PASADENA, California--The health care system in the United States has
been developed along the lines of medical specialization, which can
lead to the fragmentation of patient care. Specialties are created by
artificial divisions such as organ systems (cardiology, neurology);
age (pediatrics, geriatrics); sex (urology, gynecology); disease
(oncology); and function (surgery, obstetrics).
"Disease management attempts to transcend all these specialties
by providing a structure for appropriate, high-quality, yet cost-effective
care--often for patients with significant medical problems,"
said Albert E. Barnett, MD, former chairman, Friendly Hills Health
Care Network, La Habra, California, at a seminar sponsored by the
National Managed Health Care Congress.
Friendly Hills Health Care Network is a large integrated health care
delivery system that approached disease management with the goal of
preventing further fragmentation of patient care. Integrated internal
services were used where possible, and carveouts, or contracted
specialized services, were used "where they made sense,"
said Dr. Barnett, who is currently chairman of the Institute for
Healthcare Advancement, Whittier, California.
Southern California Permanente Medical Group, Pasadena, a group-model
HMO, with a 100% capitated system, approaches disease management
differently. Oliver Goldsmith, MD, medical director and chairman of
the board, described the Kaiser Permanente model as a "fixed
system" in which nearly all care is provided internally.
Continuum of Care Model
At Friendly Hills Health Care Network, a continuum of care model was
used to develop an integrated organizational system of medical care
to meet its members needs. The continuum covered a variety of
health care settings, including primary, ambulatory, acute, tertiary,
home, long-term, and hospice. Case managers determined which care
setting was most appropriate for patients.
In terms of disease management, Dr. Barnett said, services were
provided by group members when possible and by outside groups in some cases.
"We looked at disease management in terms of carveouts," he
said. "Carveouts were disease processes that were best moved out
of the group practice, where care could be provided more efficiently
and with higher quality."
Dr. Barnett described characteristics necessary for a successful
carveout. First, it should be a well-defined specialty. Oncology is
an example of such a specialty, since a patient either has cancer or
does not. On the other hand, it is harder to develop specific
guidelines for referral of patients to orthopedic specialists, for example.
A specialty area is also a good candidate for carveout if it produces
manageable, and understandable, results and data. In addition,
economic realities, like the need for specialized equipment and
personnel, must be considered. Finally, a plan should determine the
size of the patient base needed to make it worthwhile to provide the
specialty care internally.
Oncology a Successful Carveout
At Friendly Hills, services that fulfilled these requirements and
were successfully carved out were oncology, infectious disease
treatment, neurosurgery, and mental health services.
A cardiology carveout was not as successful, Dr. Barnett said.
Although cardiology is a very complex area, he said that referrals to
cardiologists were appropriately managed. However, it was difficult
to develop guidelines for expensive outsourced services, such as
defining the appropriate number of surgeries, bypasses, angiograms,
and echocardiograms needed by the patient population. Eventually, to
better control utilization, the Friendly Hills group decided to
establish an internal cardiology group.
A diabetes clinic was established but disbanded when it became too
costly. Since these patients typically have multiple medical
problems, the requirement to attend the diabetes clinic actually
increased office visits.
These experiences led to a refined approach. "Rather than try to
outsource whole specialties, or diseases that worked in the group
practice modality, we outsourced specific processes," Dr.
Barnett explained. Examples included coumadin and cholesterol
clinics, run by pharmacists; a wound care clinic, run by nurses; and
No Carveouts at Kaiser Permanente
Kaiser Permanentes organizational structure requires a
different approach to disease management, Dr. Goldsmith said. Since
Permanente physicians and the health plan have a mutually exclusive
relationship, 98% of patient care in the California HMO is provided
by its own medical personnel. The group-model employment structure
provides a built-in integration of services, and therefore carveouts
are not utilized, Dr. Goldsmith explained.
Disease management is one of the processes Kaiser Permanente uses to
meet patient care performance goals, or targets. Rather than trying
to get the 3,000 physicians in the Southern California Permanente
Medical Group moving in a similar direction through the use of
patient care guidelines, the Group uses internal targets, or measures
of performance, that physicians continuously strive to meet.
Dr. Goldsmith noted that physicians have been found to respond very
well to target setting. Deciding what to target, however, can be a
challenge. "You want to target something that will make a
difference," Dr. Goldsmith said. In addition, targets can be
driven by various interested parties, for example, purchasers,
members, or physicians.
To keep the improvement effort in motion, it is important to achieve
the right mix of consensus on the development of targets and to
utilize a regional management-driven push, Dr. Goldsmith commented.
Goals should be kept realistic or participation in the efforts will
decrease, he added.
Mitigating factors for the attainment of goals must be taken into
account as well. Available technology, information system resources,
membership growth, and the addition of new physicians to the system
will influence the ability to meet targets.
Sometimes creative methods are necessary to move closer to a goal.
For example, Dr. Goldsmith noted that even though physicians were
recommending mammograms to patients, mammography rates were not
increasing at a satisfactory rate.
A system was implemented that flags the medical record of a member
who needs a mammogram. When that woman is seen for any medical
service, the staff will be prompted to remind her that she needs the
test. The member can then be scheduled for the mammogram within a
very short time frame. "Once we did this, we saw a very
satisfying rise in our mammography rates," he said.
The process of setting targets provides continuous improvements that
benefit members, Dr. Goldsmith said. "Year after year, you can
see measurable, objective improvements. The absolute numbers are not
as important as continually improving the organizations
performance," he said.