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Home-Spun Health Savings

July 10, 2010

The patient, a middle-aged woman, had diabetes, heart damage and kidney disease. She weighed 300 pounds. Her doctors diagnosed her with depression but she was not ready to acknowledge that, let alone do something about it. One reason was that she didn’t trust her health care providers. Why would she? Like most patients, her office visits were typified by long waits followed by a few minutes of face time with a doctor.

The patient’s identity has been kept private by her health care providers at the Everett Clinic north of Seattle. But the Boeing Co., her employer at the time, did pay for her health insurance and, as such, had an economic interest in making sure she didn’t land in the emergency room dying from the toxins her kidneys could no longer process, her only hope being a costly transplant or a lifetime of dialysis.

There is ample evidence that the sickest patients—those with multiple chronic illnesses—are also the most costly. The Milken Institute reported that chronic illnesses accounted for $277 billion in health care costs in 2007 and $1.1 trillion in lost productivity. Many employers have begun tackling chronic illness by changing the way they design their health benefits. Some, like mail services company Pitney Bowes, reduce the cost of certain medicines to encourage patients with chronic illnesses to take them. Others, like media firms NBC Universal and Discovery Communications, have built health clinics and instituted wellness programs to give patients the kind of care they are not getting elsewhere.

Chicago-based Boeing tried a different approach. Rather than fill the gaps in the health care system with programs of its own, the aerospace company tried to prod change within the medical system. Last fall, Boeing announced the completion of a two-year pilot program in Seattle-area clinics for patients with chronic illnesses who get their health insurance through the company.

The program, begun in February 2007, was based on the concept of the medical home, which puts patients at the center of a team of nurses and doctors who are paid extra to actively manage a person’s health and health care. The company decided it had a large enough population in the Seattle area to test whether doctors could improve the care they gave to patients beset by the most complex and costliest chronic illnesses.

The phrase “medical home” is thought to have come from a 2002 study by seven U.S. family-medicine organizations advocating that every American should have a “personal medical home” to receive acute, chronic and preventive services.

Boeing’s initial results appear promising. When compared with patients who had similar illnesses, the patients in the pilot program improved their health and the company showed a 20 percent savings in health care costs, Boeing reported in the journal Health Affairs. Also, the number of sick days taken by patients dropped by more than half.

The findings add to the growing acceptance that medical homes are a viable economic alternative to the way health care providers currently care for the sickest patients. Boeing joins a growing number of employers that are embracing medical homes. Other believers include IBM and the Patient-Centered Primary Care Collaborative, an organization of more than 500 employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals and clinicians. The results of programs like Boeing’s could help other medical-home projects access billions of dollars from the federal government and spur health insurers to pay for the extra care.

     “All these pieces of evidence support the conclusion that while medical homes for everybody might not save money, well-executed medical homes for the sickest 5, 10, 20 percent of the American population can indeed reduce total spending and improve quality,” says Arnold Milstein, chief physician for Mercer Health and Benefits and a consultant on the project.

Growing interest 
Though medical homes have been around in various forms for years, the concept has gained new currency among both the medical community and employers that are dismayed over the explosion of chronic illnesses and health care costs.

“We know, and our consultants helped inform us, that people with multiple complex conditions have the highest costs and suffer from health care being delivered in a fragmented system,” says Theresa Helle, Boeing’s manager of health care quality and efficiency initiatives. In other words, sicker patients use more health care, but the additional care does not necessarily make them healthy. A major reason is that the cures for chronic illnesses are complex; patients must change habits they’ve developed over a lifetime. Medical providers in medical homes must act more like social workers, taking time to counsel, coach and urge people to manage their illnesses and their underlying social and psychological causes rather than prescribing solutions and doling out medicine during a 15-minute appointment every few months.

That counsel-and-coach approach means paying doctors differently. Boeing was willing to pay doctors more—an additional monthly per-patient fee that neither the company nor the clinics would disclose—to get them to provide the care their chronically ill patients needed. The fee is paid in addition to the money for service that doctors already receive.

Knowing that patients would be more likely to enroll in the program if they were invited by their doctor, Boeing began its program by giving each of the three health clinics it worked with in the Seattle area a list of several thousand individuals the company and its insurer, Regence BlueShield of Washington, had determined would have very high health care costs over the next 24 months.

The program was voluntary for doctors and patients alike, so the clinics that got involved had the “right mind-set,” says Pranav Kothari, co-founder of Renaissance Health Inc., a medical consulting firm in Cambridge, Massachusetts, and one of the consultants on the project. Boeing had learned the voluntary lesson the hard way when a previous effort requiring patients to switch doctors backfired.

The three Seattle-area clinics customized their approach to test two medical-home models. The Virginia Mason Medical Center’s clinics paired a patient’s existing primary care physician with a nurse case manager who acted as the point person for patients. The Everett Clinic and the Valley Medical Center had a dedicated doctor and nurse manage all the cases.

“We’re asking them to do motivational interviewing, compassionate listening, help patients change their behavior, and change the caregiver relationship to one of care partnership that works with a patient’s social support system,” Kothari says. “They’re not really taught this in medical school.”

Getting workers on board
Initially, some patients were skeptical.

“I think there was some curiosity of some of the [Boeing] staff people who we enrolled about … ‘Why is my employer getting involved in this?’ ” says Carolyn Cone, the project manager for Virginia Mason’s program.

After experimenting a bit, the clinic found that patients were more likely to enroll when their doctors reached out to them directly. Over a 24-month period, the clinic enrolled 387 patients.

Patients who opted into the program, formally known as the Intensive Outpatient Care Program, met with their doctor and a nurse who assessed their health and developed care plans intended to address their medical needs and put them on the long road to better health.

The initial one-hour “intake” meeting was itself a departure for physicians like Kevin Clay, a primary care doctor at the Everett Clinic. It was longer and more in-depth and gave doctors more time than they had ever spent with their patients. “I learned things about them I hadn’t known, and I’ve been taking care of them two or three years,” Clay says.

Cone, the Virginia Mason case manager, says the medical home helps doctors and nurses deliver care to improve a patient’s overall health rather than simply address a specific problem.

“In a typical model, you call your doctor when you are sick,” she says. “Your doctor will react to the acute condition but won’t necessarily be looking forward to address the overall problem and be proactive about a solution.” Once patients and doctors established a care plan, patients met regularly with doctors and nurses. A case manager, working with the patients and their medical providers, coordinated care among specialists. And the care team met daily to review patients’ progress.

The clinics also improved their customer service. Patients could make appointments without having to wait. Those who needed immediate assistance could call their nurse or send the nurse an e-mail without having to go through an administrator. Clay also set up educational seminars to teach patients about their diseases and how to cook healthier meals.

Helle convened biweekly conference calls with the nurses from the three clinics to share what they were learning. Consultants from Mercer and Renaissance Health met quarterly with Boeing and all the teams to share what people had learned. Helle, meanwhile, provided monthly progress reports to Pam French, Boeing’s director of global benefits.

Most important, nurses spent a lot of time reaching out to patients to give them support, guidance and encouragement. “The key to success is the relationship a nurse develops with a patient,” Helle says. “The nurse is motivating the patient to do behavioral changes which improve their health. It was all about nurse-patient relationship.”

Sherry Stoll, a nurse administrator at Virginia Mason, says doctors “talk about ‘Boy, you need to lose weight’ or ‘You are not managing your insulin.’ They have those conversations. What’s different about this program is asking the patient why they are not eating the way the doctor asks them to eat or not having their eye exam or not getting their foot exam. What the nurse does is explain why this is important … helping patients to work toward their goals, change their behaviors so their overall health is better.”

 Building trust
Because of privacy laws, Boeing says it could not make patients available for interviews. Helle quoted one patient’s feedback on the program, saying, “I’ve been helped more in the last six months than in years of seeing multiple doctors.”

Everett Clinic nurse Joleen Rodgers says many patients, especially those who are quite sick, already feel as if the medical system has failed them. By providing personalized and persistent care, Rodgers described how developing trust allowed her to slowly help the middle-aged woman with diabetes and kidney disease improve her health.

“She had not had a trusting personal relationship with a care provider,” Rodgers says. “There was nobody to deal with her as a whole person.”

Rodgers eventually earned the patient’s trust, and in the process learned more about the woman. The patient’s personal life was a source of stress, Rodgers says, with marital and financial problems and a history of child abuse. “Over time she slowly let us in and let us know about her concerns,” Rodgers says.

One concern was a breast lump that turned out to be cancer. Doctors had also suggested that she might suffer from depression; it took six months before the patient was ready to do something about it.

“How do you build trust? By building relationships,” Rodgers says. “It’s face to face. It’s following through on a care plan. It’s picking up the phone when a patient calls and being there when they need you.”

“In the normal way health care works, patients like that woman are labeled noncompliant, difficult, recalcitrant,” Rodgers says. “That’s a label without getting into why they may be that way.

“There are a lot of barriers people have, and reasons why they don’t do as we think they ought to or should do. Uncovering those barriers and dealing with them allows people to move forward. And the normal way health care works, we just don’t have time to address those complex issues with patients, especially the mental and social issues that are the drivers of what and why they do what they do.”

After two years, the patient’s health improved. She reduced her weight to 150 pounds. Her tumor was removed. She managed her mental and physical health, but it was not enough. She recently died.

Rodgers does not know the exact cause of death, though she did say the woman’s health was fragile and her death was not unexpected, especially once the pilot project ended. “I cannot speculate why she passed away, but there was an abrupt discontinuation of interaction with the medical care team after the program ended in July of 2009,” Rodgers says.

The strength of the relationship between a patient and the care team is a key indicator of whether a patient will improve his or her health. Milstein, the Mercer consultant who is also a psychiatrist and has studied the way other medical-home models have worked, says some clinics whose technical care was only average were able to improve patients’ health because the care teams treated patients with an extra measure of personal care.

Milstein says he visited practices in California that were not part of the Boeing experiment but followed the medical-home concept. And while some were not perfecting their diabetic patients’ blood sugar levels, they were doing some things very well. “They were treating these patients beautifully,” Milstein says. “I wanted to put my mother in this practice.”

Cost savings
Most of the savings in the Boeing program came from reduced hospitalizations and emergency room visits, Helle says. The company realized a 20 percent savings compared with its control group after factoring in the additional money paid to doctors. The average number of workdays missed by patients in the last six months of the program dropped by 56.5 percent.

The lesson for employers elsewhere is that it is possible to pay doctors more to take special care of their sickest patients and still save money. Doctors’ offices do not need to make major investments in IT or other infrastructure. If the sickest chronically ill patients receive this kind of care, Milstein projects an initial total health care savings for employers of 3 to 6 percent.

The key to the concept’s broader success is leadership from a large payer of health care. That could be either a large employer in a given community, like Boeing, or Medicare, with the purchasing power necessary to prod and pay doctors to rethink the way they care for patients.

Despite the pilot’s success, Boeing ended the program in July 2009. Patients no longer have access to intensive nurse case managers. The system has gone back to the way things were.

“We made special arrangements with medically fragile patients to make sure they didn’t fall through cracks,” Helle says.

The success of the Boeing program underscores its weakness: Unless more employers or health plans are willing to pay doctors extra to care for patients in this way, medical homes will not be widely adopted.

Boeing says the pilot was never intended to be made permanent. The company instead focused on seeing whether the models it designed could improve care and reduce costs. Now Boeing wants insurers to step into the breach.

The program’s success has caught the eye of health insurers in the Seattle area that are looking to replicate it by sharing the cost savings with doctors. The clinics themselves see the value of the program. Virginia Mason has adopted some of the lessons from the medical home and says it is in preliminary discussions with health insurers to get paid for using a team approach to managing patient care. Boeing says it is studying ways to expand the program in other areas where it has large employee populations.

Regence, the largest insurer in the Northwest and Intermountain regions of the U.S., this spring began implementing an approach to pay doctors more for caring for patients with multiple complex, chronic illnesses using the medical-home model.

“The complex patients, they’re at the doctor all the time,” Clay says. “The problem is, our current care model doesn’t give you time to get to the bottom of their problems. You need to slow down and take time to analyze it. Sixty percent had behavior health issues.”

Unless more insurers and employers pay doctors for the extra care they give patients, Clay says the medical-home model won’t be fully embraced by doctors. “If I saw each patient for an hour, my kids wouldn’t be in college.”

Workforce Management, July 2010, p. 17-20 -- Subscribe Now!