DISEASE MANAGEMENT: A SPECIAL REPORT
There's a line between encouragement and coercion that doctors say some health plans ignore. Given physician defensiveness, can any approach to DM work? Does capitation make effective buy-in nearly impossible?
The fate of any disease management program ultimately rests with physician buy-in. It's a corner of health care where HMOs (and their surrogates, the vendors) still hold less than total sway, a place where physicians can exercise that time-tested means of obstructionism employed by "subjugated peoples" — passive resistance. Plans are always trying to figure out ways to get doctors to buy in — to guidelines, disease management, formularies, whatever. Do they sometimes cross the line between encouragement and coercion?
"When a doctor calls and says, 'You're coming on too strong,' we listen and take advantage of his expertise and modify," says Joseph Carver, M.D., senior medical director at Aetna U.S. Healthcare, who adds that his HMO has not had conflicts with physicians over DM programs. "We don't ask him to do anything that isn't evidence based and best practice. We don't have any nuances for what we do for patients, because they're Aetna U.S. Healthcare members that a doctor wouldn't want to do for everybody else he takes care of."
All physicians agree, in theory, on the need for DM, says Thomas LaGrelius, M.D., president of the Independent Doctors Traditional Practice Association (INDOC), a group that doesn't deal with HMOs. "That's what doctors have been doing forever." The sticking point is control. "It certainly doesn't require managed care — or managed cost, let's put it that way — to encourage physicians to do good medical care," he says.
Even Aetna U.S. Healthcare, despite Carver's rosy depiction, has encountered resistance. For instance, an interview with Aetna CEO Richard Huber in American Medical News spurred such an angry response from readers that the publication had to print replies in installments. "There hasn't been a positive letter yet," AMNews noted in its Oct. 25 edition.
One of the writers was Robert L. True, M.D., an Ob/Gyn from Arlington, Texas. "...Huber mentions Aetna's 'disease management' program that supposedly alerts physicians to patients' conditions and drug usage," wrote True. "Personally, I can't think of a bigger waste of money than these programs. As an Ob/Gyn, I receive these assessments from many of the managed care companies locally. I have found that they provide no further information to me than what I already know after I have spoken with and examined my patient (as we physicians are trained to do). I am sure that this costs the managed care companies big bucks. This is a waste of health care dollars."
Carver doesn't wish to go tit for tat with True, though he does point out that Aetna doesn't have any Ob/Gyn programs. (True, for his part, did not return calls.) Carver also cites the recent plea by President Clinton for fewer medical errors.
"Clearly, the facts don't document or support the opinion that doctors are infallible and that everything we do is right," says Carver. "Anytime somebody comes to me and says 'Here's what you're doing' in an unbiased and nonprejudicial way, and it either reinforces that I'm doing good things or makes me say 'Maybe I can do that better', I appreciate that. I don't find that threatening."
In fact, Carver feels this points to managed care's original purpose. "We do give doctors report cards about how they use drugs and how they do tests and how they — to some extent — make decisions. These are not punitive, but are rather more like saying, 'We can help you do a better job.'"
Thanks, but no thanks
That wasn't how it worked for David MacDonald, D.O., a primary care physician in Renton, Wash., who says that the way plans dealt with DM is one of the reasons that he severed all ties to HMOs a year ago.
MacDonald found DM restrictive regarding alternative medicine. "Take nonsteroidal anti-inflammatories as an example," says MacDonald. "Nonsteroidals inherently have a lot of problems: Just consider the incidents of GI bleeding. We encourage our patients to try alternative methods first. We would prefer to use the natural supplements first, because of the lower side-effect profile. The natural supplements are not a panacea. However, they are much less risky than the nonsteroidal medications."
Natural supplements usually do not fit DM protocols, which forced MacDonald to either compromise or choose something outside the protocol that patients had to pay for out of pocket.
"They often didn't have the extra cash," says MacDonald. "They were already spending $400 to $600 a month for an insurance package that did not cover alternative supplements."
In addition, says MacDonald, the DM protocol often didn't cover his first choice for a nonsteroidal. "It was not uncommon to receive a call saying, 'We cover this medication, but not the one you chose,'" says MacDonald.
HMOs tended to take the same tack with antidepressants and antihypertensives, he found. "Really, it's cookie-cutter medicine with the mind-set that most people fit whatever antidepressant pathway the plan happens to be following."
How that pathway is imposed — often without consultation with the treating physician — is also a sore point. "I have sent notes to insurance companies saying, 'Please treat and follow this patient because you have a method that is different from my practice style,'" says MacDonald. "It is ethically nauseating to practice medicine that way."
Not to mention logistically impractical.
"We used to get repeated requests for documentation indicating why a certain medicine was needed," he says. "One day, 7 out of 15 patients on my schedule for the morning needed a letter, a response, a form, or chart notes that documented why I used a particular medication. Doctors just cannot keep up with these requests. Spending three minutes on seven patients means using 21 minutes of my work day that I just don't have."
LaGrelius — who now contracts mostly with PPOs — agrees that what is touted as DM too often goes no further than pharmacy management.
"They compare you with your peers," says LaGrelius, who adds that he finds that the bottom line, usually, is keeping costs down. "This is not how we should be motivated to choose drugs."
LaGrelius is doubtful that any amount of tinkering by HMOs or vendors will help because the problem is systemic. He says flatly that capitation and DM do not mix. "There's no financial motivation to sit down with a patient and discuss his disease in detail. When I have an asthma patient, what he needs more than anything else is a lot of time and careful discussion about how he controls the problem."
Under capitation, of course, time is money. "HMOs assume a six-minute interaction between a primary care physician and a patient, and that includes keeping records," he says. In stating his position, LaGrelius alludes to long-recognized and much-discussed flaws in health insurance. DM, he claims, is one of the ways HMOs address these issues short of changing the system.
"In an effort to make sure that what a good doctor doing good health care would do anyway sort of gets done, they've set up these disease management protocols," says LaGrelius. "Then they say, 'You've got to make sure your asthma patient is getting this, and this, and this.' Then they give you no time to do it."
The interference could occur on many levels.
"They often go directly to the patient," says LaGrelius. "They get a list of patients with asthma and send them information on how their asthma should be managed."
Which, of course, can be be seen as undermining the physician.
"The patient comes in and says, 'Well, the insurance company sent me this thing and told me I should be on these chronic medications all the time to keep me out of the hospital. Aren't you supposed to do this?' Makes the doctor look bad."
Good DM means good physician/patient rapport. "We need a system that pays doctors to do work and therefore motivates them, financially, to spend extra time with patients," says LaGrelius. "We need a system that does not assume six-minute visits; one that doesn't include a capitated program requiring that a doctor see 50, 60, 70 patients a day."
Physicians also have concerns about how DM programs are organized, says LaGrelius. HMOs and vendors tend to use lower-level personnel, such as nurse practitioners, to do the work of primary care physicians; and primary care physicians to do the work of specialists, he says.
"When — let's say — an asthma patient does get to see a pulmonary specialist, it's often for a one-time consultation," says LaGrelius, "when, in fact, that specialist should be handling every aspect of treatment continuously."
Far from getting too much oversight for DM, as LaGrelius and MacDonald complain, Joselyn E. Bailey, M.D., a nephrologist in Torrance, Calif., says the HMOs she dealt with didn't exhibit enough interest. (Bailey, like LaGrelius and MacDonald, does not contract with HMOs anymore.)
"I think that the authorization committees were too busy," says Bailey. "Preventive medicine issues were seldom mentioned unless they were associated with increased revenue."
Bailey also questions the motivation behind many DM efforts.
"It seems that some of these things were promoted for business reasons," she says. "That's my gripe. It was not for the benefit of the patient. It was whether or not we can give him a shot and make more money."
Even the terminology employed in the DM programs she encountered left her cold.
"I didn't spend years and dollars in medical school and medical training to be referred to as a 'provider,'" says Bailey. "Anyone can have that title, including a seeing-eye dog. After all my training and experience, I just cannot allow someone who may have gotten a GED to tell me when I can order an X-ray or blood test."
Carver, the Aetna U.S. Healthcare official, says his plan is cognizant of what doctors find irritating. For instance, just who's asking the DM questions?
"We, if at all possible — especially when there's something in question — try to make it so that the discussion is peer to peer: doctor to doctor, and maybe even specialist to specialist, depending on what it is and who it is," says Carver. "People ought to be doing what they've been trained to do. People who are trained to answer the phone shouldn't be calling doctors. I think that if the question is important enough to get a clinical answer, than a clinical person needs to make that call."
That may be one of the reasons why, for the most part, Aetna's programs are all operated in-house. Asked whether a vendor might be able to elicit physician buy-in better than the health plan, Carver says "No."
"Doctors complain that they get bothered too much," says Carver. "People are sending them mail and calling them on the phone and offering to help."
Aetna attempts to train DM workers to approach physicians with the same respect with which a nurse or nurse practitioner might approach a doctor in a hospital. "It's never with the idea that it would be adversarial," says Carver. "The things that are scripted and the MO and the training that we give people are to be a compliment to what physicians do. Now, if they see that Mrs. Smith's blood sugar is 900 and the doctor tells her, 'Put one less teaspoonful of sugar on your cereal in the morning and you'll be OK,' our DM people would never question that doctor directly. But they would go to a medical director and say 'I think we have a problem.' Our doctor would then talk to that physician to sort out the reason for this unique approach to the treatment of diabetes."
Again, he insists that Aetna's DM nurses would proceed with caution.
"I think that a nurse who is dealing with that disease every day of the week might say: 'Here's what we know about Mrs. Smith. Here's what we have to offer you and Mrs. Smith to help you do a better job, and do you want to take advantage of it?' She wouldn't say, 'Why did you do this?' That's never the encounter."
The physicians quoted above may beg to differ. But of course, they are not representative — they do not deal with HMOs anymore. Most physicians cannot, or will not, make such a radical move. They have to deal with the reality of DM under managed care.
"We've always said that we can't exist without doctors," says Carver. "I think that the enlightened doctors understand that they can't exist without us."