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In May 1999, Abigail Sulerzyski was born deaf and blind with cerebral palsy and multiple other medical complications. While Victoria, her mother, was learning how to cope with the needs of a severely disabled child, she was also learning how to fight with UnitedHealthcare.

Abigail required continuous feeding through a jejunostomy tube, and the insurer was denying the prescription nutritional supplements that Abigail needed to survive. As Victoria was preparing to mount a legal battle against United, “something changed around December of that year,” she said. The formula along with other specialized equipment was covered.

“I went from having to fight for everything to having their nurse call me every month to ask, ‘How can I help you?’” Victoria didn’t bother trying to understand this abrupt change; she was just grateful to have more time to take care of her daughter.

When I met Victoria a few weeks ago and she shared this story, I explained the dramatic shift that she experienced. The early hassles resulted from the “mother may I” medical necessity review that gave company medical directors the authority to supersede the judgment of treating physicians regarding patients’ clinical care needs.

But in November 1999, United made the bold and very public decision to stop interfering with the doctor-patient relationship. While other prospective and retrospective utilization management (UM) activities continued, second-guessing physicians came to an enterprise-wide halt. Read more »

A close friend of ours went with my wife to see a highly regarded physician for a persistent problem. This master clinician started with a warm greeting and a brief conversation about family, and then went through a detailed history of the problem that our friend had experienced for several months. He gave her an explanation of what he believed to be the underlying cause of her symptoms, gave a prescription for lab tests, and prescribed two medications. He also suggested that she see an ENT and recommended someone.

Our friend’s father had already recommended an ENT. The father, who happens to be a physician, had seen this ENT as patient.

 The contrast was stark. The physician was curt, made no effort to establish rapport, made a passing negative comment about the other physician’s medication selection without suggesting an alternative or the rationale for his disagreement, performed a 5-minute procedure of visualizing the inside of the nose (nasocopy), and, in closing, said “How do you breathe through that thing?? You should have it fixed.”

He charged $625.00 for the 5-minute procedure and $225.00 for the office visit.

The first physician followed up by phone, showed concern, and made recommendations about where our friend could follow-up within her health plan network.

Our friend, Doctor Smith (his real name), consistently shows genuine human interest, brings to bear keen diagnostic acumen, answers questions, and coordinates care. He has practiced this way for many years with patients from the C-suite and from homeless shelters. In sharp contrast is Dr. Rude, not his real name, who, sadly, gives our profession a black eye. Let’s reward and value the Doctor Smiths and devalue the Dr. Rudes.  Our provider networks, payment system, and, consumer information should align accordingly.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

One of the key downsides of market-based health care  — that if your costs regularly exceed your income you go out of business  — is not typically associated with the National Health Service in the U.K. That is about to change. It has just been announced that the three hospitals that constitute the South London Healthcare Trust in London, England are to be effectively declared bankrupt, the board suspended, and the organization put under a special administrator. He or she will have just 45 days to provide the Secretary of State with recommendations on what to do with an organization that provides emergency an elective services to about 750,000 Londoners but has racked up nearly $100 million of debt in 2011–12 alone.

Why is this of interest to U.S. readers, aside from adding to the long-running debate on the pros and cons of operating a market in health care? It is because one option is to privatize one or more of the hospitals. By privatize, I mean a whole range of options from franchising out the management to a private company to taking over the assets lock, stock, and barrel and then providing services back to the NHS.

There are plenty of other NHS hospitals/trusts in England that are in severe difficulties, so this is likely to be repeated up and down the country in fairly short order. The political fallout is likely to be considerable, coupled with howls of indignation from local populations (and hospital staff) as the new regime takes action to try to balance the books.

If any reader knows how to save large sums  (SLHT’s annual revenues are in the region of $600 million, so they are spending $7 for every $6 they get in) without a lot of pain, that person should e-mail the Secretary of State for Health without delay! In the meantime the NHS is heading into unknown waters and commercial opportunities may well result that will be of international interest. For those brave (or foolhardy) enough to take on such troubled hospitals under a microscope of political and public scrutiny, there will be an opportunity to settle a another long running dispute: whether the private sector really is better at running hospitals than its public counterpart. Whatever the answer, I wish them luck. They will need it.

Robert Royce, PhD, is Director of Strategy at Barking, Havering & Redbridge University Hospitals NHS Trust in London, England. 

Paul Terry, PhD, is Chief Executive Officer of StayWell Health Management.

As is always the case when I return from working abroad, it takes me longer, metaphorically speaking, to unpack my bags. I was ostensibly in Brazil to teach and consult about innovations in our population health management movement in America. But, as I expected, I was surely the greater beneficiary of teachings from leaders of the wellness movement in Sao Paulo, the business nexus for the world’s sixth largest economy.

Leaders of population health programs in Sao Paulo offer a self-assessment of being a decade or more behind the United States in the maturation of employee health benefits such as employee assistance programs (EAP), disease management, pharmacy benefits management (PBM), and wellness. I anticipated we would be discussing the “leapfrog” opportunities that come with later adoption of trends. For example, developing countries garnered advantage by skipping much of the costly infrastructure of cable by embracing  wireless communications.

So I came to Brazil thinking about what aspects of American health care innovation I would skip over if I had a chance to learn from the trials and errors of America’s health reforms. Read more »

Amanada Bennett, a Pulitzer Prize winning journalist, chronicles the poignant journey that she and her now deceased husband, Terrence Foley, traveled in his seven-year battle with a rare form of kidney cancer. The Cost of Hope puts into sharp focus the convoluted compexity of our health care system even for two well educated, well insured individuals with superior skills to acquire, parse and synthesize information and data.

A recent experience helping a friend with advanced cancer to navigate within two large, highly rated health care systems brought home in a very personal way the frustration and fear that our sometimes seemingly impenetrable “system” may evoke. Like the Bennetts, my friend was well informed, well insured, and had superior abilities to access and analyze infomation about his own illness.

The cost in the Cost of Hope is financial as well as emotional. Over the past few days I have asked fifteen people — nurses, physicians, and non-health-care professionals, “How many CT scans do you think that a person with a diagnosis of kidney cancer received over seven years?” (Before you read further, make your estimate.)

My informal polling of these 15 people was 18 to 30.  Amanda Bennett and her husband decided to pore over the reams of information that they had received from insurers and providers to satisfy their curiosity about the number of CT scans performed. To their astonishment, the number was 76. Though the book does not do an evidence-based retrospective analysis of the appropriateness of each of these scans, the author's perception, shared by the 15 people that I polled, is that a substantial number of these scans were unnecessary.

In the aim for the Triple Aim, we were 0 for 3. For an excerpt, please link to the article below:

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=avRFGNF6Qw_w

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

The May 17 New England Journal of Medicine 200th Anniversary edition article The Evolving Primary Care Physician highlights key structural, financial, and cultural challenges that confront primary care in the United States. Some of these include training and education that emphasizes ever greater subspecialization, reimbursement that rewards volume versus value, and an increasing reliance on testing versus well-honed history taking, physical diagnosis, and counseling and coaching of patients and their family members/care givers.

The article touches upon research conducted by Christine Sinsky and Thomas Bodenheimer, supported by the American Board of Internal Medicine Foundation,  in which they visited and observed 23 primary care practices.  A compelling distillation from Dr. Sinsky:

What I’ve really seen is a lot of waste within the health care system at the level of utilization of physician skills. I think two thirds of many [primary care] physicians' days are spent on documentation, administrative tasks, paper work completion, rote inbox management, data gathering, and data entry. It’s something that is hard to recognize when you’re the one doing it.

To re-invigorate primary care, training needs greater emphasis on history taking skills, motivational interviewing, physical diagnosis, synthesis of information, more judicious use of testing and imaging, and engaging patients in their health care.

For primary care clinicians to enjoy professional satisfaction and improve population health management, and to reduce primary care clinician time on administrative functions, team-based care is a powerful prescription for positive change.

Douglas Kelling, a general internist in Concord, North Carolina, is profiled in the article as a successful example of transformation to team-based care. Kelling’s personal analogy is to make medical care "more like NASCAR with the doctor as the driver and other team members responsible for the fuel and tires.”

Dr. Kelling’s practice is effective caring for a large population, including patients with multiple chronic conditions.

Emerging health plan and CMS models that provide payments for care coordination and outcomes-/ performance-based payments will result in many new primary care-anchored teams through the country.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

Brad Wilson

Employers and consumers, driven by the sting of higher premiums and out-of-pocket payments, are more engaged than ever in the conversation about rising health care costs. While the math is simple —overall costs equal the cost per unit multiplied by the number of units — the broader issue is anything but.

Health care transactions are complex, and each involves a unique individual and a distinct set of conditions, treatments, and health care professionals. At every point throughout the process, data related to patients, treatments, outcomes, and efficiencies is gathered and processed. These data determine how claims are paid, but they also inform new programs and approaches aimed at improving outcomes and reducing costs.

Everyone in the health care system benefits when quality increases and costs decrease. Where we fall short now is aligning our actions across the system so employers, individuals, insurers, consultants, and health care professionals are working toward this common goal. Read more »

I expect the next 10 years of policy debates, action, and inaction concerning how to curb our obesity epidemic to be an accelerated version of the last 30 years of public policy related to fighting tobacco.

This week’s HBO documentary, The Weight of the Nation, landed a flourish of solid blows against the wrong-headed notion that obesity is simply about lack of will power. The broadcast is based on the report “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.” It’s the product of an extraordinary, even historic coming together of the Institute of Medicine, the Centers for Disease Control, and the National Institutes of Health. The report and the documentary make one point exceedingly clear: Obesity is a multifaceted problem that will require multifaceted solutions. Read more »

At age 89, Dr. John Sarno has retired from his clinical practice at the Howard A. Rusk Institute of Rehabilitation Medicine at New York University School of Medicine where he is a professor of rehabilitation medicine. I consider John a friend, a thought-creator in the field of mind body medicine, and someone to whom I owe a profound debt of gratitude in that my wife, Suzanne, was cured of seven years of debilitating back pain by embracing the etiology of her pain as psychologically based.

Dr. Sarno developed his theory —  Tension Myositis Syndrome — after more than a decade in practice as a physical medicine and rehabilitation physician in academic medicine. He observed patterns of behavior and personality traits that were shared by large numbers of patients with back pain and other pain syndromes.  

 Dr. Sarno’s controversial approach to back pain, other types of chronic musculoskeletal pain — neck, shoulder, infrascapular — and other pain syndromes including migraine and carpal tunnel syndrome, is a two-part lecture to educate patients on the underlying psychological causes or triggers leading to mild oxygen deprivation to certain muscle groups. His mantra is, “The pain is real, but the cause of your pain is not.”

John has successfully treated over 12,000 patients and has helped countless others who have read one of his four books —"The Mind-Body Connection" — or who have been treated by a handful of Sarno disciples. A criticism of Sarno’s self-reported success rate of greater than 95% is selection bias. It is true that Dr. Sarno would not take as a patient someone who was unwilling to accept that his/her pain might be psychologically based. That said, I argue that John was ahead of his time — utilizing individualized medicine.

Thank you, John.  

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

The collective sigh heard earlier this month came from frazzled physicians and medical groups relieved that the Centers for Medicare & Medicaid Services issued a new deadline for implementing ICD-10, pushing it back to Oct. 1, 2014. Implementing the codes — about 155,000 of them, as opposed to the approximately 17,000 for ICD-9 — has been giving providers nightmares.

The ICD codes are actually two separate groups: ICD-10-CM (clinical modification) is a set of diagnosis codes to be used, for the most part, by health plans, hospitals, providers, and PBMs. ICD-10-PCS (procedure coding system) puts an additional burden on hospitals — and to some extent payers — because they will be used to describe inpatient procedures. There are approximately 13,000 ICD-9-CM codes; ICD-10-CM will have 68,000. There are approximately 3,000 ICD-9-PCS codes; ICD-10-PCS will have 87,000.

The codes add “granularity,” a vogue term for more detail, to the diagnosing process.

CMS’s notice of proposed rulemaking (NPRM) in the Federal Register notes that “ICD–9–CM has a single diagnosis code for fracture of the wrist. If a patient is treated for two successive wrist fractures, the ICD–9–CM code does not provide enough detail to determine if the second fracture is a repeat fracture of the same wrist, a fracture of the other wrist, incorrect billing for delayed healing, or non-union or mal-union of the original fracture.” Health plans should appreciate the finer level of detail for billing and care management purposes, although the billing part might recede in importance a bit as various episode payment schemes work their way into the system. 

The problem with ICD-10 is that it was published in the Aug. 22, 2008 issue of the Federal Register. Everybody has been warned for four years (more really, since the the notice of rulemaking was late in the game) that the changeover is coming, and yet the deadline gets pushed back anyway.

The best-selling biography of Apple founder Steve Jobs by Walter Isaacson quotes Jobs as saying: “I think Henry Ford once said, ‘If I’d asked customers what they wanted, they would have told me, A faster horse!’ People don’t know what they want until you show it to them. That’s why I never rely on market research. Our task is to read things that are not yet on the page.” It is uncertain whether Ford actually said the “faster horse” thing, but Jobs believed he did.

Jobs was a difficult man to work for. But I’ll bet that if he were in charge of implementing ICD-10, we’d be talking about implementing ICD-12 by now.

John Marcille is the editor of Managed Care.