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The Emerging Role of Physicians in Disease Management Programs


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Title: The Emerging Role of Physicians in Disease Management Programs

The Emerging Role of Physicians in Disease
Management Programs David Sobel, MD, JD Rushika
Fernandopulle, MD, MPP Emmi Solutions,
LLC Renaissance Health Chicago,
IL Cambridge, MA
Who am I?
  • Recovering Attorney
  • University of Michigan Law School (1992)
  • Paul, Weiss, Rifkind, Wharton Garrison
  • Urological Surgeon
  • University of Illinois Medical School (2000)
  • Rush University Medical Center (2000-2005)
  • Chief Medical Officer founder of Emmi
    Solutions, LLC

Historical Context
  • Life is short, the Art long, Opportunity
    fleeting, Experiment treacherous, Judgment
    difficult. The physician must be ready, not only
    to do his duty himself, but also to secure the
    co-operation of the patient, of the attendants
    and of externals. emphasis added
  • -Hippocrates

Historical Context
  • Only section of the Hippocratic Corpus that
    addresses doctor-patient communication
  • perform your duties calmly and adroitly,
    concealing most things from the patient while you
    are attending to him. Give necessary orders with
    cheerfulness and serenity, turning his attention
    away from what is being done to him sometimes
    reprove sharply and emphatically, and sometimes
    comfort with solicitude and attention, revealing
    nothing of the patients future or present
    condition. emphasis added

New Paradigm
  • In our country, patients are the most
    under-utilized resource, and they have the most
    at stake.  They want to be involved and they can
    be involved.  Their participation will lead to
    better medical outcomes at lower costs with
    dramatically higher patient /customer
  • Charles Safran, M.D.
  • President, American Medical Informatics
  • From his Testimony Before the Subcommittee on
    Healthof the House Committee on Ways and Means

  • Disease Management
  • Care Management
  • Population Management

New Paradigm
  • Medical Home Model
  • Ongoing relationship between a provider and
  • Around the clock access
  • Respect for the patient/familys cultural and
    religious beliefs
  • Comprehensive approach to care
  • Coordination of care through providers and
    community services
  • AAMC

American College of Physicians Definition
  • Best quality care is provided through
  • Patient-centered, physician guided
  • Cost-efficient and longitudinal
  • Encompasses and values the art and science of
  • Attributes of Medical Home include
  • Promotion of a continuous healing relationship
  • Through delivery of care in a variety of care
  • According to the needs of the patient and skills
    of the medical provider

Consistent Themes
  • Patient Centric
  • Wellness
  • Physician Driven
  • Enhanced Access

Even Better
  • Engaged Patients
  • Leveraged Physicians

Redefining the Physicians Role
  • Doctor walks into a bar . . .
  • Pain
  • Misery
  • Suffering
  • YOU
  • TOO

Wednesday May 14, 2008
  • 18 Patients in the AM
  • 830 -1000
  • 830 -1010
  • 840 -1020
  • 850 -1020
  • 900 -1030
  • 910 -1040
  • 920 -1100
  • 930 -1115
  • 940
  • 950
  • 21 Patients in PM
  • 100 -230 -400
  • 110 -240
  • 120 -250
  • 130 -300
  • 140 -310
  • 150 -320
  • 150 -320
  • 200 -330
  • 210 -340
  • 220 -350

How to spot a physician?
Can you spot the caregiver? Which one
manages disease?
Redefining the Physicians Role
  • CV
  • AOA graduate from Emory University Medical School
  • Internal Medicine Resident voted best resident
    by peers
  • Invited for Chief Residency position
  • How he described his patients
  • 20 semi-strangers who do nothing but complain.
  • How he described his day
  • Its like suffering through Thanksgiving
    everyday of the week.

Redefining the Physicians Role
  • Medical Home Model demands that the physician be
  • All knowing This requires technology to
    assemble virtual teams of people and
    resources as needed based on patient needs
  • Always present This requires technology such as
    IVR, web coaching, and web visits to automate
    routine communications
  • Service with a smile This requires training and
    technology to help physicians communicate with
    empathy and clarity

Conversation is the Key
  • Communication isnt a message sent its a
    message received
  • We need to be better listeners
  • People dont always say what they mean
  • We need to actively listen
  • Position demand or assertion often expressed
    with strong feeling
  • Interest the underlying concern that generated
    the position
  • Communication isnt always verbal

The Power of Conversation
  • 12 Angry Patients
  • No one is a doctor
  • Everyone is a patient
  • I know how to talk to patients

Can you catch cancer?
Can you catch cancer?
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  • The Conversation

Low Tech
  • We are sorry! We always try to meet your
    scheduled appointment time.
  • Sometimes we run late and we apologize. A
    patients visit sometimes takes longer than we
  • Sometimes that patient is you.
  • James W. Saxton, Esq., The Satisfied Patient,

Leverage Technology
  • Literature review of computer-based patient
    education (1970-2001)
  • Majority of studies showed significant gains in
    knowledge acquisition
  • Also
  • Increased prevalence of self-care behaviors
  • Improved health outlook
  • Increased adherence to health management regimens
  • Increased patient satisfaction
  • Positively impacted several different clinical
    outcome measures.
  • Lewis, D. Computers in Patient Education.
    Comput, Informat, Nurs 2003

The Disease of Familiarity
  • Interactive computer programs were as effective
    or even more effective than instruction provided
    by staff educators
  • Krishna, Santosh, Balas, E. Andrew, Francisco,
    Benjamin D., Konig, Peter, Graff, Gavin R.,
    Madsen, Richard W., Internet-Enabled Interactive
    Multimedia Asthma Education Program A Randomized
    Trial. Pediatrics, 00314005, Mar2003
  • Green, MJ, et al, Effect of Computer-based
    Decision Aid on Knowledge, Perceptions, and
    Intentions about Genetic Testing for Breast
    Cancer Susceptibility. J Am Med, 2004
  • Jenny, NYY, et al, Evaluating the Effectiveness
    of an Interactive Multimedia Computer-based
    Patient Education Program in Cardiac
    Rehabilitation. Occup Ther J Res, 2001
  • Jones, RB, et al. Randomized Trial of
    Personalized Computer-based Education for
    Patients with Schizophrenia. Br Med J, 2001
  • Martin, JT, et al. NPs vs. IT for Effective
    Colposcopy Patient Education. Nurse Pract Am J
    Prim Health Care, 2005
  • Miller, DP, et al. Using a Computer to Teach
    Patients about Fecal Occult Blood Screening A
    Randomized Trial. J Gen Intern Med, 2005
  • Evans, AE, et al, Computer-assisted Instruction
    An Effective Instructional Method for HIV
    Prevention Education?, J Adolesc Health, 2000

Best Practices
  • Visuals
  • Creating programs that rely on simple graphics
    and animation to illustrate key concepts makes
    the program easier to follow for most people, but
    is critical for those patients with diminished
    reading skills. (1)
  • Empathy
  • Studies have found that consumers seemed more
    willing to confide in computers than in human
    interviewers, possibly because the computers were
    perceived as nonjudgmental or evoked less
    embarrassment on sensitive subjects. (2)
  • Plain Language
  • Nearly half of all American adults have
    difficulty understanding and using health
    information Higher rate of hospitalization and
    emergency services when patients have limited
    health literacy. (3)
  1. Sechrest, R.C. D.J. Henry. Computer-based
    patient education observations on effective
    communication in the clinical setting
  2. Mantone, Joseph. (August 8, 2005). Reading,
    writing and relating. Modern Healthcare.
  3. Health Literacy A Prescription to End Confusion,
    IOM April 2004

Best Practices
Visuals - show it, dont say it. Empathy -
say it, dont write it. Plain Language - write
it. But, write it well.
Unlike people with type 1 diabetes, people with
type 2 diabetes produce insulin however, the
insulin their pancreas secretes is either not
enough or the body is unable to recognize the
insulin and use it properly. This is called
insulin-resistance. When there isn't enough
insulin or the insulin is not used as it should
be, glucose (sugar) can't get into the body's
cells. When glucose builds up in the blood
instead of going into cells, the body's cells are
not able to function properly. Other problems
associated with the buildup of glucose in the
blood include Dehydration. The buildup of sugar
in the blood can cause an increase in urination
(to try to clear the sugar from the body). When
the kidneys lose the glucose through the urine, a
large amount of water is also lost, causing
dehydration. Diabetic Coma (Hyperosmolar
nonketotic diabetic coma). When a person with
type 2 diabetes becomes severely dehydrated and
is not able to drink enough fluids to make up for
the fluid losses, they may develop this
life-threatening complication. Damage to the
body. Over time, the high glucose levels in the
blood may damage the nerves and small blood
vessels of the eyes, kidneys, and heart and
predispose a person to atherosclerosis
(hardening) of the large arteries that can cause
heart attack and stroke. Anyone can get type 2
diabetes. However, those at highest risk for the
disease are those who are obese or overweight,
women who have had gestational diabetes, people
with family members who have type 2 diabetes and
people who have metabolic syndrome (a cluster of
problems that include high cholesterol, high
triglycerides, low good 'HDL' cholesterol and a
high bad 'LDL' cholesterol and high blood
pressure). In addition, older people are more
susceptible to developing the disease since aging
makes the body less tolerant of sugars. Although
it is more common than type 1 diabetes, the
causes of type 2 diabetes are less well
understood. It is likely caused by multiple
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When Prescribed by a Physician
  • 89 watched program from start to finish
  • 87 of patients experienced increased confidence
    in their doctor
  • 96 of patients reported improved understanding
  • No incentives
  • No free iPods
  • No rewards or threats

Putting the Physician Back into Disease
  • Rushika Fernandopulle, M.D., M.P.P.
  • Renaissance Health
  • Cambridge, MA, USA
  • May, 2008

Start with the Sickest Patients
The most leveraged target for redesign are what
we call Complex patients- those with multiple
chronic conditions who end up costing up to 2/3
of all health care dollars, and are poorest
served by the current system.
Complex- 0-10ile- 65 costs
Simple Chronic- 10-20ile- 15 costs
Acute illnesses- 20-50ile- 15 costs
Healthy- 50-100ile- 5 costs
Source Large West-coast self-insured employer
PPO data, 2005. n147K
A new model from the ground-up
The RenHealth Complex Care Model Re-imagining the
entire care system for complex patients
  • New Processes
  • Jointly created strategic health plans
  • In depth education and coaching from RN/CHWs
  • Unfettered access to help
  • Proactive management
  • Remote monitoring
  • Integrated mental health
  • Specialists as consultants
  • New Structures
  • Different staffing and true team care
  • Robust Information Technology Platform
  • Physical Design
  • Business model
  • Culture
  • New Principles
  • Meet the needs of our patients and focus on
  • We cannot manage our patients health they must,
    and we can provide tools and resources
  • Continually innovate and improve

Early Pilots of the Model (and Variants)
Legacy Sites- Active before 2006
  • Part of a larger movement
  • AAFP- Transfor-med (36 sites)
  • ACP- Patient Centered Medical Home
  • IMP- Ideal Micro Practices
  • CMS- Case Management for high cost Beneficiaries

Sites in Implementation Phase
Sites in Planning Phase
Variant 1 Working with existing Medical Groups
  • Boeing is a leading aerospace company
    headquartered in Chicago, but with gt150K
    employees in 70 countries
  • Annual revenue 2006 US61.5 billion
  • Self insured, large, stable, geographically
    concentrated workforce gtUS2b in medical costs
  • High and rising health costs put them at a
    competitive disadvantage with their major
    competitor (Airbus)

  • Focus on Puget Sound, WA market
  • Two major plants to assemble commercial
    airliners, may other sites total of gt150K lives
  • Partnering with three well respected, progressive
    providers to build A-ICU model for 700 predicted
    high cost employees and dependents

Linking payment change with clinical redesign
  • Patients selected through predictive modeling,
    invited by their doctors to participate
  • Provide RN Health coaches to work within medical
    groups to help manage patients
  • Practice are staffed by high performing MD, RN
    health coach, other help
  • Shared care plan, access, proactive care all
  • No benefit changes, so sites continue to bill
    Fee-for-service for MD visits
  • Sites get paid a case rate pmpm (roughly 2.5 of
    total spending) to cover non-traditional services
  • In subsequent years will consider sharing savings
    with sites

Variant 2 Workplace Clinic for Complex Patients
Atlantic City, NJ
  • HEREIU Fund- Large multi-employee trust fund for
    service workers- hotel, restaurant and casino
  • Focus on Atlantic City, NJ with approx 25K lives
  • Partner with a large not-for-profit integrated
    delivery system (IDS)- Atlanticare to build a new
    clinic for predicted high cost employees and
  • Patients are given incentives (through waived
    copayments for visits and pharmaceuticals) to
    seek care at the Special Care Center
  • Globally budgeted, costs shared by Fund and
    Health System

A redesigned care space, team, and system
Anecdotally Making a difference
Physician Feedback
Patient Feedback
  • I look forward to seeing IOCP patients on my
    schedule. I can see whats happening with
    patients whom I have generally struggled with for
    years. The light bulbs are turning on, they are
    engaged and motivated.
  • Patients respond positively to their
    relationship with their care manager. Its like
    the whole tenor of the visit is changing from one
    of resignation that nothing is likely to change,
    to one of improved results, optimism, and hope.
  • I have been helped more in the last six months
    than years of seeing multiple doctors.
  • Being a patient in the IOCP has been a
    life-changing event for me. I have learned to
    change the way I live and think. I finally
    stopped smoking. Somebody actually listens to me
    and is giving me the help I need.
  • My BP is now normal after being high for many
    years. I am getting good advice about my
    prescriptions. I am able to take walks and hope
    to be swimming again soon. I am feeling positive
    now, I once felt doomed. I feel like a new

Goals tracked across multiple vectors
Health Costs Reduce net total health care
spending trend for target population vs. control
group in 1-2 years
Functional status Improve self reported
functional scores (SF-12) and improve
productivity in the workplace
Quality Improve performance on chronic disease
measures, both claims based and ones based on
clinical data
Patient Experience Improve patients experience
of care across all dimensions in a standard
survey (ACES/CG-CAHPS)
Staff Satisfaction Create an excellent work
environment for physicians and staff
Advantages Over Traditional DM
  • Much higher engagement rates
  • Able to manage with clinical as well as claims
  • In person relationship and transference from MD
    helps with behavior change
  • Effector arm to change care if needed
  • Spillover effects of collaboration between payer
    and provider

Insanity is doing the same thing over and over
and expecting different results -Albert Einstein
Renaissance Health One Broadway, 14th
floor Cambridge, MA 02142 P 617.682.3669 F
617.475.6027 W E