Managed Care 101 in 2010 (Part XIV): How to Manage the Care of People, One After Another

July 30, 2009
Jeff Kaplan

People are living longer and the population is aging; as a consequence, we are seeing more need for chronic disease management, but at the same time, there is a decline in the availability of primary care physicians.

People are living longer and the population is aging; as a consequence, we are seeing more need for chronic disease management, but at the same time, there is a decline in the availability of primary care physicians (ie, lower physician-to-population ratios). Nevertheless, primary care is responsible for equitable distributions of health, if not actual improvements in health status and clinical conditions. Beyond improved social-economic and environmental conditions as a result of public health measures and social policies, primary care is an important ingredient for achieving equity in access, clinical effectiveness, if not actual efficacy, and cost-benefit.

On the other hand, new trainees apparently don't relish chronic disease management; they seem to want to work less for more money and they balk at the administrative headaches caused by the bureaucratization of healthcare. Even for health care professionals who deal with younger populations, we are seeing more waste and duplication caused by CYA medicine and physician-induced demand, ie, unnecessary tests, visits and procedures. And, beyond the extraordinary expense of care in the United States, we don't seem to reap the benefits (See "Why Not the Best?" [PDF, page 8 of 8] where it says: "[Evidence] in the National Scorecard on U.S. Health System Performance, 2008, shows that care typically falls far short of what is achievable."

What is wrong with this picture and what can be done about it?

First a given—to improve health care, we must have data—what happens to patients, where, and when—a longitudinal view, preferably packaged as an 'episode of care.'

Second, that database must contain certain non-traditional items such as socio-demographics, past medical history, family history, adverse lifestyle choices, accessibility problems, information about compliance, how well the treatment worked, the case-mix (acuity), home assessments, barriers to good nutrition, activities of daily living, exercise and other items in the bio-psycho-social realm, to name a few.

Third, given the above, data must be translated into information that is telling about outcomes like patient satisfaction, recidivism, cost benefit, cost-effectiveness, cost-minimization, and cost-utility.

Fourth, we need to use said information and pay better when the care is better; pay minimally when the care, under control is less than optimal or deviates from an agreed-upon standard without good cause. Also, we should reward suboptimal care or care that, without good cause, deviates from an agreed-upon standard*, especially, but not only when it causes harm.

* Specialty societies should be setting these standards and they should be current.

Although referring specifically to geriatric care, the following statement is worth reiterating; it is paraphrased from Jane E. Brody's "New Model of Care is Needed, Experts Say" (December 29th, 2008, NY Times).

"The system needs to be restructured to meet the needs of people... and this can't be done with out addressing [their] social needs. If we fail to do this, we will be facing a bankrupt [health care] system."

Readers: Do you agree with Ms. Brody?