But at first, under pressure from a few investors, including one community hospital, CareMore accepted all kinds and ages of patients, including some covered by employee medical insurance (“commercial plans,” in industry parlance). For four years, CareMore operated on this basis, and like most other medical practices, it struggled to make ends meet even as its membership rolls slowly grew. But in 1997, the commercial insurers, perhaps feeling threatened by CareMore’s growing presence, insisted that the company promise it would never introduce a commercial insurance package of its own. When Zinberg and his board of managers hesitated to accept this demand, the commercial insurers abruptly canceled their contracts with CareMore.
It was a huge short-term financial blow. But it proved to be a long-term blessing. It provided Zinberg and his team with the opportunity to restructure CareMore around his original concept—a specialized health care system that focused on the elderly and put the patient at the center of the system. It also had the important benefit of creating a single funding source for the business model—Medicare. Medicare’s payment system provided CareMore with what’s called “an acuity adjusted aggregate payment” for all its patients. In other words, CareMore received an annual per-patient fee, adjusted according to each client’s risk profile. This replaced the distorted incentives of the fee-for-service model, allowing CareMore to be rewarded for driving health care innovations for its elderly patients.
“The concept was much simpler than a lot of people seem to think,” Zinberg says. “It didn’t require the brain of Socrates. You start by listing the needs of the senior population. Then you ask, to what extent can we meet those needs? And you figure out ways to provide what they need to get healthy and stay healthy.”
Like all demand creators, Zinberg had the guts to listen to customers. But there are limits to what customers can tell you. Sometimes they won’t talk about their real desires or motivations (“I bought a Mercedes to make my next-door neighbor jealous”). Other times—particularly in a technical field like health care—they don’t really know what they want, or lack the language to explain it clearly. This is why smart demand creators supplement their conversations with customers with plenty of observation, looking especially closely at the gaps between what people say and what they do.
As if guided by Yogi Berra’s dictum “You can observe a lot by just watching,” Zinberg, Holzner, and their colleagues set about doing something rather unusual in the world of health care: simply looking at the root causes of the hassles that were creating needless suffering among their elderly patients. They analyzed how these upstream events led to often catastrophic downstream consequences. Then they set about eliminating those hassles, one by one.
In this upstream-downstream analysis, CareMore was applying an old systems management principle first developed at Bell Laboratories in the 1930s and refined by management guru W. Edwards Deming in the 1950s: You can fix a problem at step one for a dollar, or fix it at step ten for thirty dollars. Or, as one physician put it, “The American health care system is built around waiting for train wrecks and then cleaning up the damage. At CareMore, we wondered what would happen if we tried preventing the train wrecks in the first place.”
One of their first discoveries was the simple realization that up to one-third of their elderly patients failed to show up for doctor’s appointments.
Why? Charles Holzner explains: “About forty percent of the elderly people we were taking care of were home by themselves. They’d outlived their family resources, they couldn’t drive, and their kids lived out of town. So when they got sick, they ended up calling 911. And when it comes to routine doctor visits, they sometimes just couldn’t make it at all.”
CareMore came up with an unconventional idea: providing transportation, at no charge, to get patients to their medical appointments. Local car service companies were happy to have the business. It cost CareMore money—but it saved a lot more. It meant that simple problems were recognized and treated in their early stages; complications were avoided; rates of hospitalization and nursing home admittance began to fall. Providing free transportation for patients isn’t the kind of thing most physicians would consider doing; focusing on nonmedical challenges that might be harming patients is not a subject taught at medical school. Perceiving such problems, much less solving them, required Zinberg and his colleagues to alter old mental habits developed over decades.
But once they started seeing and thinking in this new way—seeing health care hassles from the patient’s perspective and connecting the dots to eliminate them—they discovered more and more opportunities to improve the system and provide the kind of care patients actually wanted. And the Medicare payment model allowed CareMore to translate these health care improvements into increased margin, fueling growth, innovation, and improvements in care.
Another example: In the world of health care, “noncompliance” is a serious problem, including not just missed appointments but prescriptions unfilled, medicines untaken, exercise and diet regimens unfollowed, and symptoms unreported. Health care professionals grumble about noncompliance, but given the myriad demands on their time there’s little they can do about it.
CareMore invented a different approach. As Zinberg puts it, “Non-compliance is our problem, not the patient’s.” CareMore found that adding nonmedical services to its routine care could improve compliance rates—for example, sending health care professionals to patients’ homes to make sure they had scales to keep tabs on their weight, to look for loose throw rugs that might cause falls, and to provide “talking pill boxes” that automatically remind patients to take their medicine.
Each of these innovations led to a small improvement in patient wellness and a corresponding improvement in the economics of providing care. For the first time in anyone’s memory, health care costs began to decline rather than steadily increase.
But CareMore was just getting started.
Next, the professionals at CareMore began to focus on diabetes, one of the most widespread and debilitating illnesses suffered by elderly patients. When they investigated how the worst complications of diabetes occurred, they learned exactly how important early detection and proactive action are in caring for frail elders—and how that makes both clinical and economic sense.
Take amputations. The typical chain of events would begin with a small cut (on the foot, for example) self-treated, maybe with a Band-Aid. If the cut resisted healing for a week or more, the patient might visit her family doctor (called the primary care physician, or PCP). The doctor might clean the wound, change the dressing, and advise the patient, but the advice might or might not be understood or followed. A week later, with the wound getting worse, a second doctor visit would lead to a referral to a surgeon—the average overscheduled PCP’s only real resource for this kind of problem.
After the typical two-week delay in arranging an appointment, the surgeon might discover that gangrene was beginning to develop and recommend a consultation with a specialized vascular surgeon. And after another two-week delay, the wound would have become so serious that an amputation was now inevitable—at a cost of many thousands of dollars and untold suffering. All beginning with a single, scarcely noticeable cut.
No one taking a patient’s-eye view of the problem would ever design a system like this. No patient would ever demand it. But this is the nonsystem that had grown up in the wake of America’s unconnected-dots approach to health care. With most of the U.S. health care system working under a fee-for-service payment model, fragmented transactional care is promoted, and no payment is provided for many of the kinds of proactive engagements the CareMore team has built into their system.
CareMore responded by creating a wound clinic, staffed by nurses whose primary job was to care for diabetic patients with small cuts. They’d change the dressing every other day and spend a few minutes talking with the patient, making sure the wound was healing on schedule.
Amputation rates for CareMore’s diabetic patients fell by m
ore than 60 percent.
The HMOs whose draconian policies had so appalled Drs. Zinberg and Holzner had behaved as if excessive demand was the main problem in American health care—and that the solution was simply to say “No” as often as possible. CareMore’s approach to diabetes exposes the flaw in that thinking. Elderly diabetics—like virtually all patients—don’t actually want lots of medical treatments. In fact, they are prone to putting off doctor visits and avoiding care for as long as possible, often resulting in needless complications and enormous long-term costs. The coordinated care provided by CareMore recognizes this reality. Rather than taking the route of “No, no, no,” it reduces costs and human suffering by providing patients with the effective, early-stage treatments and diligent follow-up care required to keep them healthy and vigorous. And that, after all, is what our demand for health care is really all about.
ONE OF THE MOST important innovations pioneered by CareMore is the Extensivist. A patient is a unified being, not a collection of disconnected symptoms. Yet mainstream health care generally ignores this reality. One study of the care received by patients with chronic conditions like diabetes, heart disease, and asthma found that 40 percent of them were visiting an average of eleven different physicians; the upper quartile in the study actually averaged sixteen specialists from nine different practices. This regiment of doctors rarely speak to one another, coordinate plans, or consult on the possible interactions among their treatments.
It’s an ineffective way to deal with so delicately balanced and complex a mechanism as a human being. But whose job is it to sort out the confusion? It falls to the patient, the only one who knows everything the various physicians are doing and therefore the only person in a position to raise the issues of how they all interact—except that very few laypeople have the time, energy, and expertise to play that role. And when the patient is frail and elderly, the likelihood of communication failure and ineffective care skyrockets.
Extensivists are connect-the-dots experts—specialists in coordination and integration whose goal is taking the hassles out of health care and ensuring that what patients need, want, and get are one and the same.
Charles Holzner explains how this new type of medical specialty came into existence:
When we started CareMore, we found we needed programs to keep the elderly frail out of the hospital. A sizable fraction of our patients would inevitably get readmitted over and over again if you treated them like routine patients. But no one wants to spend time in the hospital, and needless readmissions are a huge waste of energy and resources.
So to keep our patients out of the hospital, I began seeing them myself every week or two. I basically became their personal doctor, making sure they understood their post-operative regimen and were following it correctly. But very rapidly I became overloaded. So I told Dr. Zinberg, “We need more people like me.”
And that’s how the concept of the Extensivist was born. The CareMore team realized that elderly patients commonly have many interdependent clinical conditions. Without an integrated care plan, problems will inevitably fall through the cracks. Whole person integrated patient management is a new kind of job in the health care field. It equips a doctor with an array of powerful tools that make it possible for the needs of the whole patient to be considered together. These tools include Patient QuickView, a system of unified electronic health care records of the kind that the Patient Protection and Affordable Care Act, which became law in 2010, aims to foster on an experimental basis around the country, but which is already up and running at CareMore. The Extensivist doesn’t rely on a patient’s memory or the hand-scrawled notes of his fellow physicians; each CareMore patient’s complete background data are available at the touch of a button.
Another set of tools is a series of interlocking protocols for treating the most common chronic conditions, incorporating the latest insights from the burgeoning science of “evidence-based medicine.” Let’s go back to the example of diabetes. A patient in CareMore’s diabetes program receives a comprehensive medical assessment, wound care management and supplies, routine foot care to avoid needless amputations, the Diabetes Health Planner regimen, the “Shape Up and Levels Down” exercise and strength training program, and a personally tailored and monitored nutrition plan. Several dozen metrics are monitored at least monthly, and care plan adjustments are made accordingly.
The Extensivist makes sure that all these pieces of the puzzle are in place—in fact, that’s her sole job. As a CareMore brochure puts it, “Integration and coordination of care is not voluntary.” That means it actually happens. And because frail elder patients need integrated whole person care, the Extensivist role is the cornerstone of CareMore’s clinical and economic success.
CareMore has developed similar programs for other chronic conditions like end-stage renal disease, chronic obstructive pulmonary disease, and hypertension and congestive heart failure. Having studied the evidence about what combination of practices yields the best impact on patient well-being, CareMore doesn’t leave the choice of treatment up to chance or even to the whim of an individual physician—it provides a road map and a to-do checklist, much like the checklist airline pilots follow to make sure that every step in their preflight routine is completed before the jumbo jet leaves the runway.
The Extensivist must be a knowledgeable physician, of course. But people skills and a talent for clear, effective communication are even more important. “It’s all about trust,” Holzner emphasizes. “I saw that when I got involved in a patient’s care, if I gained his trust he would do anything I told him to do. So showing patients that we have their best interests at heart is key to a strong and healthy relationship.”
Today, whenever Holzner hires a new Extensivist, he recommends journalist Daniel Goleman’s book Emotional Intelligence and urges him to apply its lessons to his work.
The Extensivist focuses on the sickest 15 percent among CareMore’s client base, partly because those relatively few patients traditionally generate 70 percent of health care costs. One of his chief goals is to avoid needless hospital stays. “When a patient goes into the hospital for an unplanned reason,” says CareMore executive Leeba Lessin, “we consider it a failure.” Providing the frail 15 percent with efficient, complete, and coordinated care helps prevent small problems from becoming huge ones, reduces the number of five-figure bills that CareMore must pay, and has cut readmission rates by a third. And that frees up resources to improve every patient’s care.
This all sounds startlingly like common sense. As CareMore’s Dr. Balu Gadhe asks, “What’s the point of spending up to three hundred thousand dollars on complicated in-patient care for congestive heart failure when you discharge the patient to a home where there’s no family support, no food in the fridge, and no money for medication?” But mainstream medical care produces exactly this outcome thousands of times a day, since current fee-for-service Medicare programs leave gaping holes in coverage, incentivizing fragmented transaction medicine and exacerbating the cost problem at the expense of frail patients. It’s another example of the gigantic gap between the health care people want and need, and the care they end up buying for lack of a better alternative.
At times, the CareMore intervention team even goes beyond what common sense would dictate. Gadhe recounts the case of a patient who refused a needed stay in an assisted-living facility because she couldn’t bring her dog along. Her CareMore social worker solved the problem by adopting the dog and bringing it to visit the patient regularly.
The work of Extensivists helps produce some of CareMore’s remarkable outcome statistics—for example, a rate of hospitalizations that is 24 percent lower than the industry average, average hospital stays that are 38 percent shorter than the norm, and a dramatic reduction in bedsores, that scourge of hospitalized patients that is one of the leading causes of iatrogenic (medically induced) deaths. (In a country where thousands of elderly people in nursing homes suffer from bedsores, CareMore’s nursing home residents
have reported, over the past two years, a total of one bedsore.) At-home follow-up care helps patients maintain the health benefits they received in the hospital and reduces readmission rates, now one-third lower than the Medicare average.
CareMore provides care to its members in several settings: hospital, home, and the CareMore clinic. All patients have access to the CareMore clinical center, where an array of services is available under one roof: health assessment, self-management skills training, mental health and social services, wellness and nutrition guidance, diagnostics and lab services, and counseling on the total package of benefits available through CareMore. Patients no longer have to trek from one clinic or doctor’s office to another by car, cab, or bus, often toting X-rays, lab results, or folders of documents that are easy to lose, damage, or misplace. CareMore even provides toenail trimming for patients—because research shows that old folks with well-tended feet are better at keeping their balance.
New programs are constantly being tested. Two recent innovations are wireless monitoring for patients with congestive heart failure (CHF) and hypertension. Scales automatically send a CHF patient’s daily weight to medical assistants at CareMore, so that an increase of three pounds or more (which may signal dangerous fluid accumulations) can be quickly noticed and dealt with. Blood pressure cuffs transmit readings for hypertension patients back to CareMore. The patients like knowing that someone is paying attention to their condition every day. And in the first six months of testing the wireless scale system, CareMore found that hospital readmissions for CHF had fallen by 56 percent. Now similar systems for diabetes monitoring and the use of camera phones for daily conversations with a nurse practitioner are being tested.
Demand_Creating What People Love Before They Know They Want It Page 9
