Archive for September, 2006

In Case of Emergency: Emotions Can Cloud Your Judgment

September 27th, 2006 by Melanie Matthews

I pick up a lot on this job that helps make me a wiser and healthier consumer — tips for evaluating healthcare benefits and providers and making smarter lifestyle choices. And I recently learned something else: how to figure out when to go to the emergency room (ER).

One day this month we were finalizing the description for an upcoming audio conference, “Non-Urgent Emergency Room Usage: Proven Ways to Redirect Care to Appropriate Settings.” That evening, my 17-year-old daughter began complaining of head and neck pain, the result of a minor car accident that had occurred that afternoon.

By the time she shared the news about the accident, our primary physician’s office was closed. Not entirely sure that this warranted an ER visit but also disinclined to downplay the risk from a head injury, I took her to the hospital emergency room at around 9 p.m.

Most importantly, her injuries were minor and we were sent home around 1 a.m. with a prescription for muscle relaxants and rest. However, during our four-hour wait for care, I had a lot of time to consider whether I had made the right choice in bringing her there. It was certainly a decision colored by emotion, made by a parent with their child’s best interest at heart. But if I had taken the time to research, I might have come across these guidelines from Health Pages, an online consumer healthcare service that provides a list of good reasons and bad reasons to go to the emergency room. Severe bleeding, signs or heart attack or stroke, loss of consciousness or a major injury such as a head trauma (which, I rationalized, was where we fit in) are some good reasons for going, according to this resource. Sprains, sunburns, rashes, fever (unless the patient is convulsing) and colds, coughs and flu are bad reasons for an ER visit.

Also, a little preparation now can help you make an informed decision in case you or someone in your care needs medical attention outside of doctors’ office hours:

ï‚· Get a primary care physician. Having a regular doctor who keeps your medical history on file, who is available to see you in a pinch and who will take your phone call outside of office hours is one of your best recourses in an emergency.

ï‚· Research other healthcare facilities in your community. Sometimes 24-hour walk-in clinics and minor emergency centers can care for non-urgent conditions faster and less expensively than a hospital ER.

ï‚· Keep important medical information on you. It’s a good idea to carry in your purse or wallet a small card that notes the name and telephone number of your regular doctor, any allergies or chronic medical ailments you may have, and any medications (along with dosage) you may be taking. Also jot down whether you are pregnant. This will save the ER doctor a lot of guesswork when trying to diagnose and treat your condition, particularly if you are unconscious.

ï‚· Locate the best emergency rooms near where you live and work. Not all hospitals are equipped to handle every emergency or even have emergency care. Emergency facilities are rated Level 1, 2 or 3. Those rated Level 3 are the most comprehensive trauma centers with high-tech equipment and specialists on the premises at all times. Level 1 and 2 centers can handle many kinds of emergencies, but may not have specialists on hand for some needs. Find out what type of emergency services are available at the medical facilities in your community.

ï‚· Review Insurance Coverage. Know which emergency services are covered and what instructions you need to follow in urgent situations. For example, if you go to an ER with an ear infection, your health insurance may not cover the cost. Also, some plans require that you notify them within a few hours of being admitted. If you don’t, your treatment may not be covered.

ï‚· If possible, call the ER before you go. There are no guarantees, but notification that you’re on your way may cut down on your waiting time by allowing the staff time to prepare for it. You will probably talk with a triage nurse who will ask you about your symptoms (or those of the person you are assisting) and will tell you whether you need to come in; whether to call the Emergency Medical Service (EMS), which can be reached in most areas by calling 911; what you can do before you arrive; what information you need to bring to the hospital; and whether you will be better off going to a different ER.

ï‚· Take advantage of your health plan’s 24-hour nurse line. Many health plans now provide a 24-hour nurse line that seeks to direct callers to the most appropriate level of care. Through one-on-one counseling available by phone any time of day or night, participants can make more informed decisions about their use of healthcare services.

The American College of Emergency Physicians also offers a list of warning signs that constitute a medical emergency.

Whether as providers advising patients or patients ourselves, we can do our part to reduce unnecessary ER utilization, preserving the service for those who need it the most.

Healthcare Self-Management: An Economic Model

September 22nd, 2006 by Melanie Matthews

Our managing editor returned to the office this week after covering the Health Management Congress in Las Vegas last week. An overriding theme at the conference, she reported, was patient self-management. How do we put the responsibility for healthcare in the hands of the consumer?

In this week’s edition of our newsletter, The Healthcare Business Weekly Update , Dr. Richard Citrin, the former vice president of integrated care management at CorpHealth, discussed the ways that CorpHealth determines if a person is ready to make a healthcare behavior change.

He reported that people change when the benefits of changing a behavior exceed the resistance – it’s an economic model. His comments were excerpted from “Motivating Resistant Patients: Influencing Behaviors to Improve Outcomes.”

Accepting responsibility for one own’s healthcare and making the necessary behavior changes that can impact health are all part of this self-management.

Diabetics who measure their blood levels, asthmatics who use peak flow monitors, overweight individuals who begin exercise programs and choose healthy food options are just some of the ways that this self-management is occurring in the industry – with help from insurance companies and disease management companies that are incorporating this type of self-management into their program design.

Health coaches, web-based health information and interactive voice response systems are all emerging as new tools in this self-management arena.

Offering these options are truly a great way to get people more engaged in their health and accept responsibility for the management of their own care. But unless it’s done with an economic advantage, the required behavior changes just might not be made.

In New Disease Management Model, Patient is Part of the Solution

September 19th, 2006 by Melanie Matthews

Decimated. Dying. Crumbling. Just a few adjectives used by presenters at the 11th annual Health Management Congress to describe the state of primary care in the United States. Discouraged by increased demands on primary care providers and reimbursement formulas that may eat into their expected salaries, 50 percent fewer medical students are choosing family medicine as a specialty. With patient visits limited to 10 to 15 minutes, primary care physicians don’t have time to address the behavioral issues associated with many chronic illnesses. In addition, their medical training has not prepared them to properly educate patients. While health plans and hospitals figure out how to woo more general practitioners into medicine and adjust reimbursement and education models, patients are being asked to take a more involved role in the management of their chronic illnesses.

Kate Lorig, a registered nurse, doctor of public health and professor of medicine at Stanford Patient Education Research Center, believes that patients themselves may be the best medicine — so much so that she has tapped them to lead her organization’s self-management programs for people with chronic illnesses. Over the last two decades, her organization has developed, tested and evaluated self-management programs for the chronically ill. “In order to help patients become better self-managers, we must raise their self-efficacy,” she said during a congress panel discussion on behavioral advances in effective health and disease management programs. “We must address the anxiety, depression and fear of the chronically ill before their behaviors can change.”

Led by a pair of lay leaders with related health problems, Dr. Lorig’s programs are designed to help people gain self-confidence in their ability to control their symptoms and understand how their health issues affect their lives. The small-group workshops for diabetes, arthritis, HIV/AIDS, back pain and chronic disease are generally six weeks long, meeting once a week for about two hours. The meetings are highly interactive, focusing on building skills, sharing experiences and support.

To listen to Dr. Lorig describe the identification and training of patient leaders for the self-management workshops, cultural considerations and other program details, please click here.

Many of the completed programs have been adopted by health plans, organizations, American cities and locations outside the United States for use in their disease management efforts. Several of the programs are offered in Spanish, and web-based versions of patient-led self-management efforts are being developed. Dr. Lorig’s team is currently seeking volunteers with type II diabetes to participate in a six-week online workshop. Participants will learn the skills needed for the day-to-day management of type II diabetes as well as maintaining or increasing life’s activities. To find out more about the program, please visit:

Health Management Congress Update: September 14, 2006

September 15th, 2006 by Melanie Matthews

What’s in a Name:

Welcoming attendees of the 2007 Health Management Congress, congress co-chairman Dr. Thomas J. Foels, associate medical director, Independent Health Association, reflected on the organization’s name change from Disease Management to Health Management Congress: “We are moving beyond managing illness to managing the entire continuum of care,” he said, and the new congress name reflects this direction.

Disease Management Industry Update: 2006 and Beyond

Four panelists shared their views on the challenges facing the disease management industry. One trend is a move toward a “patient-centered medical home,” a concept being refined by the American College of Physicians, represented on the panel by Michael S. Barr, M.D. Dr. Barr said his organization is focusing on improved quality of care, and in particular, improved quality of primary care medicine.

Dr. Alan Spiro, vice president and chief medical officer of Anthem National Accounts, a Wellpoint company, fears that the industry has become so focused on metrics “that it is missing the people.” “We’re falling down on engagement,” he told the congress. “Our goal should be to create simplicity in the system — provide a single phone number and point of contact for members and patients.” He said his organization is utilizing the concept of “primary nurse” who is the single telephonic contact for a patient. To hear a follow-up interview that HIN conducted with Dr. Spiro, click here.

Heard Around the Health Management Congress…

Reaching Out and Improving Diabetes Outcomes: After implementing an interactive voice response (IVR) system from the Eliza Corporation that makes contact with participants in its diabetes disease management program, MVP Healthcare has nearly doubled member engagement and increased member satisfaction with the automated outreach calls. (The company was formerly using live callers to reach out to members.) The effort identified 20 percent of members who experienced depression in conjunction with their diabetes. Also, of the 80 percent of members who felt that they were in control of their diabetes, the outreach identified significant numbers who had not had required tests (Microalbumin, LDL, HbA1c) in the last year. The diabetes outreach program provided physicians with actionable information about the member, which has been positively received by the providers. The system has the ability to “remember” past interactions to create ongoing dialogues with patients. (From Jerry Salkowe, M.D., vice president of clinical quality improvement, MVP Healthcare.)

Addressing Pharma Non-Compliance: In response to rising pharma costs in the early nineties, Pitney-Bowes put all generic and brand name drugs for asthma, diabetes and heart conditions in Tier I of its pharma coverage. By lowering the costs for drug therapies addressing chronic conditions, Pitney-Bowes improved pharma compliance among its 35,000 employees worldwide, according to J. Brent Pawlecki, M.D., the company’s associate medical director. He shared this strategy during a pre-congress workshop, “Harnessing the Power of Value-Based Healthcare – Managing Employee Health Throughout the Care Continuum.”

Addressing Cultural Considerations in Program Development: In the same session, Jenn Archure, senior director and team leader of Pfizer U.S. Pharmaceutical’s Healthy Directions program, described how her team customized the program for various locations. For example, when Pfizer launched the effort in Puerto Rico, families of employees were invited to share a nutritionally correct meal on company premises.

Co-Locating DM Case Managers with Providers Frees Physician for Additional Appointments, Needier Patients

September 13th, 2006 by Melanie Matthews

Many health plans and employers already have disease management (DM) programs in place as a hedge against healthcare costs and a strategy to improve health outcomes and cost performance. But for those that don’t, two health plans today provided primers for constructing and evaluating DM programs. At this morning’s Health Management Congress pre-conference workshop, Dr. Victor Collymore, medical director, Group Health Cooperative, and Dr. Jaan Sidorov, medical director, care coordination, Geisinger Health Plan, chronicled the roads to their organizations’ respective DM initiatives.

Group Health Cooperative is poised to launch its DM program this fall for its 526,000 members, Collymore said, in response to declining enrollment over the last five years and increased inpatient hospitalizations. The case management approach for this health plan/healthcare provider is built on a centralized triage function, he explained, which will evaluate cases coming from a variety of sources: claims review, referrals from practitioners, HRA results, member self-referrals and more.

For elder patients being discharged from a hospital stay, the triage staff will use a 14-question “Bridging Tool” to evaluate whether patients understand the reason for their hospital stay and their follow-up care. Those who score below acceptable limits will also be referred to the case management program to ward off hospital re-admittances. Group Health Cooperative is aiming to touch approximately 5,000 members or 1.5 percent of its population with this program—the chronically ill, those afflicted with catastrophic conditions, those at risk for complications, hospitalizations, emergency room visits and inappropriate outpatient visits.

The triage function will be performed by R.N.s, who will spend an average of 40 minutes per case, Collymore estimated. The triage staff will review the patient’s electronic medical record (in place for all Group Health patients), telephone the patient and/or primary care provider, and perform other steps to facilitate the patient’s entry into the case management system.

Case managers will be managed centrally but work on-site in the organization’s medical center, and have an average of 225 cases per year. They will establish the patient’s collaborative care program, visible through the patient’s EMR, Collymore said.

Primary care providers are excited about this approach, he added. His organization is optimistic that they can reduce per member per month costs by $190 in one year, and realize a 5.4 percent reduction in medical inpatient admissions, he said.

By contrast, Dr. Sidorov provided some perspectives on DM efforts as his organization approaches 10 years of DM offerings in 2007. (Note: Dr. Sidorov described Geisinger’s DM efforts in diabetes in a June 2006 Healthcare Intelligence Network audio conference, Diabetes Disease Management: Practical Strategies for Identifying At-Risk Populations and Avoiding Complications.) Geisinger Health Plan, with 200,000 members in the northeast, uses R.N.s co-located at the primary care site —often hired from the PCP’s own staff — to perform the DM function. While the components of Geisinger’s Care Plan include patient and family engagement, medication promotion and the development of an action plan, Dr. Sidorov finds the patient education component the most valuable. “Our nurses are teaching patients about timely access to outpatient care,” he said. “They are teaching patients not to call doctors at 4:30 on a Friday afternoon, which will most certainly lead to an inappropriate use of the emergency room.” The nurses evenly split their time between face-to-face meetings with patients and telephonic counseling, he estimated.

Geisinger has EMRs for its DM population as well, but Dr. Sidorov said that is not a requirement for a successful DM effort. Rather, it’s the personal contact and follow-up with the patient that gets results. “You don’t have to add a lot of bells and whistles (predictive modeling, master’s level professionals) to a DM program to get results,” he said.

A good in-house DM program can take 12 to 18 months to build, he said, and is best attempted when internal expertise, leadership support and administrative funds are plentiful, he said. Those organizations lacking in-house expertise and ramp-up time and facing a large affected population with severities across the board would do well to tap an outside organization that can guide them in their efforts and launch a program within a few months.

Geisinger, too, gets positive feedback from physicians who work side by side with DM nurses. “With a good DM nurse who can discuss medication compliance and other aspects of the care plan with patients, the doctor has more free time, which can be spent with needier patients,” Dr. Sidorov said. Specialists are seeing fewer inappropriate patients, who are weeded out earlier in the DM program.

Both organizations mentioned some issues unique to the DM nurse working in the provider setting. “We sometimes find that nurses get very attached to patients, and keep them in the system longer than necessary,” said Collymore. For this reason, Group Health Cooperative is considering placing a limit on the time patients can spend in the program, he said. Dr. Sidorov acknowledged that this occurs in the Geisinger program as well, and added that sometimes nurses in the PCP environment tend to “go native,” becoming more a part of the provider’s environment than the insurer’s. To address this, Geisinger DM nurses participate in periodic training sessions to reinforce the goals of the program, he said.