Stopping on Green - Part 2

By Laurie Gelb, July 28, 2014

(Read the first installmant of this part post at Stopping on Green) 

 They Don’t Need No Satisfaction

If/as we rethink the adherence doctrine, with its emphasis on following bottom-up, and begin to consider supporting patients as largely self-informed deciders rather than passive consumers, to what corollaries does that lead?

Imperative 1: Consign “patient satisfaction” to the worm bin, and focus on beliefs and behaviors that drive optimal outcomes.  These are not the same thing. The latter arise from knowledge, experience and culture.  Patients aren’t satisfied, and can’t be, with a product that they hate, fear and continually shy from, unless they seek it out obsessively. They can be content with a single or series of encounters that turn out well, or “the best they could,” but we don’t want them to repeat the experience unless/until they have to, and indeed most of them [the worried well notwithstanding] don’t.  In what other category do we worry about who likes Dr. Smith how much while telling all and sundry that only 10% of the solution rests with Dr. Smith? And speaking of that 90%…

Imperative 2: Disease management that constrains high utilizers’ cost curves while optimizing the outcomes for which we all pay.  As we tell patients continually, but fail to support, we are actually not in charge of managing _their_ disease. To manage disease, we have to support patient, clinician and caregiver choices that avoid duplication, optimize coordination and keep health, not health care, as the laser focus. 

Imperative 3: An an e-health platform that supports all of the above.

E-health is only as good as the health part. It can’t be acceptable to cede EMR design to bureaucrats, process refinement to the business office and online functionality to Webmasters and programmers. 

Baby, I Don't Have a Car

Are we so focused on “consumer-driven care” that we have forgotten to provide consumers with a vehicle to drive toward optimal outcomes? 

We can’t decide to educate simply if/how/when to deviate from our bibles. It doesn’t pay enough for a layperson to learn our bibles. We have to educate in a different way — not simply about vocabulary and labels (the much-touted health literacy, which means about as much as knowing how to read an electrical schematic out loud). 

We can, as any educational program, provide healthcare intelligence. A consumer knows how to change a light bulb and if/how she can rewire a socket. In short, she knows what she doesn’t know. When we preach “follow,” many patients are honestly unsure as to the decisions they have the capacity to make. Then, when they call the overloaded provider’s office to ask about their current concern, we fail to address the underlying uncertainty about the parameters that prompted the question in the first place. Definitions of terms are not a substitute, since knowing what wiring is doesn’t mean I’m off to the junction box.  

The Long and Winding Road

I know that on some freeways, I can exceed the speed limit, but that still doesn’t mean I can drive 100 mph [an action whose commitment time is obviously greater, given braking distances, than if I were driving 70]. I also know that speed can mean death [stakes]. We know that we must never pour a drop of water into a gas tank, to take one example. Or that we should never pour gasoline onto a flame. We are not going to deviate “just a little” to see what happens. How did we internalize, abstract the rationale for these absolutes? We learned something from someone and/or tried it once, depending on our respective backgrounds.

Even when disease management prides itself on counseling small, incremental changes (bring an apple to work!), we are prescribing without insight on either side. If I hate apples, I’m left wondering if it’s comparable to bring a red plum, which I do like. Think about how long that simple question would take to answer via the Internet, and you have a glimpse of the muddy information overload around fruit. And everything else that might be healthy. 

Few of us eat eight servings of fruit and veggies daily (or know how many we ate). We can’t. When as content providers we offer these lofty outcome measures as “information,” consumers roll their eyes, laugh, sigh, blink, snort, tune out and move on. We want and expect them to deviate if/as necessary. In wellness, we encourage them to “do the exercise you like” and eat the greens they like, etc. We don’t say, eat a carrot salad every day because we know they wouldn’t, however good an idea it might be. Yet our most common copy point in command voice is, “Eat [insert official content here].” That implies a literal meaning, for something that we don’t mean. This language is worse than gibberish; it spawns opposition because it rings so far from the truth of daily living. 

Moreover, to apply information, you have to know something about evaluating information quality, relevance and how literally you need to take it.  How are we imparting a health care “street sense?” 

Teach Your Patients Well

If we put on a can of peas the bland, cover-the-bases “content” that populates the major health information sites, human knowledge of peas would come from experience and the “word on the street,” just as it does for other areas in which the “official voice” is seldom heard because it is too opaque. How much of what you know about street drugs comes from officialdom? Amazon can recommend, sales associates can counsel, but for health care, with far greater stakes, there’s canned risk assessments (scripted encounters, waiting room brochures, package inserts, click here for a percentage you’ll need the footnotes to understand). For the obese, the dyslipidemic, the diabetic, the hypertensive, the smokers, we’ve made a better path the ultimate cliché. 

For decades, we’ve said, “We need to teach people the principles of weight management,” while forgetting the public health 101 concept of self-efficacy. If they don’t believe they can’t do it, they won’t even try. Weight management and all the rest of the “good ideas” require a series of choices that many people don’t believe they have the wherewithal to undertake, particularly in the face of an increasingly contradictory evidence base that our nagging letters usually fail to acknowledge at all. We’re not having conversations, as occur whenever you chat with your mechanic; we’re lecturing, pretentiously, and everyone’s falling asleep, only to wake up when the EOB appears.

And then we have the “act as if” faction in our ranks. “Big change is the only way it happens!” Yes, big change can happen if/when someone is scared, cornered, bored, self-impatient, angry, sorrowful. But we’re being paid on outcomes. Can we bank on emotion to inspire often short-lived change? And change from what? Our baseline measurement system is hopelessly flawed. Surveys reveal “the right answer.” Focus groups are pay for-a-play. Claims data reflect reimbursement, less often reality. Medical charts reflect adversarial legal incentives and a shortage of time. Even “real dialogues” during outpatient visits vamp to the camera, and social media monitoring finds the outliers with lightning speed. The best evidence of the real you have at your disposal any time is looking at you in the mirror.

Tell Me Why

Our risk assessment tools don’t allow the patient to contribute the facts that s/he knows best. Clinicians use heuristics to document and chart. Most charted histories omit at least one potentially relevant condition, event or genetic predisposition; it was not on a form, and/or it was not discussed. Many patients also reveal “medical history fatigue” which constrains the completeness of any particular history, and patients who have seen their chart notes are also aware that not all the information they provide is captured, apart from the form itself.  

 Since our brains are small, our days short and we’re only human, just as we have to use heuristics (decision shortcuts) to make everyday decisions about which route to take to work or what to order for lunch, we use heuristics to prioritize, consider, make, avoid, deny, delay and simply tune out myriad health issues and choices.  We’ve failed miserably to convey stakes and commitment times in health care, a lack of knowledge that can only constrain optimal decision-making. If an alien from another planet watched TV or went online for a few minutes, who could blame him for thinking that allergies or erectile dysfunction must be the world’s worst plague? 

It's All in the Game

In short, instead of focusing on an illusory “healthy mindset” whose stock doctrines are breathtakingly obvious (don’t touch the hot stove, stop smoking and cut back on Twinkies), we can more productively allocate all the money spent on bland DM pap to upgrading to the decision support available for silk blouses and video games. 

This week’s stiff-upper-lip letter from a major network, syndicated by a major vendor: …”We understand that there are many reasons why you may not want to take your medication…if you have any questions or concerns, we encourage you to contact your doctor or local pharmacy.”  Talk about “information” that will never be [read or] used! Each two-page letter contains two sentences about the particular drug’s rationale and consequences for not taking it; the rest is unadulterated condescension. How recently was any of your communication…interactive? Inquisitive? Conversational? Brief? 

Direct education in decision-making requires not just doling out information, but encouraging its acquisition through other channels, preaching that it is best leveraged in combination and in understanding, not rote. And then, it falls to MCOs, agencies, clinicians, jurisdictions…anyone with skin in the game, to kick our cheerleaders off the field and start playing full contact football. Our opponents include disease, ignorance, fear, denial, poverty, hunger, addiction and crime. And they've got a large lead. 

Stopping on Green

By Laurie Gelb, June 9, 2014

The intersection greets you with a green light, but an accident blocks your lane. You brake instinctively, disregarding an official signal to proceed. Contradictory stimuli define our lives. 

Cut to health care’s adherence doctrine. “Ask your doctor. Take your medication as prescribed.” In what other subject area is it optimal for end-users to follow instructions without having internalized a rationale and therefore knowing when and how to ignore them? If you’re repairing something and the instructions say “use an inch of duck tape” and it takes two, do you stop working or use more tape?  You make a split-second decision in the moment. 

We expect to kludge. Every day, most people take action that is unprecedented for them, slightly different, under new circumstances or seen in a new light. When a wall-mounted sink falls off, most of us can imagine that we should use the main water shutoff even if we’ve never used it before. And if we came to a screeching halt at every choice about food, drink, OTC, rx, exercise, surgery, medical equipment, caregiving, parenting, safety, environmental controls, etc., we couldn’t function. Certainly, some health decisions merit more than a second for consideration, but that doesn’t mean they get it, whereas some receive more consideration than they deserve.

You might ask, why is understanding the rationale for and exceptions to instructions so important, considering that patients can consult a clinician that knows both well? But you know the answer: seldom is the clinician or the network next to patients as they make critical choices to act, avoid, deny, even everyday re-evaluation of instructions about meds, diet, exercise, procedures, lifestyle, rehab.The vast majority of decisions that drive health outcomes are unknown, unseen and uninfluenced by content and service providers. And our constituents, knowing their own context better than anyone while facing their own toppled sinks, must often take what is for them unprecedented action. 

As the green light illustrates, we haven’t abstracted information until we can act optimally when things go wrong, or when conditions differ from a perfect world. The necessity of lifelong learning applies to health care in spades, while the evidence base for preaching “follow” (along with paternalistic clinicians and arsenic cosmetics) reeks of mold.

Memorizing that 2x2=4 doesn’t mean that you understand arithmetic. When a toddler repeats words, she hasn’t yet learned the language. We should want health care choices made by reason, not rote. Since any ongoing regimen, including observation, should be re-evaluated periodically, the notion of “set it and forget it” doesn’t apply. 

Few life choices entail a greater emotional investment than your own and loved ones’ health, while typical messaging dispassionately informs you that following the rules offers the best odds.  Yet the “exceptions” are so ubiquitous as to be cliché. Long-distance runners drop dead of early MIs as grizzled sun-worshippers light up into their 80s.  The “what you get is what you follow” thesis merits growing skepticism as truisms (fats block arteries, calcium strengthens bones, exercise prolongs life) emerge as increasingly complex and non-curvilinear propositions. Moreover, today’s patients face competing risks and lifestyle choices that their ancestors never knew. 

Instead of preaching reliance on catechisms that may or may not apply to a given situation, how about skill-building in decision-making directly, including the rationale for caring at all, transcending health calculators and guidelines. Economic studies show lower costs for the “engaged.” It can’t be an innate urge to obsess about health care that engages them, since hypochondriacs entails higher costs. The truly engaged understand enough to add value to their care.

Let’s not seek “informed consumers” a la the cereal aisle, who can only consume the information and care we provide, but informed patients, caregivers, clinicians, administrators and payors, who can collectively lift all boats. Clinicians can ask better questions to optimize outcomes, while EHR designers find better ways to incorporate the answers. Payors can better align provider and patient incentives. Patients and caregivers can ask better questions as well, while acting optimally on the stimuli life presents. 

Our “best” patients are not necessarily the most compliant with our every word. Instead, they ask realistic questions and probe for the best kludges so they can best apply what they know to what they don’t. Indeed, exploring disease information on one’s own has been associated with greater adherence in the traditional sense, time and again. Our “best customers” and the caregivers that support them understand that intention is not action, there is no free ride in health care and sometimes they must preserve their own health and even lives by stopping on green. 

Last week’s Modern Healthcare piece on the Cleveland Clinic illustrates, hardly for the first time, that even marquee institutions mislay part of the achievable.  By the same token, the lives we can save or improve by helping decision-makers to do their best work are incremental to the followers who leave more to chance.

Next installment: what are quick wins for patient satisfaction [sic], disease management and e-health if/as we rethink the adherence doctrine?

Members from Mars and Their Cars

By Laurie Gelb, December 10, 2012

You wake up one morning and decide gasoline costs are just too high. You want to begin filling your car's gas tank with water, which is, of course, much cheaper. You call your mechanic to find out if this is a good idea. He sadly tells you that it will not work. Chastened, you text your broker to invest in some alternative energy stocks.

What is unlikely about this scenario? Well, first and foremost, you have already internalized the fact that water will not run your car. You don't blame car manufacturers or your mechanic or even the oil producers for this. You don't call them biased and part of the IMF conspiracy. You recognize that what they all say (and consistently) is a fact and you proceed accordingly. In part, this is because you have abstracted at least of the chemical differences between gasoline and water, which will also help you recognize important safety hazards  like not throwing water on certain types of fires.

How much do your members and patients know about the vehicle they occupy 24/7-- their own body?  How much do you know about what they know? How many hopeful or destructive assumptions are they making, seeking information about, and/or simply acting on with no relevant evidence at all? Apart from transactional correspondence like enrollment and EOBs, the common thread within all your health communication can perhaps be described as attempts to drive behavior and choices that safeguard your customers' vehicles, if you will.

Unfortunately, health and disease management are often perceived in terms of being a cheerleader for fresh fruit snacks, when instead patients could most benefit from the calm, factual mechanic who leverages his customer's existing knowledge to improve understanding of the mechanisms that run your car. If you in a moment of extreme forgetfulness or frustration did ever call your mechanic and ask, "Why can't I use water in my gas tank?" he probably wouldn't begin his answer with, "For centuries, cars have been designed to utilize gasoline" or "Are you insane?" He'd probably say, "Carl, I realize it's tempting [empathy] but not only won't it work, it'll destroy your car's engine [clarifying stakes]. If you want to save money, have you thought about buying a car with better mileage or a hybrid? [positive alternatives] What are you driving now, that old Buick? [baselining]" And so on.

The bottom line: any mechanic or service provider...until we get to health care, education and a few other problem areas... that receives frequent customer calls and has a successful practice has likely learned how to communicate reasonably effectively while still driving repeat business and trust. And the auto/energy industries as a whole have largely succeeded in disseminating/reinforcing certain key bits of information on a pre-need basis. So the least sophisticated teenager knows not to pour water into a gasoline-powered engine, complete klutzes like me can put air in a tire or change a light bulb and life goes on.

Yet, with the stakes higher in medicine, people don't always dose analgesics correctly. Why? In part, we have failed to remain calm, neutral information providers in the face of human fear, anger, denial, confusion and vulnerability. Health care is no more the place for cheerleading or fear-mongering than the automotive world. Auto dealers do not post signs saying "Warning! Buying the wrong car could result in a fatal accident!"  even though technically it is true that car integrity/stability/maneuverability varies. Instead, they build a case across media channels, back it up with evidence and build its salience via brands. Which do you think is safer, a Volvo or a Lamborghini?

When a migraine or cerebrovascular event strikes, we want the patient to be responsible with OTC preps and seek care if/as needed. These are both pre-need education stories, but they only get internalized to the extent that they are believable. When they are dogmatic, on the order of "Are you insane?", contradictory, jargon-laden and/or confusing (sound familiar?), they cannot be internalized as early and often fail to drive outcomes.

So before you approve any more educational copy this week, you might ask your mechanic if it makes sense.

DME: A Modest Proposal

By Laurie Gelb, April 18, 2012

What's a "convenience item?"

For most plans, it's anything from the elevation feature of a wheelchair seat to a motorized patient lift to a track to move a shower chair into a traditional stall. In other words, it's features, equipment or supplies that you don't want to reimburse.

The rationale for non-reimbursable DME is most often that in and of itself, the "convenient" add-on or gadget doesn't treat a disorder or isn't essential for ADLs. A power wheelchair's tilt and recline functions, for example, are reimbursed because without them a chair-bound patient is more likely to acquire pressure ulcers, which are costly to treat. But vertical elevation -- that's just patients trying to belly up to bars and kitchen counters, right?

Not only.

Often, the elevation feature is used to prolong the time until a passive lift is necessary for transfers. The same is true of hi/lo beds.

So what?

Watch an assisted standing transfer with a confident patient and assistant. Then watch a lift transfer as the patient dangles from a sling, often scraping body parts against a metal frame and risking already-fragile joints and skin. Which one do you prefer from a cost standpoint?

Taking the whole wheelchair higher may also enable use of a urinal or bedpan (supplies that you don’t pay for, whereas you do pay for catheters + the infections they cause), to make it easier for tall helpers to place a lift sling (or to do pivot transfers with more agile patients), for dressing, feeding and many other purposes. If you think about those specific activities, it’s evident that neither tilt (angled seat) nor recline (angled back) can substitute for elevation in those situations.

Now back to reimbursement. Not only is elevation per se often considered a “convenience, but often it’s not even submitted for reimbursement. Many patients don't even ask for it, even if they are aware it exists, because their DMEs tell them not to bother. Sit-to-stand lifts and chairs are another example of usually-unreimbursable items that yield huge health outcomes for appropriate patients, from avoiding hospital stays for impaction to improved respiratory function.

Much very pricey DME, from mobility to respiratory aids, is never submitted for reimbursement because of time pressure (quicker to buy from the Internet or as self-pay); complexity of the reimbursement process; pressure from a DME to file the easy part; a required preauth wasn't filed in time; DME annual limits and/or specific exclusions.

Is all the DME being bought and sold via the Internet (whether Craigslist or DOTmed) or donated by others good or bad for MCOs? To the extent that it's not reimbursed, you might think that it's just fine. But then turn full circle for the sequelae of obsolete, inappropriate and/or flat-out dangerous equipment and you'll see plenty of potential costs.

Ill-considered Internet purchases and donations aren't the only threat to DME safety; wheelchair-bound/NIV patients who "give up" on or wait forever for unresponsive DME firms who avoid service visits (in part because reimbursement is so uncertain) are practically a cliché.

Visit the homes of the chronically ill, even those comparatively well off and with private coverage, and you'll see fraying slings holding patients whose fall would mean a final hospital stay; rusty equipment with unpredictable steering; BiPAP and even vents being used improperly because no one in the household knows how to titrate them and can't get anyone to help; family members (likely in your network as well) risking severe back injuries because the right equipment for transfers/showering/toileting isn't available.

Some paras and quads "eat like dogs" (often choking in the process) out of bowls because they don't have access to a helper to feed them, and of course wheelchair trays and special utensils aren't covered. Nonetheless, your budget will take a hit at some point, and nutritional status compromised by illness comes under the heading of medical need in most textbooks.

Undeniably, your DME charges for lease months and sales for what you do cover, are way more than patients can pay on the Internet or elsewhere. And this goes back to inflated manufacturer pricing, often in expectation of contracted discounts but also in some cases, simple greed.

The root cause: contracted prices and often suboptimal product quality/selection deplete your DME budget to the point that you can't see a business case for the simple items that would pay for themselves and support your case for "caring" as well. Moreover, DME caps basically tell patients to go anywhere but the traditional system to access equipment. How predictable are the outcomes of back alley DME acquisition?

To put it another way, how much do you know about Helen Jones' fall because the eight-year-old walker passed on from her great-aunt wasn't gripping the sidewalk any longer? You paid for her hospital stay and rehab for a broken hip, and she may need home health on discharge. She didn't know that her walker needed new feet (nor would she have known where to get them), because she has low vision and no one she knows has any familiarity with checking walker feet.

No one teaches us about DME; the provider/plan Web sites so thick with rich media ignore it, so the major sources of information on DME are patient forums and YouTube videos, neither of which Mrs. Jones, 82, is likely to access.

The reciprocal of DME providers’ natural desire to remain profitable, is patients who don't know the system, who don't know when/how to use network benefits and when/how not to; how to access help with equipment that they need to have, or that doesn't work how they need it to; and a system that seems massively disinterested in the change that everyone "agrees" is needed. We obsess about medication errors that leveraging IT and FMEA can fix, but don't touch a larger, increasingly relevant (checked the age trend of your membership lately?) issue.

Beyond medical costs, MCOs incur the cost of fraud. I’ve seen recent drastically upcoded invoices to MCOs from DMEs that patients and family members, exhausted from the calls needed to obtain a facsimile of necessary equipment, not to mention the burden of care, didn't even perceive, or when they did perceive them, didn't blink. Why should they care if the MCO pays more than its contract stipulates, for something they never received, when they perceive that the MCO is depriving them of needed equipment and help?

From the other side, I've seen invoices with incorrect patient names, provider names, equipment codes and diagnosis mismatches sail through (as with home health, but that's another story). The DME claims processing burden is great on the payor side as well. The complexity of regulations for the sake of cost control are only getting worse.

The US managed care maze has also kept many highly-rated European manufacturers out of the US market entirely, except for authorized facility-only distributors, who don’t want the hassle of selling to home care.

Does US access to European products matter? Well, only if you’d like your members to have access to options like wool and fleece lining for slings to protect delicate skin; smaller patient electric lifts and tracks to use in apartments, as opposed to relatives’ [insured by you?] backs; freestanding track systems to reduce mobile lift risk, better repositioning aids, etc. Oh, but wait --none of these are usually covered items, anyway. Well, therein lies part of the problem.

Now imagine that DME was reimbursed like an office visit or injection. Provider in network? Check. Correct coding? Check. Eligible patient? Check. No duplication within six months (just as we don't reimburse two fills for the same med if dose is available or two right leg amputations)? Check. Not experimental? Check. Medical/ADL use (like, not a scooter flag or strobe light)? Check. Then you process the claim.

• How much would you lose?
• How much would you and patients gain?
• How much admin cost would you save?

Sure, you'd cap coverage at one power chair per interval, and other obvious constraints. But a track to get quads into a shower, yes, you'd pay (paid for any skin infections or UTIs lately?). Or an elevator on a power chair. Or a new sling to replace the one that’s frayed past safety.

And on this planet, reputable Internet suppliers could be in-network, too. Yes, certain manufacturers would be upset by this. But, down the road, how long can you continue the game? We’re not in Kansas any more.

Could you pilot a low-complexity DME program for certain dx? Patients at risk and/or high utilizers? Maybe in conjunction with existing disease management? Of course you could. Medicare, Medicaid or private plan, everyone’s feeling the pain (quite literally).

And why would you make the effort? Because the next patient held hostage to inadequate equipment and support may be someone you know.

Very Wired Meets Very Tired

By Laurie Gelb, January 24, 2012

We recently moved to a new city, so I set us up with docs at a Very Wired Hospital (we'll call it VWH) that boasts a fully integrated health system and enterprise EHR. My husband sees many specialists, so we've made several visits there already. I was excited that he would finally have a single record.

The yield to date on my attempt at integration: six paper vintage 1980's medical history forms and one woefully inadequate oral interview. One doc's explanation for the manilla madness was "It's for billing [so we can charge for appropriate complexity]." My contributions to these mostly took the form of "see attached" scribbles, referring to my own far superior pt summary sheet, tailored to each specialty...hm, why not specialty-specific intake forms? In the outcomes age, is that really so radical?

I did finally see a specialty-specific form from podiatry. It arrived via snail mail, barely in time-- "We can't use e-mail [to send the form] because it could be hacked." Somehow, though, sending us e-mails about billing detail is OK. It evidently hasn't occurred to VWH yet that PDF forms can be hosted on Web servers.

I could go on and on about VWH (the wall-to-wall paper at every elevator bank is staggering, the appointment and patient tracking process archaic, and yet its reputation allows stratospheric list pricing to plans), but let's focus on EMRs and payor initiatives. It's probably pretty evident that when its flagship providers lag in HIT, no network can realize optimal value from performance management.

BTW, the mail order debacle I wrote about a few months ago culminated in a pharmacy customer service e-mail asking my husband to reply to a general mailbox with his name, DOB, phone and all the incorrect rx he saw on his Web record. We politely declined, for obvious reasons. Somehow the duplication was resolved without this step.

Unfortunately, I very soon thereafter invested 2 weeks of calls in a routine refill that was repeatedly rejected [by the all-knowing, all-seeing adjudication app] for no reason that anyone at the plan, PBM, mail or retail pharmacy could pinpoint. Finally, I was put through to someone at the PBM who was able to determine that the latest PA had no refills appended instead of the 3 that it should have. Do you think that was put on anyone's future checklist? Let me know if the Easter Bunny stops by.

So how does a provider's EMR, however implemented, benefit payors? There could be lower processing costs secondary to more accessible documentation/claims denial support. The EMR should support health outcomes research, disease management, cost management, UR/QA, contracting...so many possibilities.

Many payor networks are building/upgrading their own data warehouses, and, increasingly, aggregating them with other networks.  Plans and providers are sharing via HIEs, pilot projects, academic research and more. In some geographies, public sector HIEs are being superseded by private efforts. Usability on the local level increasingly benefits from...wait for it...local oversight.

In any geography, though, we're drowning in a sea of input screens and datasets that don't reflect real people, workflow or medicine. Transaction and opportunity costs are soaring when you consider the dollars flying out the door due to long and no fixes for often undetected errors, like my husband's pharmacy döppelganger.

What can we control out of all this? Process! 2012 can be the year of common sense, when we give up tweaks to a patchwork, hands-off patient/member/customer flow in favor of [cliché alert] collaboration with those on the front lines (docs, nurses, physician extenders, call center reps, admitting reps, PBX operators and anyone with a finger on the flow) to image and set the break rather than cover it with a cast and good wishes.

Mystery-shop your PBM, clinics, DM vendors, hospitals, plans, call centers, anyone who touches those who pay your salary. Assign the same task to anyone who says, "There's just not that much we can do." If that doesn't work, a few uninterrupted call center hours just might do the trick. Rather than rearrange the deck chairs, as recent tragedy reminds us anew, some people just don't work out in their jobs.

I = Innovation

By Laurie Gelb, October 17, 2011

If you thought the 80's were "the Me Decade," consider these the "Me, Myself & I" years. Introspection is in, singly or in groups (witness the Occupy Wall St. Movement).

What does this have to do with managed care? Depends on who's doing the managing (or thinks they are).

A top tier disease management vendor's intake form currently includes the following question:

Do you currently have any of the following conditions:

[list of 12]

where the list includes cancer, pregnancy, poor circulation, heart attack and stroke, among others, in seemingly random order.

So just as they're signing up for a program that invites unknown strangers into their care, the first thing that [mostly seriously ill, some terminal] patients learn about their disease manager-to-be is that it's insensitive to the distinctions between acute and chronic, and between clinical and colloquial dx. There is no clue as to what, if anything, a given patient should write in the "other specify" field.

What exactly would "currently having" a heart attack or stroke mean? That you should call 911, of course. So the first thing you've learned is not to take DM communication literally. It's only a short step to take it for a joke, like most of your mail.

Nor does this invitation reminder letter explicitly mention that program signup is optional, not mandatory. In fact, it finesses the difference "introducing the program...part of your health benefits coverage..." If I were the plan sponsor's risk manager, I'd feel a bit squishy.

So the promise on the accompanying letter that "Your health is important to us" (appearing once on each side of the paper) is ringing a bit hollow, no? And our introspective, seeking-the-good member is blatantly being treated like a number, a bundle of [poorly] specified conditions, from intervention day one.

There isn't a simple declarative, personal, conversational sentence in this enrollment package. The signature is in cursive typewriter font, in the proudest tradition of 1970. I've signed thousands of letters to document I cared enough about someone's behavior to wield a pen my own self.  (And yes, there are scanners, too.)

So as you expend your resources and your members' time, goodwill and wellbeing on DM, consider that for every condition listed in a vendor's portfolio, there is a SNF, a clinic, a university program, an industry pilot, a health system, a single clinician whose DM is state-of-the-art. I'm not talking about 7-8 figure CER, AHRQ style, but the one-patient-at-a-time evidence base that can blossom into something new and improved.

For example, one psychologist (whom I'm proud to say taught me Psych101 eons ago) directs translational research into innovative Alzheimer's care that has been successful in several facilities. To what extent would moving the needle on AD progression and sequelae in any setting benefit your organization and/or anyone you care about?

The corollary question is whether you have appropriate resources allocated to find and leverage this essential intellectual capital. You know that incents -- from money to recognition -- can move the needle when little else can (and let's not pretend the wormy apples of P4P or buy-me pharma grants are the same thing).  If and when you spark something real, that helps create competitive advantage that in turn adds to brand and ally equity.

Did you notice Wendy Schmidt's contest to find better tech to clean up oil spills? The winning team tripled the "industry standard." When they asked the contestants why they hadn't tried these new approaches before, the responses boiled down to, "No one else [e.g. oil company clients] cared. Everyone felt they were doing OK."

What's in your MCO's wallet? Maybe the down payment on improved outcomes for millions.  All it takes is an I for innovation.

Top 5 reasons that members ignore disease management messaging

By Laurie Gelb, October 10, 2011

1.  It's inaccurate and/or inapplicable. "Our records indicate that you have not filled a prescription for ... [recently sent to pt continuously on drug for 8Y w/ no sampling] Reverse-gender content is common. 

Variable data printing is a wonderful thing! Information can be stratified by database variables such as gender, age, zip, fills, dx and more. And it's much better to present the information standing free than the usually-unnecessary but still Orwellian "our records [about you]."

If VDP won't work, segregate stratified info and ID it with a revealing heading, so members can skip past it easily. A general newsletter directed toward all household members can do this, although it's time to question the ROI of this approach. PR, podcasts, videos, etc. should be target-specific and clearly titled, for the same reason. 

2.  It's wordy. Most Americans do not read a daily newspaper, nor read extensively in their daily activities. Data suggest the reading ability and habits of even college grads have declined. A full-page, single-spaced letter is seldom digested in full, let alone acted on. 

Use active verbs and state the facts, using gradual reveals even in print.  "For recipes and tips, call 800 VEG 4NOW or go to veg4now.com." Footnote or link the legalities rather than filling the page body.

3.  It's condescending. "You may feel that eating five servings of vegetables is too difficult, but did you know that a 6 oz glass of tomato juice is one full serving?"

Best practice: a sidebar or callout with examples of popular, little-known or tasty veg choices, without airing your assumptions about people you've never met. 

Stock photos of happy, multiracial people clusters, whether in print or on line, are a similar turnoff. Perfect people can't get sick. Picture something from real life that matters (examples in our next installment). 

4.  It's impersonal. "Some patients may..." 

Best practice: Use "you" if/when it makes sense. "You may feel dizzy, nauseated and even vomit after your first dose of an x drug."

5.  It's contradictory. Messaging about the high sodium in tomato juice has appeared adjacent to praise for vegetables and their juices. Fruit juice often suffers from the same fate. 

Choose your core objectives based on member and epi data and follow through. One well-supported message makes more impact than four throwdowns. And "lower-sodium" can modify every mention of tomato juice. As for fruit juices, recent evidence is more positive, apart from drug interactions to avoid, so why not give them their due?

-------

Each of these reasons is a way to ice the dialogue before it begins. Does the car salesman approach you and say "You look like a luxury buyer" or "I'll bet you can barely afford a beater"? No, she generally asks what you have in mind, because that's her quickest path to a sale. The more interaction, the more specific the stimuli you can present. Content that's personalized, urgent, relevant and engaging (PURE) drives behavioral change.

Keeping It Clean

By Laurie Gelb, July 7, 2011

Recently I became aware that my husband’s national pharmacy record contains not only his own data, but that of another patient.

The root cause: the other patient, in another state, with a different payor, was never asked to confirm his address when he picked up his meds. He has the same DOB, first and last name as my husband, though their middle initials, and, of course addresses, are different. Naturally, a "boomer" generation yields birth date clusters. Had anyone ever asked him one simple question at each pickup, “What is your address?” and compared it with the primary address on screen, I wouldn't be writing this.

Between the pharmacy that repeatedly pulled up the wrong record, me, the health plan, the Web team and the pharmacy’s HQ, there have been about 20 phone calls + a series of logins to investigate and re-separate the records of these two patients. I have participated in about half of those. I was told that “one other case” has occurred in memory, meaning probably thousands as yet undetected or unresolved.

A month since I first notified the pharmacy of the issue, the incorrect data are still mingled, though not for lack of trying. As a last resort, my husband’s record has been deleted and re-created, so far with two sets of login credentials for the new record, neither of which works.

Now the question for your EHR vendor: what automated internal validity checks are run on the data populating the record associated with a single MR number, other than obvious single-field validations like date formats? We've already seen the error rate in e-Rx. An EHR selling point is medication alerts. We would expect a pharmacy record to do as well, no? However,  for months now, no edits or alerts have popped up, though the combination of my husband and his counterpart results in a patient who has been on two macrolides, a steroid, warfarin, rx NSAID, ED drug, opiate and four antihypertensives, among other things.

So to your knowledge, do clinicians entering EHR data routinely verify anything other than name? Or do they simply presume the applicability of a paper chart that someone else pulled, or the EHR that they just opened? We certainly can’t tell ourselves that they would always spot internal inconsistencies.

No doubt accidental merges have already occurred in EHRs. And clearly the structure underlying most EHRs (if not all) would have a difficult time backing out a large quantity of data and re-associating it with a second identifier, until we really standardize import/export formats. 
And is it the clinician's job to reassign data into the appropriate records?

Certainly there are HIPAA implications as accounting of disclosures becomes more robust. With an increasingly cloud-based environment but no über-record, contradictory information will find its way into multiple databases, with little impetus or procedure for reconciliation.  I don't see the words “cleaning” or “data validation” anywhere in the PCAST HIT report, or in too many near-term HIT agendas. 

My pharmacy woes don't bode well for the far more complex EHR. As it happens, I've seen errors in every personally-verifiable EHR I've ever skimmed, including at sites used as Federal models. And if I weren’t ordering refills via mail order, I would never have seen the merge, with unforeseeable consequences.

For example, my husband wears a MedicAlert bracelet, linked to an accurate drug list. In an ER, which list would a physician believe: the one from a pharmacy, that a fully functional EHR will link in, or the “self-reported” one? But the former would be dangerously misleading, and, in fact, would also call the list of conditions on my husband’s wrist and his PHR into question. Then what?

Probability of 100% human verification in the next decade? Zero, unless you design systems that require it. Of course, there are many solutions for positive ID, from biometrics to unique credentials. All require time and money. Whose?

In the zero payment for errors mindset, as EHRs become the go-to reference, who does the cleanup and how? And why -- what are the incentives for doing so? The answers to these questions may influence your cost trend over the next few years than we yet know.

Coming Down from Cyberchondria, part II

By Laurie Gelb, June 7, 2011

Actual hyperchondria, by definition, entails inappropriate self-dx and/or care-seeking (fueled by what Microsoft’s paper calls “the escalation of medical concerns”).

So what escalates concerns, whether you’re buying a car or selecting a health plan? Feeling like you’re being played by self-interested advisors. Being unable to get “a straight answer.”  Reading legal disclaimers instead of declarative sentences that apply to your situation. Looking at your organization’s health content, can you honestly deny any reasons for user frustration?

What we can foster via the social Web is appropriate self-dx and care-seeking. Let’s do our best not to conflate the two.

The danger in making any important choice has always been relying on any single information source, from your best friend in the cave to a medicine show huckster – or, today, your physician or a blog post.

Recent adherence literature gives us more reason to believe what common sense reveals, that patients who believe they receive all their disease information from physicians are less compliant. If you can’t internalize your health status by and for yourself, you can’t act on it appropriately.

Two decades past the launch of the health Web, many of its content providers still occupy one of two counterproductive positions:

1. Displays polite aloofness, with “keeping our distance” copy, stock imagery and very little to address anyone’s information gap. Syndicated, bland content meets the barest of localized/personalized functionality.
2. Genially hosts “”whatever people want to talk about.” Want to believe that whatever you have, it’s really Lyme disease? Blame your parents for all your allergies? Your headaches on your soda habit? There’s a board for you. Hosts chat boards/rooms/live chats on which spam posts, obsession with “censorship” and a few self-appointed experts constantly duel for position.

The net effect of Model 1, where people with questions get general platitudes, is to reroute them to [the more appealing] Model 2, where reason is often drowned out by the “squeaky wheels” with personal agendas other than the truth. Dr. Oz’ gradual descent from evidence-based innovation to mystical conventional medicine critic is an example, sadly enough.

How constructive is either of these models? Is there an ROI for doing anything about it? Let Dr. Oz answer from his April 26 show:

“Do drugs and surgery work? Yeah, they often work pretty well, and they have side effects... But the difference for me is a bow and arrow, a stealth approach to getting exactly what you want to get that works in you versus the ballistic missile approach that we have so often become comfortable with.”

MCOs: do you want to pay in goodwill or dollars for the implementation and/or consequences of the “stealth approach” Dr. Oz advocates here, which has included everything from reiki to a delayed immunization schedule? Or do you want to invest in worthwhile personalization of interventions with better track records – for you and members?

The fork in the road lies before you – choose wisely!

Coming Down from Cyberchondria, part I

By Laurie Gelb, June 1, 2011

In 1998, Harris Interactive came up with the above term to describe health Web information-seeking, and has been popularizing the phenomenon ever since. HI’s official definition states that this dread disease applies to hypochondriacs for whom the Web contains “too much information,” i.e. they become convinced from Googling “headache” that they have a brain tumor.

Might someone who honestly convinces herself, with or without the Internet’s help, that every headache is a tumor, demonstrate an impaired belief system in other respects? But it’s trendy to blame the Net for neuroses, just as we once convinced ourselves that allowing women to read would only breed or worsen hysteria.

According to many reports, it’s a closed circle. If you research symptoms on line, you’re diagnosing yourself. And if you’re diagnosing yourself, you’re a…no, I can’t say it.

Predictably, Microsoft published a white paper on “cyberchondria” in 2009 and recently it made TV news again as a new phenomenon. What’s the next hot ticket – hula hoops?  

So it’s OK to self-diagnose your dishwasher’s or car’s ills on line, and seek appropriate care, but not your body, because…wait a minute, what do I know about cars? Well, I’ve mastered filling up at the gas pump, and my skills at clearing a fogged windshield are unmatched. But neglecting my car can’t kill anybody, right? Oh, hold on…

Can we draw a line that includes reasonable presumptive dx? When your members think they have a simple headache that’s not life-threatening, most of them pop two NSAID tabs. That’s totally appropriate self care. Do you want patients to rush to their docs for simple headaches so you won’t judge them as cyberchondriacs? Or because you just did?

Self-diagnosis and care, to a point, relieve strain on our overcrowded system, produce cost-effective outcomes and improve health status. We spend a lot of money on decision support to help patients understand that point –and rightly so.

In 2011, asserting that the Web fuels hypochondria is akin to lambasting the existence of motor vehicles for encouraging speeders. Like it or not, the health Web is not the pool room south of downtown that respectable people shun. It is the commons of your world. If you want another planet, I hear Mars is lovely in the spring.

We miss opportunities to play a win/win role in millions of health-related explorations that can and should improve care and outcomes – and on which any rational sufferer will embark -- when we glibly apply the language of disease and switch the burden of proving “appropriate” exploration to the user – while at the same time preaching minimalist self-care. If you’re concerned with the reliability of what’s out there for member consumption,  don’t shoot the messenger, improve the landscape.

Researching the Real

By Laurie Gelb, April 25, 2011

While the rest of the social Web is constantly redesigning itself based on user context and needs, the health Web lags. Personalization, filtering, sorting, non-linear exploration and other “Web-standard” capabilities on sites like Amazon is lacking as yet.

Why?

One possible reason is that surveys of health Web users commonly manifest a “how much” obsession, neglecting the who, when, where, what, how and why. This creates misleading constructs for action, which we will continue to explore in future posts.

Let’s examine on just one question that Pew asks [not picking on Pew, just that its survey is widely quoted]:

Q32 Overall, who do you think is more helpful when you need... [INSERT FIRST ITEM] – health professionals like doctors and nurses, OR other sources, such as fellow patients, friends and family?  And who is more helpful when you need... [INSERT NEXT ITEM; RANDOMIZE]?  AS NECESSARY: Professional sources like doctors and nurses, OR other sources, such as such as fellow patients, friends and family?  

a. An accurate medical diagnosis

b. Emotional support in dealing with a health issue

c. Practical advice for coping with day-to-day health situations 

d. Information about alternative treatments

e. Information about prescription drugs

f. A quick remedy for an everyday health issue

g. A recommendation for a doctor or specialist 

h. A recommendation for a hospital or other medical facility

1 Professional sources

2 Other sources

3 (VOL) Both equally

8 (DO NOT READ) Don’t know

9 (DO NOT READ) Refused

Beyond the ambiguity ("day to day health situation") and heterogeneity in some of these question items (you might have a different process for researching someone/ somewhere to remove an ingrown toenail vs. a CABG), we can summarize the problem here with two words: false dichotomy. 

How actionable can these answers be, even when tracked over time? The answer items are all binary, they relate to categories rather than actual resources and the unaided “both equally” option is a copout/source of social bias rather than a reality. 

What Pew could be asking:           

Have you or anyone whom you help make health decisions, such as a family member, ever faced  [specific situation]?

[if yes]

How recently did you or someone you care for face [specific situation]?

These decisions never stop [they don't, for someone w/ chronic illness/injury, often neglected in these surveys but also often your high utilizers]

Dealing with that now

Within the last month

A month or two ago

A few months ago

About a year ago

More than a year ago

When situation X most recently arose, from which of the following did you receive information before making a final decision? Please check all that apply. [randomize order w/ selected anchors]

• Your or the patient's physician
• A staff member in that physician's office or clinic
• A brochure or video in a physician's office or clinic
• The Internet
• A magazine or newsletter
• TV or radio program
• Friend or family member who works in health care
• Friend or family member who does not work in health care
• Other (please specify)

Often, we then zoom in on that recent situation and dissect how well the search process (or lack thereof) worked out in terms of needs vs. outcomes.

What else can we ask Web users, that we don’t know the answers to, that we can actually use to design stronger decision support?  An example…when we look at choices that are being made NOW – which we will need to branch into – we can find out:

• Who helps whom (for example, what percentage of the sample is currently influencing (1) health decisions on a child’s behalf (2) health decisions on an adult’s behalf other than themselves. This and the next item will aid subgroup analysis/tracking.
• Is the current decision process around self-care or accepting a professional’s recommendation?
• Where/how do they think they need to research, if anything before making or accepting a choice?
• If the decision process is ending, is it by choice or necessity?
• How well do they think they are succeeding in getting what they need? This is categorical like in real life -- not at all to it's done.
• What else do they need to know, that they do not yet? This can be structured, open-ended or both.
• What are the barriers to getting what they think they need? (e.g. not enough time, not sure how to search, overwhelmed with info, didn't have long enough chat w/ doc, not sure if insurance will cover…)

Does this sound really nitpicking? It’s really no worse than the research process we go through for cereal or paint – just that instead of keying on the purchase process, we are keying on information-seeking. User-driven branching and filtering moves the respondent through quickly. BUT – we should never assume prework. If I walk into CVS like a robot and walk out with my default OTC analgesic, you should know that as well.

It's always a worthy goal to keep your information specific, your verbs active and your sentences short. If you wouldn't say it, apart from legal disclaimers, why write it? 

Life in the Web: What Page Are You On? (part II)

By Laurie Gelb, April 8, 2011

In our last installment, a typically-networked physician was driven to distraction by his patients’ reliance on the Internet for personalized health advice, and an MCO director struggled to understand why her network’s disease management materials were failing to influence member behavior.

Both might benefit from a better understanding of how, when, where and why members of the lay public utilize online medical resources. These questions have seemingly been the subject of much research. However, surveys have primarily focused on scope -- “how much”—rather than the deconstruction of how and why.

To put the question another way, what does the social Web (an umbrella term for social networks/the Web/mobile media) offer that a physician’s appointment or disease management brochure doesn’t?

Unlimited time and bandwidth. The ability to filter and search, with the hope of greater personalization. Diverse opinions. Colorful, unequivocal language. Identification of and interaction with trusted resources on demand 24/7 from any Internet-connected device. Hyperlinks to explore more quickly and less linearly. Ability to go from structured resources like encyclopedias to Facebook and back again. Social bookmarking that eliminates the need to “start from scratch.” If you have two more hours, we can keep going.

To what extent has research into health Web use helped us to better utilize the physician’s medical expertise and communication skills to design better health information portals and tools? Apply the MCO director’s knowledge of demography, utilization and trends?

Not so much.

And to what extent are social Web-savvy content developers in charge of creating health advice on the Net, self-help tools or member disease management communiqués?

Not so much.

Now, going back to our Net-savvy physician – how much money has gone into e-prescribing, clinical tools, formulary references that he uses every day…as compared with the resources that a patient would use? How much connectivity is there between MedicAlert or  Microsoft HealthVault and the answers patients get to their health questions on the Net?

Not so much.

In short, content and tool developers have pretty much failed to bridge the gaps between what their masters (us) want to convey and where their so-called audiences want to be. Is it surprising that people don’t particularly want to be “herded” into a maze for which they write none of the rules, that they would rather be setting the terms of engagement?

Yes, the process of accessing information, care and reimbursement for said care is currently perceived as adversarial. And battles lines are being drawn…from the receptionist’s window and business office to your Web site and shiny new brochures. And no one else gives a flip about your communication strategy. Most agendas read, “Pay less, get more and never have to say ‘I’m sorry.’”

So now what? If you want to play to win (i.e. to improve the odds that someone receives optimal care), you need to gather and then use some intel, some real insights, not the pablum of yesteryear. We’ll discuss how to do this, next time.

Life in the Web: What Page Are You On? (part I)

By Laurie Gelb, February 15, 2011

A physician turns to a nurse between patients and snorts contemptuously. "Dr. Google convinced my last patient that she should stop taking her beta blocker because she might get dizzy. Why do these people believe everything on the Net and nothing I tell them?"

"Maybe because the Net isn't you," the nurse half-jokes.

She brushes past him to place some educational brochures (which include a list of URLs for patients to visit) into the waiting room rack, as he double-checks a digital database for drug interactions  while going into the sample closet for a waiting patient. 

When he returns to the exam room with a sample pack, the patient is tapping her iPhone. She says, "Should I be taking that since there's a precaution for people my age?"

As the physician fumes inwardly, he explains, "Your kidney and liver function are normal, and you're in excellent health overall. So I think on balance, this is the best choice." 

She arches a skeptical eyebrow, then opens an e-mail window to remind herself to ask the same question of her brother, a podiatrist in another state.

Meanwhile, an MCO executive is wincing at dismal performance metrics for her network's latest disease management initiative. The letters and brochures looked so pretty and inspiring in the shipping boxes, but failed to produce results. Follow-up calls found that they barely generated awareness, let alone action. 

She makes a note to consider a new vendor for next quarter's program, with a reduced budget. Her thoughts wander to text messaging and e-mails, which might be more effective. She recalls that an agency contact said something last week about a Twitter feed and puts that on the next meeting's agenda.

Shaking her head at the futility of it all, she reaches for the latest cost trend reports and considers another espresso.

--to be continued---

The Truth Is Out There –Are You?

by Laurie Gelb, July 28, 2010

Health care surveys still ask “analog questions” in a digital world, limiting the impact of disease management, marketing initiatives and even transactional communiqués like EOBs. Besides evoking “socially acceptable” responses (who wouldn’t want to be healthily skeptical and savvy, unless you wanted to be stubborn and oppositional?), surveys in 2010 often still rest on “service as product” and “product = attribute bundle” paradigms, which apply poorly to medicine.

As interventions move into the social and mobile media, the risk of pouring more money and brand equity into misguided action increases. In fact, adding to “stimulus overload” can hasten patient and caregiver denial, apathy, fatalism, overkill – and it’s ever-easier to tell everyone in their social networks how and why they got to that point.

Health care realities that are often overlooked by forced choice (e.g. A vs. B scenarios, point allocations, rankings) and attribute-based questions include:

• N=1. No two patients have exactly the same personal/family histories and environments. Yet we ask everyone the same questions. Why? We have computers now so we can personalize questionnaires in real time, the same way we say we want to personalize interventions.

• Heuristics – shortcuts – are more necessary to making health choices than any other kind. You may be able to consider all the possible routes to work in the morning, but you can’t consider – ever—all the supplements you could be taking.

• Opportunities to re-evaluate choices like daily dosing, glucose monitoring, diet, exercise are infinite– unlike  the dishwasher that you’re basically stuck with for a few years

• Instability/unpredictability of product “attributes” – we don’t all define “effectiveness” the same way, yet we all know what “four bedrooms” means, and the drug you took with no issues yesterday can land you in ER today.

• Inability to create what everyone knows would be the ideal product (want a vitamin water that melts solid tumors?), unlike, say, the cereal industry (Apple Jacks with 12g sugar/serving)

• No single “health personality.” For me, popping a naproxen is nothing; for my son, it’s agonizing. Yet he’s blasé enough to have visited a chiro, whereas I never will. So if you ask the two of us the same questions about beliefs and recent care, you’ll miss why our choices differ.

• In for a penny, in for a pound. A plumber can unclog the kitchen sink with no effect on the bathroom, whereas treatment focused on one system often adversely affects another. And when weighing the zero-sum game of deductibles, co-pays and OOP limits, it’s easy to feel that there are no good choices.

By replacing traditional questionnaires with decision-centered designs in which no two respondents may see exactly the same questions, we can understand and track what our audiences believe they know and the extent to which these beliefs are associated with their choices. With dynamic surveys, domains, measures and thresholds are not pre-established but are provided to us by respondents (with whom we are conversing, not forcing them to abstract something that is very real). This on-the-ground data enables us to better address knowledge gaps, evolving expectations, epidemiology/behavior, barriers to action and more – often with interactive tools. Moreover, patient, clinician and payor thresholds often differ significantly, creating misaligned incentives. When we understand how these differ, we can realign programs for “win/win/win” scenarios that optimize health outcomes.

Telling the Whole Truth

by Laurie Gelb, June 17, 2009

Watching the back-and-forth regarding “health care reform” calls to mind many untold truths – that it may not be too late to tell.

AARP’s monthly magazine has an “8 Myths About Health Care Reform” feature in the current issue that should not go unchallenged by any patient, let alone health professional. This “myth list” in fact recapitulates several red herrings propagated these days by many legislators, media outlets and influencers.

So, whatever your personal or professional position, here are a few talking points that you might consider attempting to insert into the debate before the dotted line is signed.

AARP’s “myth”	The reality
Those with insurance won’t benefit	AARP argues that new legislation will provide a safety net for those destined to lose their coverage in the future. “Just because you have health insurance today doesn’t mean you’ll have it tomorrow,” the author warns. Well, yes, that’s true, because many employers, associations and trade groups, many of whom cover people on the margins, are going to use a public plan option as an excuse to drop or limit access to their own plans. Thus, this is a self-canceling argument that skirts the stated objective of universal coverage (not to mention the somewhat paltry incremental 16M Americans gaining coverage estimated by the CBO this week).
Boomers will bankrupt Medicare	AARP points to costly technology (“think MRIs and CT scans”) and over-treatment as primary cost drivers of the current trend. Unaddressed is the difference between a scan that enables an early diagnosis and an improved prognosis, vs. a study that is not indicated, or effective vs. ineffective treatment. That private payors have been more active than Uncle Sam in identifying and addressing inappropriate care is never stated. However, it would also be helpful for payors to acknowledge that they have often ignored myriad opportunities to improve the aggregate efficacy of self care, and commit to greater action in the future (such as the decision support programs discussed in other posts).
Reform will cost us more	AARP makes the analogy between health reform and the upfront cost of an Energy Star appliance, reassuring its readers that by 2020, reform “could save us approximately $3 trillion.” Unstated is just how this might occur, though indeed you could wake up tomorrow as a British monarch. But we need to discuss the concept of annual budgets, something that most Americans understand, and the fact that Energy Star savings are quantifiable in a way that vague promises/threats about HIT, CER and (more) de facto rationing are not. Then we can begin talking about low-hanging fruit – treatments of unquestioned efficacy for the vast majority of a given patient population, to which access and adherence are suboptimal. At the same time,, fully involving privacy advocates and community clinicians, we can talk about standardizing the EHR and getting it to the point of care in a way that actually saves everyone time – and saves lives.
My access to quality care will decline	“Just because you have access to lots of doctors who prescribe lots of treatments doesn’t mean you’re getting good care,” counsels AARP. This sly truism in no way addresses the issue at hand, which is the extent to which public sector plans already inhibit access to care, if only because physicians withdraw from their networks every month. The time that docs and their staffs spend trying to eke (substandard) reimbursement from public plans is somehow omitted from this answer (and the entire AARP policy agenda). And, this week, MedPAC raised the spectre of denying coverage for “new drugs” unless they are “proven” superior to “old drugs” (not clear if safety or tolerability or convenience of dosing will count—it rarely does in the health care hells the politicians are claiming not to emulate), not to mention linking “value” of therapy to reimbursement – and AARP can continue pretending that the reform movement is “hands off” clinical and personal choice? Take a trip across the border or the ocean and see. [I’ve been in UK hospitals.] Again, AARP is only disingenuous to avoid discussion of what a clinical decision is, vs. what a political funding mechanism is.
I won’t be able to visit my favorite doc	Once again, the fact that many clinicians and facilities deny, limit or delay encounters with Medicare and Medicaid patients is nowhere stated. Instead, there’s the classic red herring reassuring readers that “clinical effectiveness research” is a good thing. Indeed, but how does that relate to physician access? It’s as if AARP shuffled the cards with the questions and threw them on top of a few “politically correct” answers.
ERs provide the uninsured with good care	AARP correctly points out an ER can’t be a medical home, and that the insured pay for part of the ER visits that result from uninsurance. But this is a straw man myth—no one is seriously suggesting that ERs substitute for insurance. The real question is, how do you get all these chronically ill people in need of monitoring access to primary care, when PCPs are already in short supply and becoming more scarce as you read this? How do you support better health decision-making across the board? How do you help a clinician at 2 am make a quick, accurate connection between the patient presenting to him and the same person who presented 500 miles away a month ago?
We can’t afford to tackle this now	AARP notes that people are delaying care and not filling rx, suggesting that reform is urgent. Indeed, no one questions that costs are soaring, nor that the current unfree unmarket is more like a bazaar. However, creating a sense of urgency doesn’t serve reformers’ objectives when basic questions like financing of the plan, contribution to the growing deficit and how clinicians and patients will be served are overlooked in the name of that urgency.
We’ll end up with socialized medicine	Quoting a RWJ researcher, AARP concludes its feature with the assurance that “we will come up with a uniquely American solution…a mixed public and private solution.” Well, most “single payor” countries count as a “mixed” solution, too, if you consider that many citizens in such countries, where possible, purchase additional private coverage because the public plans are so inadequate. As reassurance, this isn’t exactly warm and fuzzy, especially given the shortcomings of both our private and public plans. Mix them together, and you get the equivalent of goulash over jello. Moreover, AARP’s soothing words to the contrary, the signals out of Washington speak to a new willingness to consider a wide array of new controls over individual actions, from “Any Unwilling Provider” mandates to limits on therapy. “Socialized” is a buzzword, but health freedom is not. If the managed care sector doesn’t speak out – honestly and completely – about what’s good and bad about the current system, and promote proposals that address the real issue – the right person receiving the right treatment at the right time for the right duration – we may all be a good deal worse off – and poorer – a year from now.

Misdirection Can Be Fatal

by Laurie Gelb, March 17, 2009

ETHEX has initiated a retail-level recall of tablets found after the fact to have been manufactured in non-cGMP conditions. A Blues plan finally sent out a one-page masterpiece of misdirection, one that I'm confident was replicated similarly nationwide, to patients for whom one of the affected scripts was reimbursed. Unfortunately, in this case, misdirection could potentially be fatal, so a communication like this is worth delving into.

First, the letter is dated February 2009, though received in March. ETHEX PR is dated Jan. 28, so there's been a communication delay.

The salutation, despite the fact that these letters are obviously databased from PBM records, is the time-honored "Dear Valued Member." So what would cue a member that this letter, unlike several others received this quarter, should actually be read? The outer envelope holds no clue, either.

The sentence announcing the recall is in bold. That seems scary and necessitating action, doesn't it? But no.

We read that these prescriptions were no longer processed by the PBM as of January 30. If I were comparing this with recalls for cars or food, that would mean that I should take it back and get something fixed or refunded, yes?

Not here. Of course, use of the word "recall" isn't the plan's doing, but there remains the responsibility to explain it.

About halfway down the page, we read "...it is recommended that you continue to take them [the medications] in accordance with your prescriptions, as the risk of suddenly stopping needed medications may increase your risk for side effects."

Side effects -- not quite the term that most clinicians would characterize as the risk of suddenly d/c'ing nitrates or beta blockers. So this letter is presuming that the patient knows why s/he is on each medication (and remember, each of these is listed only under its full generic name). Alas, if the good ship Argo...and since the letter lists each of the recalled tabs, without specifying which one(s) were filled for the patient, it would be easy to skim this long, complex list and not see the connection. Another form letter gone astray, one might think.

But let's say the patient does recognize one of these meds. She should be thinking that she should do nothing, right? Side effects and all that. But the very next sentence advises: "Your physician is in the best position to help you slowly discontinue use of the medication..."

Wait a second. So the member is supposed to "discontinue?" That sounds like "stop?" But that logic fails when there's no mention of getting a replacement supply, because, of course, the letter is not really recommending that anyone d/c her meds. It's just saying that if you wanted to, you should let your doc in. In fact, it's not saying anything at all, but merely palming patients off on the Ethex customer service number or the MedWatch URL.

The closing: "Thank you for your attention to this matter," once again suggests that you should do something, but by this time, we're immune to confusion (and conclusions). Time to cue up the David Bowie song, "Changes."

This letter mentions five different organizations by name: the plan, its PBM, its pharmacy "consultant," ETHEX and the FDA. However, nowhere does the letter explain any of their responsibilities, roles, accountability or possible usefulness in sorting out any of the letter's contents.

Some of the recalled tabs may be over-generous with the active ingredients. Nowhere in this letter does this fact appear. What to do about refills when shortages for some of the compounds in question have been news for months is nowhere addressed (some patients have been switched over to immediate release vs. extended release metoprolol, for example). Even if the PBM is fully stocked, that reassurance is not made. Nor are terms like cGMP explained. Nor is it identified which drug(s) on the list may apply to the patient (we call it a mail merge with a form field). A single-spaced missive that fills a page, this letter raises more questions than it answers, yet it hints delicately at clinical implications.

When you read polls about distrust, mistrust and misunderstanding of the health insurance industry, remember this letter. A patient who is on a recalled med, based on the PBM's data, is sent a letter in a 8.5 x 11" envelope, signed by a PharmD. There's bold face type and mention of the FDA. It seems serious and worth reading, (well, if you get past the first sentence regarding "changes to prescription drugs in the marketplace"). But, in the end, it's not only unhelpful, it's anxiety-producing or a sedative, depending on which sentences one reads. The tone is cold, formal, impenetrable and replete with jargon. Health plan as robot? We are here.

What would the LA Times think and write about a physician who sent this letter? A hospital? What would you think? Need a plan somehow avoid any visible role in medication management beyond formulary access? The plan will certainly assume a broader role when it comes to hospitalization, surgery, medical devices, etc. and patients know this very well.

So to the Blues plan and your sisters and brothers: After the next recall, if you can't acknowledge the facts for whatever reason (and remember, there's more than one general counsel in the sea), please send your members somewhere that offers actual answers. For example, see the simple language about this recall at the Facts & Comparisons Web site: http://www.factsandcomparisons.com/News/ArticlePage.aspx?id=8294. Ironically, this para is written for HCPs, but is simpler than many of your letters to members.

And next time, don't delay. Spring for a mail merge that produces a personalized salutation and short name rx info. A member with a condition serious enough to justify a drug that you're paying for deserves personhood, not to mention the fact that you might want to converse with that person in the future. Names of drugs and people are a good start. Run your next effort by some real patients, please, and if you can't come to grips with the fact that these are sick people, you might want to think about finding a vertical with lower stakes.

Thank you for your attention to this matter.

Easy Answers Make Poor Gifts

By Laurie Gelb

A new political era is upon us, and the red herrings that should be frolicking in the wild somehow never left the boardroom.

You’ve heard them all. Members are lazy slugs. Docs are mercenaries with stethoscopes. Pharmas suck the last dollar out of destitute Part D recipients. Often, the pharmacy chains come out best in this narrative – their low generic pricing is actually both market-driven and good for adherence. But improved outcomes are unlikely to be driven in large part by CVS or Walgreens in the current regulatory environment. So what’s next?

Recently, I’ve explored scores of managed care and health system Web sites as a strategist and competition judge. As I’ve pointed and clicked across this year’s domains of top-tier AMCs and health plans, I’ve reflected on my MCOL presentations of the last few years.

Many of us preach the need for customized decision support that validates the complexity and importance of stakeholder choices. Yet the health Web on evidence in 2008 continues to propagate the false dichotomies of idiot vs. expert, with information accessible through clunky largely static pages, with only the most rudimentary support for critical decisions like choosing a physician or evaluating the urgency [often confused with indications] for surgery.

If all you care about in selecting a doc is gender, languages spoken and hospital affiliations, you’re in the right place. If Flash first-reads displaying ethnically diverse docs and patients are your idea of immersive storyline, Google “hospital” or “health plan” and go to town. If your idea of a surgical consult on the Web is a pretty graphic and a few FAQs, welcome to the Net. But don’t we spend a lot of offline ink telling members that they need to ask much more probing questions?

Has Revolution Health and/or HealthGrades provided a quantum leap here? Hardly. Rate-a-doc portals? These probably eliminate some docs from consideration lists, but there’s scant evidence that they are helping distinguish the incompetent from the competent. The “rate a drug” racket probably does more for the raters than the readers.

Finally, hospital rankings and mortality stats, flawed in so many obvious ways, also divert attention from the notion of physician selection as a starting point, not to mention the idea of a medical home. Yes, the data quality is improving, but the support for the right ways to use it is not!

Instead of directly addressing patient and caregiver reasons for fear, loathing and denial of clinical realities (such as very few placebo-equivalent drugs or no-risk surgeries), content developers often seem to think that simply acknowledging the existence of these phenomena solves the problem. The proposition that “I’m OK, you’re OK, disease is OK” is in danger of replacing actual decision support in the health digisphere. With a President-elect who admits incomplete smoking cessation but exercises diligently, might we have a teachable moment here?

As for rational consideration of potential health decisions, the mass media’s tendency to discuss competing risks using anything but anecdotal evidence has increasingly obscured the differences between population-level statistics and individual considerations. And judging from the conflict-of-interest stories sprouting like mushrooms, no one at an academic medical center ever took money from pharma or device manufacturers till recently (NOT!) Another walk away from the real, toward the valley of oversimplification.
Disease is a real entity, with disability and death possibilities for everyone every day “We’re never promised tomorrow,” as Chief Daniels noted during one of his Polonius moments on Hill Street Blues. At the very least, addressing unpleasant facts so as to minimize risks entails the willingness to believe that decision-making can entail choosing among suboptimal choices. When members lose sight of the complexity, the effort, the costs of acquiring and acting on the best information, we’re only letting them kid themselves.

Baby talk is maybe talk. “Eat less simple sugar today! You can do it!” Passive voice is well, passive.
How honest, precise and strong are your communications?

Can decision support consist of more than threats, promises and stiff upper lips?

By Laurie Gelb

Can decision support consist of more than threats, promises and stiff upper
lips?

Here's where domains, measures and thresholds come in.

Here's where the rubber hits the road.

In one study, sufferers, clinicians and payors were asked how they would
measure the value of a drug for a condition for which disease- modifying
therapy did not yet exist. The same methodology works whether options are
plentiful, mediocre, whatever.  But in this case--

Physicians highlighted clinical results in one or more domains, all of which
have a demonstrable impact on quality of life.
Patients focused on being able to experience things they have not been able
to experience recently.
Payors wanted to see statistically significant differences from placebo on
some objective measures, not really caring which -- the FDA's job.

Every stakeholder was able to specify domains (pain being one, just so we're
clear on what a domain is) that were relevant to him, and whether or not an
improvement in that particular domain would in itself justify
prescribing/taking/reimbursing therapy. Obviously, not all domains were
salient to every stakeholder.

Every stakeholder was able to specify how improvements in salient domains
would be measured (numerically and/or categorically) as well as her
threshold for that improvement -- what number or value or outcome would
constitute sufficient reason to act.

But the answers were different for everyone.  (So were the questions, of
course -- computer-assisted interviewing uses previous answers to frame
relevant questions).

So, when you're doing stakeholder research, instead of dragging out a stack
(real or virtual) of static scenario cards for tradeoff analysis and
sorting, instead of asking about abstractions like preference and
satisfaction that aren't used in real life, what if you asked about:

Domains that are salient
Measures that are used to measure change or value in those domains
Thresholds applied to those measures to justify action

Bear in mind, these are studies that run (very) low five figures and a few
weeks, all told -- this is a framework for frequent studies, not once a
decade. So you can track how the findings change as the environment does.

What next? You might design decision support that makes very clear...

What domain(s) are affected by the intervention you recommend or wish
considered What measures show change when the intervention is used, in whom,
and how frequently. how predictably To what extent any particular threshold
of change can be predicted, guaranteed or even hoped for

Of course, you update this as the data come in and time goes on.

Presto! User-centric decision support can be yours.
And it can be theirs.
If you do all this on the Web, kiosk or CD-ROM, you can develop a "wizard"
that enables the user to "buy in" to their choice using their own criteria.

The decision that's owned is the result that's achieved.

We're not just talking about justifying or avoiding therapy -- this is about
staff/physician recruitment/retention, open enrollment and a thousand other
choices.

Effective decision support reduces and supports the burden of choice.
How is yours doing?
Any stories to share?

“Personal” is more than a word

By Laure Gelb

In my last post, I speculated as to whether 2008 might be the year that disease management communication from MCOs finally got personal. The next one-page MCO piece I saw (an EOB insert) offered the following snippets:  

“We think getting personal is a healthy idea.”

“We know that nothing is more personal than your health.”

“Do you take a healthy interest in good health?”

This piece of paper attempts to induce enrollment in the personal health coach program. But where are the benefits offered for this proactive behavior?  

“If you qualify…one person to call for answers and advice. It’s confidential and it’s free.”

o      OK, so you want me to transfer the expectation that my physician will offer answers and advice, to a nurse whom I’ll never meet.

o      You want me to believe that it’s confidential, when I’m reading every week about health insurance data privacy breaches.

o      And you want me to celebrate that it’s “free,” when my premiums and copays have never been higher.

 Health coaching should ideally align with the patient’s medical home. Can we more strongly link that proposition to premiums and copays? Talking points could include:

 

• The relationship between OOP costs, medical errors and drug interactions
• The higher risk of unidentified ME/DI among patients with multiple conditions/polypharmacy
• The opportunities for improved outcomes that multiple conditions can obscure
• The importance of a “medical home” in reducing ME/DI
• What a health coach actually does, and indications that having a coach might help; how the coach and the medical home can support each other

 Although managed care has been “doing” disease management since the 80’s, a patient’s “buy-in” to disease management, with the time, effort and emotional costs it entails, will be short-lived unless it’s obtained through honest discussion of its potential benefits, rather than demanded or condescendingly waved in front of someone with many conflicting priorities. And I haven’t seen an EOB insert yet that addressed questions like:

 

• Why I am on two drugs that are supposedly “contraindicated” in combination?
• Does anyone at the MCO know or care about all that treatments I’ve had?
• Isn’t a health coach going to refer me to a doctor for the tough calls anyway?
• How will a stranger get me to do all the things I already know I should do?
• Why can’t the health plan just find me a better physician?

There’s a real shortage of health content in member communication, and it’s no wonder that members find it difficult to read, let alone remember (or act on) any of it. The next time you want to change a member’s mind or otherwise influence behavior, you might want to check your communiqué for a few basic points:

 

1. Is it clear what you are asking members to do?
2. Is a coherent value proposition for them to take this action presented and are potential objections addressed?
3. If members to whom your request is directed are not appropriate candidates, how will they know?
4. Is there a high ratio of important content to buzzwords like “personal,” “healthy” and “wellness”?

 All this is no more than Marketing 101, of course. When disease management diverges from marketing exchange theory (equal value achieved by all parties to a transaction), it is less likely that any transaction, change or improved outcome will result. And, at the end of the day, the evidence suggests that clinical outcomes are more durably and significantly improved by self-imposed than externally-imposed change. Yes, the MCO (and the physician, nurse, et.al.) can help present the rationale for change, a means for implementing it and incentives for doing so. But only the patient “pulls the switch” each and every day. Every day brings new health decisions (like self-dosing qd), challenges and opportunities. It takes more than a few clichés to frame and support optimal choices. And there has to be a balance between “happy talk” and the certain knowledge that some “good” decisions and intentions go horribly wrong.

Next month: domains, measures and thresholds -- the keys to behavioral change.

Can 2008 be the year that health communication gets personal?

By Laurie Gelb

It's safe to assume that your organization's 2008 objectives include some combination of member/clinician behavior change and cost containment. To that end, consider the following. 

Scenario 1: An organization sends you snail mail and e-mail that obviously is the same for everyone. It references products you don't need, ignores your previous transactions, frequently repeats the same message and offers you no way to personalize its communication to you.

Scenario 2: (a la Amazon.com) An organization sends you snail mail and e-mail that clearly has entailed an analysis of your pre-existing relationship with the organization. Future purchases are recommended, reminders are tailored to the interval at which you made previous purchases, etc. You are also offered the opportunity to personalize the offers and reminders you receive, and to update this information when you see fit.

Which organization are you more likely to do more business with? Recommend?

Now consider what last year was like for one of your members (every example below is from actual MCO communications). He is male and receives a letter that clearly recognizes that fact (it's addressed to Mr. Smith). The letter references the fact that he might be pregnant. It also invites him to call a "local number" to reach a health coach, for which the area code is an hour away and actually a toll call. The signature on this invitation is a typewriter font.

Does any of this seem personalized?

He receives two successive letters "from his doc," via a joint initiative, that encourage him to get an A1c and includes a form wherein he can have a lab tech sign off on the test, send in the form, and receive a trivial incentive. This is right after the visit at which he and the doc went over the results of his recommended interval A1c test.

He receives an EOB with an insert encouraging him to get a flu shot.  The EOB is for his recent flu shot. Every EOB he receives over a six month period includes the flu shot insert, long after he has received the shot. 

He tries to order rx refills from his PBM over the Web. He finds out by trying to do this (over a half hour with increasing frustration) that his former user ID is no longer valid. When he tries to create a new one, he gets repeated, incomprehensible error messages with no information as to how to resolve the issue. Ultimately, he has to call the refills in, but after explaining the issue to the representative, he receives no information on how to fix the log-in.  The member hangs up still unsure whether he will ever again be able to refill rx on the Web, and with no incentive to pursue the matter.

Do personalized mail merges and sorts cost more? You be the judge.  One thing is sure -- if we stipulate that the "informed health consumer" expects a win/win relationship with her payor, it's hard to see how that relationship is fostered by "one size fits all" communication. Consider how easy it is to complete a transaction on amazon.com (or at any one of thousands of Web sites) that actually begins and maintains a personalized relationship, as opposed to the feedback members receive from an MCO or PBM transaction. It's not just a matter of behavioral change; think of all the goodwill you're losing, and all the adversarial baselines you're creating, by seemingly refusing to treat members as people.

It's easy to say that health communication is a two-way street, that patients need to take responsibility for ontrollable risks and lifestyle factors. It's more difficult, but ultimately more rewarding, to walk the walk from a payor standpoint. Tools that support plan design choices came into being several years ago. Have tools to support health decisions and encourage appropriate behavior matched that early promise? Not yet.

Need evidence that any of this matters? A modest proposal would be to run some pilots that compare "one size fits all" messaging with something that takes previous information into account. Pretend that you're at an organization where "one size fits all" communications simply aren't done.  What would you do to stratify your members? You might begin with gender...

Happy 2008 to all, hopefully a year in which all of our initiatives increasingly facilitate appropriate prevention, screening, diagnosis and treatment.