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THE challenge we all face as doctors is how to manage the rising tide of patients with chronic illness.
Our success in preventing death from heart disease is a fine example of our dilemma. Mortality rates have tumbled but patients who previously would have died live on with damage, which can progress over years to heart failure.
Cancer has become a chronic disease, requiring ambulatory care services for years with only short hospital admissions at diagnosis and initial treatment, and at the end of life.
We have good health services in Australia but they exist within formal boundaries of hospital, general practice and community care. Getting these elements together is a big deal.
The only equivalent challenge I know of is organising a 21st birthday where pillars of the family and factions of friends require diplomatic skills of a high order to be brought to a point of conviviality and harmony. Unlike the birthday party, the coordination of care for patients with serious and continuing illnesses is a long-term undertaking.
To succeed, coalitions have to be built to last. Putting the patient at the centre of it all sounds trite and is difficult to achieve, but is essential.
It is in this context that there is energetic worldwide interest in integrated or coordinated care, which is growing apace, driven by concerned clinicians, patients and health insurance agencies, and governments who have to pay for health care.
I spoke recently with a health minister who had undertaken a brief world tour to see how care was organised in Europe and the US. The same challenges were visible everywhere, and although local responses varied, managed, coordinated care was apparent in each country. “It’s the same everywhere I went”, the minister said.
There are a growing number of examples of how managed care can succeed.
McKinsey & Company, a global management consulting firm, has worked with health service providers in the US, the UK, France and Australia on ways care might be better provided for people with chronic problems.
Major health insurers, such as Kaiser Permanente in California with about 10 million health plan members, have been active in the introduction of coordinated or integrated care.
Meanwhile, Australia is moving cautiously.
One of the major elements of successful managed care is having one payer (an Australian example is the Department of Veterans Affairs) for all forms of care so that resources can be moved between the hospital, general practice and community to provide the most efficient care for the patient.
All managed care programs that have succeeded have expected discipline among doctors that many in Australia find irksome in concept, leading to protests. But there is support, particularly when doctors find that working in a managed environment, where their performance is monitored and where incentives are offered for high-quality care, is more congenial than they imagined.
It is true that effective information technology (IT) systems that permit records to be linked between service providers generally feature as part of effective managed care, but they are neither essential nor sufficient, though few programs lack them entirely.
Human communication among the providers and patients and carers is the critical dynamic in managed care. That’s fortunate because we still have some way to go before we have sufficient IT resources for coordinated care in Australia.
With good models of managed care and satisfied providers in other countries, Australia should consider its wider application here.
The opportunity to have a care system that works for the patients — wherever they are and at whatever stage of illness — is deeply attractive. A bonus is that with successful programs, costs generally come down.
Most patients need less hospital care and less medication confusion. Our health system needs less waste, particularly on duplicated tests.
With well run managed care, everyone wins.
Professor Stephen Leeder is the editor-in-chief of the MJA and emeritus professor of public health and community medicine at the University of Sydney.
Jane McCredie is on leave.
There has been a lot of praise aimed at Kaiser Permanente and quite a lot of careful appraisals. My only contact with a clinician working in that organisation was a paediatrician and provided a welcome opportunity for quizzing. She was a very happy camper and answered my enquiries with ease. I didn’t ask about coders but she wasn’t an orthopaedic surgeon. Perhaps we need more, and more wide-ranging, information, but there seems to be a lot going for that model to be seriously considered as we battle with the problems facing our health care systems. After all, Kaiser has to be competitive for patients and staff and also keep financially afloat.
The only system with millennia of proven success is the hippocratic concept of the doctor acting in the patient’s best interest, with the patient having autonomy to accept or reject treatment. The problem with other models is that they all have a core business other than the patient’s welfare, whether that be budget restraint or shareholder profit. My American orthopaedic colleagues who deal with Kaiser Permanente and other HMO providers employ on average 1.6 clinical coders per orthopaedic specialist, to deal with the paperwork. These administrative costs are passed on in the form of higher prices.
Prof Leeder’s enthusiasm for the Department of Veterans’ Affairs would not be shared by my Dubbo patient, who was informed that he would only be reimbursed for travel to Newcastle, rather than Sydney, because the DVA computer showed that Newcastle was nearer – notwithstanding that this individual had a hand injury, and was unable to drive, with public transport requiring him to go through Sydney to get to Newcastle. In 24 years of private practice I have never cancelled a patient for elective surgery (other than for medical reasons), but in my Public hospital, hundreds of patients were cancelled as cost saving measures, due to a policy of cancelling elective patients for subacute trauma cases. The enormous productivity cost to society of those who had organized time off work, was never considered, let alone the stress on the family of bringing someone into hospital only to have them sent home. This was ‘care’ managed by the state government, with its multi billion dollar bureaucracy. Keep the patient as self-manager, with a good GP to aid him.
Managed Care is not something with a set definition. It could be said the average GP is already involved in managed care whenever the public system sends patients home after admission, having arranged appropriate allied health care and medical follow-ups. The balance changes when patients are unable to access public care and rely on the GP for more assistance over a longer period for the same problem. Increasingly via systems already in place (like EPC referrals), GPs are part of managed care systems. It can be helpful, although proving it via overall outcomes is not easy.
The difference is when some other entity controls Managed Care. New issues enter the patient management equation. Not all of these are unique to general practitioners. They may include financial limitations; diagnosis based outcome predictions, rather than patient based outcomes; temporal outcomes rather than encounter-based; added red tape and reporting; and the personal electronic health record with the inherant problems of not being in control of what is entered, but probably being responsible for the consequences.
Every time I hear someone not directly involved in patient care is going to improve patient management, I have doubts. Too often it is the voice of government or an insurer with another agenda. When medical management is dictated, even by way of added time not devoted to patient care, it is more of an escuse for care. There’s already too much of that within our public to private, primary care medical interface.
Convince me better please Stephen
I have managed a lot of patients well into their terminal years because of the advent of excellent pharmacological agents and various CVS related procedures. Some families do an excellent job of keeping the old and frail at home with minimal need for outside agencies to become involved.
Big business can see this area as a business opportunity without any real interest in patient care.
using DVA as an example of a single payer creating efficiency in patient management is surreal.
As an Oral and Maxillofacial Surgeon i have the dubious “pleasure” of negotiating with both sides of that department.
The medical side is eminently reasonable, whereas the dental advisers point blank refuse gold standard treatments, refuse to supply the evidence base upon which these decisions are made, nor the composition of the board responsible, nor any submission to same. They even require the patient to be assessed by their GP to ensure they are fit for the treatment I am recommending – presumably they believe my medical degree came from the inside of a cereal packet?
This exmaple only goes to show that unfortunately “single payers” are not necessarily exempt from blinkered and prehistoric thinking and draconian attitudes – none of which benefits the patient and in a managed care environmnent precludes the patient seeking appropriate management elsewhere
I am unclear as to what Prof Leeder is saying about care management, at present general practice takes on the long term care of chronic illness, whether it be heart disease or cancer. The challenge would be to continue care at home rather than in nursing homes and other forms of residence. Training young people to be assistance in the persons home using the assets ot the home to pay for these services should be the role of government. The use of the home assets would be a way of funding which needs to be considered to cope with increasing health costs of chronic illness and aging. What I am suggesting is reverse mortgaging which would require government backing to provide accommodation in a nursing home when home care no longer possible. The formation of this type of plan for better skills of care in the home should be an objective of improving general practice. Maybe some other readers could explain to me better ideas that need to be understood to better manage care. I feel the time has come to deal with this situation of the aging chronic illness and dementia care before we reach a stage of chaos.