February 16, 2003
By MICHELLE ANDREWS
HEN Florence Phillips was told by her doctor two years ago that she had congestive
heart failure, she didn't have to worry about how she would manage the disease.
A health educator from her doctor's practice, the Hill Physicians Medical Group in San Ramon, Calif., called her immediately to talk about her condition and sent along a packet of material about it. Over the next several weeks, Ms. Phillips, 86, received more information and follow-up calls. She learned how to deal with her illness daily by watching her weight, restricting her salt intake and keeping up with her medications. She learned to look for signs of problems that would require her doctor's immediate attention, and to schedule regular checkups to monitor her condition.
Although there is no cure for congestive heart failure — which occurs when the heart cannot pump blood efficiently — her illness is under control. Ms. Phillips is pleased with her care. "They check into everything, and if I have any problems they always get me in right away," she said.
In recent years, disease management programs have sprung up nationwide as employers and insurers grapple with rising medical costs. Nearly two-thirds of those costs go toward treating chronic illnesses like congestive heart failure.
But Ms. Phillips's experience is uncommon in one very notable way: the disease management services are being sponsored by her doctor and her doctor's medical group, not by a health insurer or an employer. And her doctor stands to make more money from the Hill Physicians Medical Group, in the form of an annual bonus of roughly 10 percent of his compensation, if he can keep her and his other patients out of the emergency room, keep their cholesterol under control and make sure they're taking their medications, among other things.
This is not the way doctors normally practice medicine, but maybe it should be. "The American medical system has been designed around heroic efforts, not around creeping diseases," said Steve McDermott, chief executive of Hill Physicians, an independent-practice association with 2,000 doctors and 350,000 patients in Northern California.
For example, he said, heart surgeons are among the highest-paid doctors and often perform heroically during emergencies.
"You want your reactive systems to work very well," Mr. McDermott said, "but that's a talent and a skill and a mind-set that's very different than the teamwork that's required in disease management."
Doctors are only beginning to embrace this approach. A study published last month in the Journal of the American Medical Association found that the average physician group with 20 or more doctors used just 5 out of 16 "care management processes" prescribed by the authors, like case management and patient education, to treat patients with four chronic diseases — diabetes, asthma, congestive heart failure and depression.
Because smaller practices lack the people and resources to put these systems in place, they "are almost certainly doing even less of this," said Dr. Lawrence Casalino, an assistant professor of health studies at the University of Chicago and a principal author of the study.
Disease management programs sponsored by health plans or employers may do an excellent job, but they're often perceived — sometimes accurately — as limiting care rather than encouraging it. Catherine Marschilok, manager of the Northeast Health Diabetes Centers at Albany Memorial Hospital and Samaritan Hospital in Troy, N.Y., described the not-uncommon experience of a patient whose doctor referred him to Northeast Health for a five-session diabetes self-management course after the diagnosis. The man's insurance company refused to pay unless he had been hospitalized or admitted to the emergency room twice, citing the contract with his employer. "I was shocked," Ms. Marschilok said. "What they paid in disease management they could actually save in hospital costs."
From a patient's perspective, it makes sense that a doctor would be the point person in managing care: the doctor, after all, does the examining and sees the patient regularly. Traditionally, however, doctors haven't been paid to monitor and manage patients' care. Instead, their compensation has often been based on diagnosis and treatment. In other words, they've been paid to make you healthy, but not to keep you that way.
Offering financial incentives to doctors, as Hill Physicians has done through its bonus program, is an effort to shift the focus toward better patient care management. Others are trying similar approaches. In one of the largest experiments, six California health plans covering eight million patients in health maintenance organizations started a "pay for performance" effort in January in which they agreed to pay physician practices extra for meeting certain performance measures.
It's too early to tell. "We currently have a payment system that's very wrong-headed," said Margaret O'Kane, president of the National Committee for Quality Assurance, which accredits managed-care plans and last year began accrediting disease management programs. "The question is how do you get people motivated," she said. "They're running out of tools to drive better quality, and this is a new approach."
With any luck, giving doctors performance incentives will turn out to be a
bonus for patients, too.