A supportive physician backing a DM program can often be the difference between success and a lost opportunity.
In order to improve member lifestyles via DM, most experts believe all stakeholders must get on the same page to help those faced with diabetes, asthma, and chronic obstructive pulmonary disease (COPD).
However, in many cases, an unsatisfied physician, who may remember managed care slights, can become an unmovable barrier to a healthier lifestyle. It’s not that the physician wants to block a patient from positive outcomes, but the doctor has negative experiences with managed care organizations and believes they serve as a barrier.
“I think they feel neglected, threatened by the disease management companies who really work for the plans, not for the doctors,” says Michael Eliastam, MD, associate dean of SABA University’s School of Medicine, a Caribbean school that is headquartered in Gardner, MA. “By and large [the health plans] basically tell patients, ‘We’re here to help you deal with your diabetes,’ and the doctor at best is ignored, at worst feels threatened and angry about it.”
The patient is more trusting of his or her PCP than a faceless health plan or DM organization, and gaining the physician’s trust is a critical stamp of approval for the program.
Whether that river of doubt and suspicion can be crossed is the question.
“I would be naive if I said to you that it’s easy because so much water has gone under the bridge. There’s so much bad feeling,” says Eliastam, who has worked for Boston City Hospital as chief medical officer and clinical leader of Accenture, a global healthcare practice.
Three experts who have experienced success bringing physicians into the fold (James Ehlen, MD, chair of Halleland Health Consulting in Minneapolis, Sandeep Wadhwa, MD, vice president of care management services at McKesson Health Solutions in San Francisco, and David Kelley, MD, chief medical officer for the Pennsylvania Department of Public Welfare’s Office of Medical Assistance Programs in Harrisburg) spoke at an August 28 HCPro, Inc., audioconference, “New Directions in Disease Management: Strategies to overcoming physician resistance.”
When it’s time to create a program, the experts suggest the following:
Follow the AMA’s pay-for-performance (P4P) guidelines (see “AMA’s P4P principles” on p. 131)
“The overarching theme here is to pay attention to detail that is important to physicians and caregivers,” said Ehlen. “It’s important that before the program is installed that the key stakeholders are engaged . . . We found that communication back to the physicians in days and not in weeks was deemed to be more effective. We also learned from our system that talking to the proper physician was important.”
Ehlen said Halleland needed to show the physicians that the managed care organization was committed to the particular DM program.
Constantly switching focus to the so-called new-and-improved programs only leads to cynical physicians, he added.
To demonstrate sustainable outcomes was helpful in winning physician support, said Ehlen.
McKesson Health Solutions is involved in a Medicare Health Support program in Mississippi. McKesson identified approximately 21,000 beneficiaries for the intervention group in the rural, poor population, and nearly 14,000 participated.
The managed care company also signed up about 40% of the PCPs in the state.
Getting the physicians on board and being part of a Medicare program were positive steps for patients. The organization needed to repair hurt feelings and misunderstandings from past negative managed care experiences. DM programs should bring each aspect of a person’s healthcare together—not divide them with managed care on one side and the physician on the other, said Wadhwa.
“We needed to regain our trust with providers in the community,” Wadhwa said.
McKesson was able to accomplish this by clearly explaining the program to physicians. Not all physicians were keen on taking part. Wadhwa reported nursing home doctors were slower in showing support and were not responsive to mailings. Instead, McKesson found face-to-face group meetings worked.
Having both Medicare and the individual physicians behind the DM project made patients more apt to take part. “We thought that was a strong message to say this program is sponsored by Medicare and endorsed by your doctor,” said Wadhwa.
Kelley said the ACCESS Plus Program, which covers 290,000 people living in rural Pennsylvania, found success through collaboration.
Approximately 34,000 ACCESS Plus Program members have chronic diseases (e.g., asthma, diabetes, COPD, CAD, and CHF) covered by a DM program operated by McKesson Health Solutions.
During the planning stage of the program’s pay for performance, officials brought many different healthcare stakeholders to the table. The Pennsylvania Medical Assistance Program formed a P4P workgroup that included several state medical organizations and consumer groups to help them create a program that both physicians and consumers would support.
“We have a lot of consumer advisory activity in the state of Pennsylvania. We thought it was important to get their input on the program,” said Kelley.
Communication is key when working with physicians. “Incorrect communications could be worse” than no communication, said Ehlen. “Making sure that we are communicating in the right direction can be a way to avoid the skepticism.”
Phase one of the P4P program included early rewards, such as $200 for signing up for the program, $30 per patient to encourage consumer participation, and $40 per patient for identifying DM candidates.
Phase two focused on payment for collaboration via care plans, such as $60 per care plan with a cap of two care plans per year.
Phase three of the incentive plan involves quality of care process improvements and a $17 payment per process accomplished for each patient. Kelley said the next wave of payments will be linked to quality of care processes.
Almost two years into the P4P program, Kelley said, there are more than 800 participating providers, whose offices care for more than 15,000 DM patients (more than 7,000 high-risk patients). The P4P program has meant more than $600,000 to the physicians who have taken part.
Higher payments needed
In general, Eliastam says P4P payments must increase in order to have physicians interested in DM programs. Paying a physician a small amount does not affect his or her practice in a grand scale, he adds.
“I’m underwhelmed at the size of the pools being put out there,” says Eliastam. “I think you have to put some serious money into this stuff, like 10%–20%, to get a change in behavior . . . They’re not going to do that for nothing. You have to share the wealth.”
In order to get physicians on board with DM programs, Eliastam suggests increasing payments, providing money for electronic medical records so physicians can communicate effectively, and involving doctors to refine call centers.
Eliastam says managed care must also spark interest among patients to see the benefit of DM programs.
“You can see the patients don’t see that much value yet. You look at the enrollment rate and the compliance rate. You don’t see people beating down the doors to be in disease management programs,” he says.
Eliastam shares the view of many physicians who simply are not sold on DM. He wonders why managed care programs back DM and suggests there is political appeal and public relations value for insurers to buy DM programs.
“I think the theory is correct. I think population health and interventions and stratification of populations and customized interventions helping patients in collaboration with their providers is excellent, but that’s not what we got,” says Eliastam.
For more information about the audioconference, visit www.hcmarketplace.com/prod-5629.html or call 877/727-1728.
AMA’s P4P principles
American Medical Association lists five principles for pay-for-performance (P4P) programs:
1. Ensure quality of care
2. Foster the relationship between patient and physician
3. Offer voluntary physician participation
4. Use accurate data and fair reporting
5. Provide fair and equitable program incentives
Source: AMA’s Web site: www.ama.assn.org.
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