A blueprint for high-volume, high-quality lung cancer screening that is detecting cancer earlier—and helping to save lives
The first thing you notice about Ronald Brooks, M.D., is your second surprise of the day. Brooks, a network medical director for Aetna U.S. Healthcare, has agreed to let you follow him around so that you can see how one physician executive handles the various challenges thrown his way in a "typical" day.
Brooks — a distinguished-looking man of medium build and salt-and-pepper gray hair — greets you in a manner friendly enough to put you at ease. You will not have to expend a lot of energy extracting information. He will be forthright.
The first surprise of the day had to do with the overall casual and friendly atmosphere exhibited at the company's sprawling campus in Blue Bell, Pa. You've done homework in preparation for this excursion, including reading an article in the New Republic in which the writer explained his frustration in trying to secure access to Aetna employees.
"Arranging interviews at Aetna, it turns out, is harder than arranging them at the Pentagon," wrote Gregg Easterbrook. "The company kept scheduling interviews and later canceling them, then finally declared its official and preapproval personnel were just so incredibly, astonishingly busy — every single one of them — that no meeting was possible. Aetna, which has a horrible public image, seemed determine to convince me that it deserved it."
Aetna U.S. Healthcare's headquarters, in fact, does not resemble the Pentagon. Everyone you meet at this huge, many-building complex responds to requests for directions with a courtesy that exceeds what you may find, for instance, at your typical supermarket. (Most of the people you'll speak to that day won't know their official titles, a manifestation — Brooks tells you — of the company's emphasis on teamwork.) There are no furtive figures following you, guards demanding ID, or public relations personnel tugging at your sleeve (for now, anyway). Brooks, in phone conversations that set up the interview, promised access — and access appears to have been delivered.
Of course, you don't want appreciation to slide into naiveté. If there are people around denying cancer treatments, you will not be shown that, you realize.
(In fact, Aetna's cone of silence will descend later, when Brooks meets with disgruntled primary care physicians. If you want to sit in, you'll agree to withhold names to ensure that Aetna does not "criticize a practice by name" in print, as one company official would later put it.)
For now, though, what you notice is that Ronald Brooks walks fast, perhaps because he often has to hurry across expanses of corporate parking lot to make it to meetings in various buildings. He is one of four network medical directors who are responsible for 700,000 enrollees in southeastern Pennsylvania. More to the point, his job is to try to ease the concerns — and increase the cost-effectiveness — of physicians treating those patients. The four cover about 1,300 primary care offices and 6,000 specialists.
Brooks left a burgeoning private practice in the early '90s to join what was then U.S. Healthcare. In terms of compensation, the move was a lateral one in which, as he puts it, he traded one sort of stress for another.
"I decided, 'I think I ought to try it. I can always go back into practice,'" he recalls. "Here I am still."
Where he is — at 8:15 a.m. on April 7, 2000 — is in Building 2, heading for his first meeting of the day. Brooks is greeted with "Hey, doc" a few times as he wends through the halls.
This, it turns out, is an apt warm-up to what follows, in which phone-bank personnel who field questions from primary care physicians all day discuss issues that have been thrown at them for which they do not know the proper response.
The meeting, a weekly occurrence, is called "What's up, Doc?" and starts at about 8:30.
The initial questions, submitted in writing, are read by Brooks in front of about 10 employees. One involves a request from a urologist on whether the plan covers collagen skin test kits.
"We do cover them for particular providers because they can be used to control urological incontinence," Brooks explains. "If they were being used for cosmetic surgery — cosmetic surgery is not covered."
Another question is whether the plan covers costs for batteries used for durable medical equipment.
Depends, says Brooks. If it's a special battery for a motorized wheelchair, then yes. If the batteries for the equipment can be purchased at a drug or hardware store — if they're cheap and easily obtainable, in other words — no.
Brooks goes over the questions with two different groups of phone-bank employees and, at the end of each meeting — which lasts about 15 minutes — asks if there are any other concerns.
Jo Ann Vollmer has one. She saw on the local news the other night a story about a videophone that helps monitor shut-ins. Vollmer thinks a competing plan covers the device.
"This is the first I'm hearing about it," says Brooks, who tells you a minute later that that is often his response. "Usually, I learn as much as I'm able to impart because there's tremendous knowledge that comes from these people who answer questions about these things day in and day out. Sometimes, someone will ask a question and I'll start to give what I think is the answer, and they'll be able to correct me. They'll say, 'We had this a week ago and we went through this research, and here's what we found.'"
The meetings, themselves informal, produce formal procedural changes.
"Minutes are created from this," explains Brooks, "to verify all my answers to make sure that what I said, they understood in the way that I meant it to be. Sometimes, also, I'll go back and I'll actually reverify the information with somebody who is an expert in that particular area. They distribute the minutes to everybody. It takes about a week. This gives us time to research and make sure the answers that anybody gives here are 100 percent correct."
Speed, as well as accuracy, is valued.
"The goal is to answer every phone call within 30 seconds," says Brooks. "We don't want to keep any physician waiting longer than that. The less information employees have to research manually, so to speak, the quicker they can get back to that person."
Contracted physicians are not shy about asking questions either, says Jackie Schumacher, a supervisor who's worked for the company for 15 years. Her group fields an average of 3,000 calls a day, but the crunch is between 9 a.m. and 3 p.m.
"January is a busy time, maybe because most employers renew as of Jan. 1," she says. Calls often have to be handled gingerly, she adds. "They're really not calling us to tell us how wonderful we are."
Brooks says that the company places an emphasis on how such contact is handled.
"One thing we always try to say to all the people who work at this company is you have to realize that every time you interact with somebody, there may be a member or patient on the other end of what that question might be," he says. "You need to think about how you feel when you're a patient or have a problem so you treat everyone with courtesy and the urgency with which you'd want to be treated. There's a tremendous appreciation of the fact that this is a health care company and a lot of times people are under stress when they're calling."
Brooks seems to truly enjoy interacting with employees, but this silver lining comes with a cloud. Arguably, the only professionals who know as much about life's fragility as physicians are economists.
In hard times, those employees whom medical directors rely on — many of the people Brooks has interacted with today — face layoffs. Given Aetna's financial difficulties, this threat looms even larger. Brooks shakes off such concerns.
"I think actually morale's pretty good," Brooks says. "The average person is concerned with doing a good job and what's going on in Wall Street does not necessarily affect his everyday work."
Still, it doesn't take a recession to make an HMO lose money, as events in the industry over the last half decade indicate. There is often a point where a physician executive will have to review his place in the corporate scheme, cautions David Shulkin, M.D., CEO of Doctorquality.com, an Internet health care company, and former chief medical officer/chief quality officer for the University of Pennsylvania Health System in Philadelphia.
"Being a medical director, where you're asked to build and create new programs and systems, is a very different job and skill set from one where you're being asked to participate in downsizing and in taking down programs," says Shulkin.
When Penn fell upon hard times and 20 percent of the work force had to be cut, Shulkin took that as a cue to go as well.
"One of the great delights that I had in being at Penn for 10 years was that we had the opportunity to create innovative programs related to health care quality," says Shulkin. "We built some very fantastic infrastructure and programs that would help a great deal of people and make the system better. When you're looking at what your role is in an environment where you have to do budget cuts, that's a whole different way that you have to spend your work day, and a whole different set of skills."
Charles Derus, M.D., medical director of Accord Health Network — a management services organization in Chicago — experienced the same discomfort when the company exited the HMO business. (Accord Health Plan was small, contracting with about 2,000 physicians. The major players in the Chicago market, Derus points out, contract with between 10,000 and 12,000 doctors.)
"I think at our peak we had about 65 employees," says Derus. "They're all gone."
This was both a professional and personal blow.
"You put together a business plan with certain assumptions and you head out into the market and see what happens," says Derus. "Obviously, everybody's got 20/20 hindsight."
"As a physician, you've got to be able to sit down with people and tell them that they're going to die and prepare them for death," says Derus. "It's a lot easier to tell people in a market with two and a half percent unemployment that they're being laid off. At least you're not dead or disabled for life. Yeah, it hurts. You've got a personal relationship, but a lot of times you've got that same relationship with patients. It's difficult, but if you're going to go into management, you've got to learn to deal with downsizing as well as growth."
You may also need to learn when to duck, says a former medical director of a large California health plan who did not wish to be identified.
"I had joined because the president is a very close personal and professional friend of mine, and I was extremely impressed with the team he had assembled," he recalls. "About 12 weeks or so after I joined, the entire industry tanked in terms of stock valuation. There began a lot of change in leadership. A very large number of people left. I, at that point, did not fit into the organization."
By about 9:30, Brooks is in his office in Building 3, checking on E-mail and reflecting on the challenges of his profession. The office is not huge. Prominently displayed are photos of his wife and two children, and his degrees.
When pressed about where the next generation of savings will be found, Brooks continuously points to disease management and the attendant better outcomes that will follow. Which, of course, brings up the issue of physician buy-in.
"There are certain things that are indicated for everybody, everywhere," he says. "For example, the American Diabetes Association says all diabetics who are over 29 should get a yearly eye exam. Doesn't matter whether you're in Alabama, California, Minnesota, or Philadelphia. There are certain things that truly are universal recommendations. They have been studied, they have been well thought out, they have been proven effective in preventing further illness from occurring. That's where I think we need to strive to get the homogeneity of everybody fulfilling those requirements."
Brooks, like his peers, strives for "homogeneity" with an eye toward NCQA accreditation and the accompanying HEDIS scores, which is typical of the position, according to a New England Journal of Medicine article. "Virtually all medical directors agree that preparing for NCQA accreditation and improving HEDIS scores are two of their top priorities."
The acceptance of the theory that quality health care costs less begs the question in more skeptical quarters: If it could in fact be proven that poor quality costs less, would health plans be so insistent on improvement?
This is, after all, a business, a fact that's made clear to you when Brooks introduces you to Thomas A. Wolk, M.D., one of the medical directors with whom Brooks works closely. That morning Wolk had sat in on a three-member appeals panel. A patient wanted $400 orthotic inserts for her shoes to be covered by the health plan. Wolk, along with an ombudsman and a physician participant, voted to uphold the plan's ruling to deny coverage for the inserts.
"The patient looks upon her Aetna card as a Visa card — she thinks it covers everything," Wolk explains.
Perhaps ignorance, rather than greed, motivates such requests, Brooks says. "People don't understand that there are benefits — some that are covered, some that are not covered," he explains. "There's a feeling out there that 'Everything in the world should be covered, and I'm entitled to everything.'
"People forget that 'Gee, when I purchase a package, this is a covered benefit, and this is not a covered benefit.' They don't really understand what their benefits are. That's where a lot of confusion and anger starts."
He could tell you more, but it's nearly 10 a.m. and time for the next meeting. This one will be about the plan's U.S. Quality Algorithms subsidiary, which measures and improves outcomes to try to reduce errors in hospitals.
The purpose of the meeting is to let Brooks and James A. Cowan, M.D., M.P.H., Aetna's patient-management medical director, hammer out a quality performance report made up of clinical measures that the plan wants to use to evalutate hospitals. What clinical measures would be appropriate?
No one mentions that with all the recent talk of reducing medical errors, this is a hot topic. You are, however, asked not to record the proceedings because — as James R. Grana, director of research and development puts it — this kind of report could give Aetna U.S. Healthcare a tool it can use to a competitive advantage.
Brooks, earlier, said much the same thing. "If you could get people to cut down on medical errors, that would be a tremendous savings. There's no positive effect when somebody makes an error. All the costs that relate to that error — you could take those dollars and pay for benefits."
Grana points out that once Cowan and Brooks come to an agreement, and if the checklist survives layers of internal review, it will be tested in perhaps one or two markets. That's the way the company operates, mostly to keep the cost down, Grana explains.
"If we mailed out just one single-page letter, with a 33-cent stamp, to each of our 22 million members, that would cost us about $10.5 million right there," he explains. "We pilot things."
One of the keys to reducing errors, according to the company, is to give hospitals access to data Aetna possesses.
"After you actually leave the hospital, you go to your specialist and you get certain care from your specialist," Grana explains. "Some of that care, and some of the medications, may be reflective of higher or lower quality of care."
Then, there's the issue of readmissions.
"The hospital knows whether you were readmitted to that same hospital, but the hospital does not know whether you've been admitted to a different hospital," says Grana. "If you get admitted to a different hospital down the road, that first hospital doesn't have the benefit of knowing what happened to you at the other hospital. This is information that we can provide to hospitals that they otherwise wouldn't get, and hopefully this is medical feedback that will help them to provide better service."
Whether hospitals will appreciate this is an open question — but they're going to get it. The medical-errors stink has simply added impetus (the cynical may say an excuse) for HMOs to continue greater review of hospital activities.
Derek van Amerongen, M.D., chief medical officer for ChoiceCare Humana in Cincinnati, will later suggest that HMOs believe they have a better idea concerning the needs of the ultimate consumer. "Talk to any physician, and he'll tell you that hospitals are set up to serve the physician and staff and — a distant third — is the patient."
When Grana expounds on all the information the company can provide, you ask about confidentiality. Has the government ever looked askance at Aetna U.S. Healthcare's access to some of this material?
Just the opposite, he insists.
"The government's interested because it wants to learn from us," says Grana. "Uncle Sam has come to us over the years. We're working very closely with the Centers for Disease Control. We worked very closely with the FDA on safety studies."
Through the course of the meeting, it becomes evident that Grana is one of those "numbers people" who can supply clinician managers like Brooks and Cowan with the sort of data that can make dreams of population management — the fun part, as Derus earlier put it — come true.
After the meeting, Brooks leads you to the cafeteria where you, he, Cowan, and Wolk grab a bite.
This is when Brooks sets the scene for the next event. He plans to visit a primary care practice in Levittown, Pa., about 30 minutes away. This practice, he says — holding his right hand above his head — began as one of the top-ranked groups in the plan. Over the years, (right hand comes down, left hand rises) the practice improved, but not at the same rate some other practices did. (The hands are level.)
"Now, it's about in the middle," says Brooks. "So, I tend to hear a bit more whining from them than I typically hear on my visits."
He says that he's offered the group hints over the years for improving business, but few of his suggestions had been taken.
(Even if you're no practice management expert, you'll come to learn that there may be a basis for Brooks's criticism. In the course of writing this article, you'll try to call the group's office several times and, in each instance, you'll be put on hold for eternity.)
Brooks's warning is one signal that this, from Aetna U.S. Healthcare's perspective, will be the diceyest part the day. Another is that Jennifer King, an Aetna public relations official, will accompany you on the road trip.
The waiting room at the practice, which is in the last stages of being remodeled, is a spacious lobby with a command center in the middle. (The staff seems to be still learning where some things are now kept.)
After about 10 minutes, you are ushered into a back office that's obviously used as a lunchroom Some of the doctors are just finishing their meals. Brooks introduces you, telling the doctors that you are writing an article about a typical day in a medical director's life.
When the lunch knives are put away, the metaphorical ones are unsheathed. (Later — nearly two hours later — Brooks will tell you outside that your presence probably inspired the tone of the tense discussions that went on.)
The purpose of the meeting is to let the physicians, who serve about 4,000 of the HMO's members, know how they fare in certain categories in the health plan's evaluation.
"We try to teach them how to make their office more efficient," he said earlier. "We've created various charting aids, just as an example. It's amazing how many people don't use something like a health maintenance flow sheet.
"We've had a tremendous number of physicians who've adopted that and said, 'Gee, this is wonderful. I can't believe we've never done this. It's made me a better physician. It saves me time in the long run. I'm doing a better job when my patients come in.'"
Promoting systems such as this can be one of the more satisfying parts of the job, he added.
Such enthusiasm is not in evidence at the practice. Much of what he suggests is at first met with rolled eyes, but it doesn't stop there.
Doctor S, for instance, says the tracking mechanism for diabetics isn't realistic.
"Some of the people are not diabetics," she says. "Some of them are dead. Some of them are gone. Some of them are transferred. We're having the office staff contact the person and say we need a urine sample, or you need to go to the eye doctor, or you need to go to the podiatrist on an individual basis. That's going to take time for us to do."
The longest part of the discussion focuses on the group's prescribing patterns:
BROOKS: I can tell you there has been a tremendous increase in pharmacy costs to the tune of close to 20 percent this past year. So that that's why these rules are put in place — to make sure that people don't get things that really aren't appropriate. Sometimes the rules seem onerous. Sometimes they are onerous.
DOCTOR T: They are.
BROOKS: But sometimes, in hindsight, they actually make sense. [He says that a system whereby off-formulary prescription requests can be faxed to the pharmacy benefit manager, and a ruling can be faxed back, should make things much easier.]
DOCTOR T: That's still a lot of work, a lot of work on us and our staff — work that we're really not compensated for. That's a lot of looking up...
DOCTOR T: ...our staff faxing back and forth...
DOCTOR T: ... and then the approval can take up to a week. I've had shouting matches with my aides, the pharmacists, and the patient because no one knows yet or can tell me anything while we're waiting for approval.
DOCTOR G: You're making me change to medicines I've never used before. We're basically talking about how I'm comfortable practicing.
BROOKS: There are certain realities of the economics of medicine. You've really got to determine which of these drugs makes sense. Formularies are not going to go away. You buy insurance for your group here. You make a decision about what you want. There's not a doctor I visit any more who has straight indemnity insurance. We would all like everything to be covered without any hassle.
DOCTOR T: The onus for all this cost savings is falling on us but we're not seeing any money.
[The conversation gets to the point where Brooks states for the physicians what he said at lunch — that the group, which had once been one of the better performers in the plan — is now in the middle. "I don't agree with that," snaps Doctor G.]
BROOKS: Your patients are still spending more time in the hospital than in your average family practice. Your patients are spending more time in the hospital than 90 percent of the other practices.
DOCTOR G: We're not getting enough money to survive. Consultants that we've hired say that we're not seeing enough people to survive. We're adjusting as best as we can, but over time we won't be here. The consultants tell us that the deal is not to practice better medicine. The deal is: How can we beat the company?
BROOKS: You can go meet with the doctors [at better-performing practices] yourself. I'll give you their names. If you're interested in improving, that's what you have to do. There's more to practicing medicine than just taking care of patients' complaints. In the old world, no one was paying attention to whether someone was getting A, B, C, or D.
It is nearly 3:30 p.m. by the time Brooks and you are saying goodbye in the parking lot outside the practice. The interview is over, but Brooks's day is not. He will return to his office and paperwork that will occupy him to about 6 p.m. (He usually works 8 to 5.)
Before you part, he wants to make sure that you noticed what went on "in there."
"You saw that I offered to give them the names of practices who've improved thanks to our help, but no one took me up on it," he says. He adds that the remark about consultants telling groups that the way to improve income is to beat the insurance companies is a "new one on me."
Still, Brooks looks neither disappointed nor shaken by the reception. It's all in a day's work, as he earlier suggested.
"Doctors would rather not have rules and regulations," Brooks said. "For a lot of us, when we first started, that's the way it was. There were no rules and no regulations, and nobody was looking over our shoulders to make sure we were practicing quality care."
While that's changed, the scope of a plan's influence still depends, in large part, on physician buy-in. That — Brooks doesn't have to remind you as you stand in the balmy April afternoon — is the reason for his professional existence.
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