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.