Filling the Gaps in a Porous Medical System

     "I was trying to talk but nobody could understand me," she says.

     Her facial paralysis scared her into her local emergency room. An MRI of her brain showed eight dark spots. Each one measured a small stroke. Doctors put her on a blood thinner and Lipitor, the cholesterol-lowering medication. Most important, they told her, quit smoking.

     It seemed simple enough, but it wasn’t. Rochowiak had been a smoker since she was 13, and for the past 10 years her Newports were a pack-and-a-half-a-day habit. The first smoking cessation medicine she took didn’t work. The next one, Chantix, wasn’t covered by her health insurance.

     If Rochowiak was going to quit smoking she was going to need some help. This was just the situation Hess had in mind when it hired Quantum Health Solutions, a Columbus, Ohio, patient advocacy company that believes it can help reduce health care costs by making sure patients do not fall through the cracks of the health care system. Like so many employers, Hess was looking for a way to reduce health care costs while making sure its employees got the care they needed.

     "There is waste and extra costs in the system because the process is so fragmented," says Kara Trott, founder and CEO of Quantum Health. "Patients have no easy way to get the care they need."

     Trott says most of the obstacles are small, but quickly add up.

     Since 1997, when Trott founded Quantum after quitting her job as a securities lawyer, the $2 trillion health care industry has become chock-full of companies offering services that are meant to patch the cracks in the health care system: technology that reviews claims and identifies utilization trends, telephone counseling, acute care coordination, patient education, disease management and so on.

     "We’re much more focused on the whole continuum," Trott says.

     Quantum employees also act as patient advocates helping to coordinate a patient’s care. They act as social workers, reaching out to health insurers and other caregivers as well as helping patients manage their diseases. The company also helps employers design their health care plans by emphasizing preventive medicine and the value of teaching patients to use their primary care physicians.

     "The Quantum health approach is pretty labor intensive, and most other vendors are not willing to put that kind of labor into that approach," says Dennis Boen, a senior vice president of employee benefits with broker Sky Insurance in Wooster, Ohio. Boen is a broker who regularly reviews the performance of companies like Quantum in order to evaluate their effectiveness. "Most of the other vendors are looking for a technology solution … but in this arena you are dealing with people."

     A service that is labor intensive, however, is also much more difficult to measure.

     "I have to tell you initially, it was a hard sell," says Stacey Irvin, vice president of human resources at Hess. "You have to ask yourself, ‘How in the world can you guarantee savings with what you are going to do?’ "

     Another sticking point for many employers is the idea of having to pay for a service that is not guaranteed to save them any money. Most companies charge a per-member, per-month fee. Others, like Quantum, only collect fees if they can prove to an employer that they helped save the company money. This was a decisive difference for Hess when the company hired Quantum four years ago, a time when Hess was experiencing double-digit cost increases. Today, 800 employees and dependents use the service.

     A lot of energy, at first, went into patient education. Hess employees did not like the idea of having to submit to Quantum the name of their doctors and their health histories.

     "Oh, they were vocal," recalls Irvin, who called in her broker and held meetings with employees to explain the change. "Our employees interpreted this as ‘Big brother is going to be watching me now.’ "

     But soon the employees warmed up to the idea of having someone with whom they could meet every other month to help them deal with their health insurance and their doctors. As anyone who has ever had to find a doctor or been denied a health insurance claim knows, the health care system is porous. Patient advocates can help fill the gaps.

     In Jaime Rochowiak’s case, the gap was about $118—the cost of a month’s smoking cessation medicine. Rochowiak, a single mom who makes $12.31 an hour, simply couldn’t afford it.

     "If I can get it approved for you do you promise me you’ll quit smoking?" the advocate asked Rochowiak.

     Soon after, her insurer agreed to cover her prescription for Chantix for three months.

     After the first month, a pack of cigarettes lasted her just over a week. Her care coordinator called every day to check on her. By the second month, Rochowiak was down to one cigarette a day. But that’s where her progress ended. She couldn’t stand the nausea she felt while taking the medicine. She let the third month’s prescription go by unfilled. She’s back up to a half-pack a day and missed her last appointment with her care coordinator, who, she says, no longer calls her.

     "She probably figured I quit because I missed my appointment," Rochowiak says.

     Rochowiak illuminates an important question.

     Hess says Quantum has saved the company money. And its health care costs per employee are 23 percent lower than in 2006. A lot of the savings have come from eliminating redundant tests and getting patients to a primary care doctor who can send them to the right specialists.

     Some of that savings, though, may come from people like Rochowiak: patients who do not follow their doctor’s orders and simply fall off the radar of their caregivers. Not only did Rochowiak not refill that third prescription, but she also never went back to her specialists at the Cleveland Clinic. She says she found them to be condescending to smokers. She told herself she’d go back when she quit smoking.

     Rochowiak knows she is writing herself a prescription for long-term medical problems and high health care costs. Quantum, which had not realized its patient was smoking again, says it will reach out to Rochowiak, who, a year and a half after her trip to the emergency room, says she still wants to quit.

     "I have a daughter," she says, "and she don’t have nobody else but me."

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