Wednesday, November 30, 2011

MoreCare: prevention-centric, not repair centric...have a look Canada!

By Tom Main and Adrian Slywotzky Atlantic Monthly, November 2011
The CareMore story begins almost two decades ago, with a man named Sheldon Zinberg, a gastroenterologist who was deeply concerned about the changing economics of health care in Southern California. There, as in other U.S. markets, health-maintenance organizations, or HMOs, had come to dominate the landscape. The theory behind HMOs was attractive: “managed care” was supposed to coordinate and guide treatments in order to maximize both patient wellbeing and economic sustainability. But under pressure from corporate health-insurance sponsors and government agencies (as well as investors seeking profits), HMOs increasingly focused on reducing costs by any means necessary—including short-term fixes that often led to worse patient outcomes and, in the long run, even higher medical expenses. Patients were suffering, doctors were getting squeezed, and costs, after falling for a time, were soon spiraling upward again.

Zinberg was alarmed. Back in the 1960s, he’d founded a large internal-medicine practice that had grown to include some 20 physicians in a range of specialties, from cardiology and oncology to rheumatology and nephrology. But by the late 1980s, with a small number of HMOs growing more dominant, referrals were dwindling and restrictions on services were multiplying. Zinberg and his colleagues were forced to spend ever more time on the phone with “benefits coordinators,” whose main job seemed to be finding reasons to deny coverage.
Already in his late 50s, Zinberg could have simply retired and walked away from the problem, as many of his colleagues were doing. Instead, he made a different decision. Zinberg had long been mulling the elements of a coordinated-care system that would be centered on reducing hassles and improving outcomes for patients rather than simply cutting costs. He began to envision a health-care organization in which teams of doctors, nurses, therapists, trainers, and other professionals worked together, continually sharing information and insights about their mutual clients and providing whatever services were needed to keep those clients in the best possible physical and mental health. ...
One of CareMore’s critical insights was the application of an old systems-management principle first developed at Bell Labs in the 1930s and refined by the management guru W. Edwards Deming in the 1950s: you can fix a problem at step one for $1, or fix it at step 10 for $30. The American health-care system is repair-centric, not prevention-centric. We wait for train wrecks and then clean up the damage. What would happen if we prevented the train wrecks in the first place? The doctors at CareMore decided to find out.

An early discovery was that CareMore’s elderly patients failed to show up for as many as one-third of their doctor appointments. As Charles Holzner, one of Zinberg’s initial partners at CareMore and now a senior physician with the company, explains, “About one in three of the elderly people we were taking care of were home by themselves. They’d outlived their family resources, they couldn’t drive, and their kids lived out of town. So when they got sick, they ended up calling 911. And when it came to routine doctor visits, they sometimes just couldn’t make it at all.”
CareMore’s unconventional solution to the problem was to provide transportation, at no charge, to get patients to their medical appointments. Local car-service companies were happy to have the business, and while the transportation cost money, it ultimately saved a lot more. Increased regularity and consistency of medical care meant that many simple problems were recognized and treated in their early stages: complications were avoided, and rates of hospitalization and nursing-home admittance began to fall.
The problem of “noncompliance” isn’t limited to missed appointments, either. Patients, especially elderly ones, also leave prescriptions unfilled, medicines untaken, exercise-and-diet regimens unfollowed, and symptoms unnoticed and unreported. Health-care professionals often grumble about noncompliance, but given the myriad demands on their time, they generally can do very little about it. At CareMore, by contrast, Zinberg decided, “noncompliance is our problem, not the patient’s.” So the company began adding more nonmedical services to its routine care in order to improve compliance rates—for example, sending health-care professionals to its patients’ homes to make sure they had scales to keep tabs on their weight, to look for loose throw rugs that might cause falls, and to provide “talking pill boxes” that remind patients to take their medicine with preset alarms. Each of these innovations led to a small improvement in patient wellness and a corresponding improvement in the economics of providing care.
Next, CareMore began experimenting with an aggressive treatment of diabetes, one of the most widespread and debilitating illnesses suffered by elderly patients. The primary treatment for diabetes, insulin injection, had long been considered inappropriate for the elderly—too intrusive, too difficult, and too costly for patients whose life expectancy was already short. But CareMore doctors made insulin-injection treatment available to their patients. They also set about investigating exactly how the worst complications associated with diabetes occurred.
Imagine a health care system premised on healthy outcomes and not on crisis management or repair. Prevention has never been as "sexy" as crisis intervention but MoreCare demonstrates that addressing patient issues is a far more "healthy" approach that to wait for those patient issues to blossom into a full-scale crisis before intervening.
There is so much common sense in the More Care approach, and much of the approach is already targetted in the Health Care Reform Act in the U.S. However, in Canada, for example, we are still struggling with a crisis management system which is demonstrably much more costly and much less efficient.
Imagine if Canada were to blend MoreCare principles into a single-payer system already in place how Canadians would come to know the benefits of monitored and coached health care, based on a whole-patient, integrated approach!
There is clear evidence here that our costs for health care would drop significantly while our health and lifestyle would be significantly enhanced.
Would the empirical evidence, albeit from the southwestern U.S., reduce its acceptance among Canadian health care designers and providers to the point where it would be excluded from the options being considered by those negotiating the new health care accord between Ottawa and the provinces? Let's hope not!
How soon will it be before Canadian health care policy researchers invite Dr. Zinberg to address their think-tanks and to generate the needed public debate about both MoreCare interventions and outcomes, as well as direct and indirect costs and cost projections.
In an aging demographic, clearly a more enlightened premise for health care is not only welcome but essential.
Here is one model for consideration right before our eyes, for which, once again, the Americans have proven their innovative tradition!

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