URL: www.nejm.org/doi/full/10.1056/NEJMp1203365#t=article

But I also have a few points of contention that are not directly addressed with the article.

1. It’s obvious that in this environment, trimming the health care industry from 17% of GDP to a more manageable number, say 9%, is going to be unpopular from a policy standpoint due to the sheer size of the health care industry itself (read jobs). However, this would not be disastrous as the more efficient allocation of resources in a free market would be a net benefit in the long term. However, the political will can only exist if the electorate is also willing, a political rant I will forego right now.
2. It does bring me to my next point however; I think the author asks too much of the average physician without bringing in the most important component of the equation: the patient. Patient education is the only way to really solve the waste problem, in my opinion. Unfortunately, the path to an informed and enlightened patient takes time and effort. Physicians are already inundated with large numbers of patients, ever lower reimbursement rates, malpractice threats and the cost of practicing defensive medicine, not to mention the stresses of simply running a practice. I’m not a physician, nor an expert in these matters, but it seems naïve to me to expect physicians to take on this extra task. So, there must be a better way to get the patient to make better decisions and reduce wasted resources.
3. The final issue I have with the physician-driven nature of this article is a moral one. The decision to ‘ration’ cannot come from “without”. Because the rationing we are talking about is often going to involve foregoing costly procedures, we arrive at a very gray area in which the care-taking physician must try to be an objective advisor. They are far too financially involved, as the author mentions, in the outcomes of the patient’s decisions to truly be the trusted source for advice.

Posing questions about the ethics of rationing is a great place to start the conversation. And physicians are a crucial gate-keeping mechanism to avoid waste. But I think the author may be trying to solve a problem by creating a more complex system instead of the solution I see as painfully obvious throughout the health care system. It goes to a fundamental component of economic efficiency: a system is efficient if each actor is allowed to maximize their individual utility.

Simply put: the answers need to come from the patients themselves. We need to create an environment in which patients can seek the answers and information that allow them to make efficient decisions without feeling that care has been rationed away from them. They need to own the decision.