At Risk and Under Scrutiny

By Joanne Conroy, MD

I read a New York Times article about how the heaviest users of health care are now under scrutiny by insurers, who are trying to figure out how to manage these heavy users aggressively and effectively. Insurance companies are becoming increasingly sophisticated; they can identify those users and are trying to intervene before bad and expensive things happen. But they are still “grappling with their understanding of human nature,” as Reed Abelson writes, struggling to understand why some people just don’t take care of themselves.  They acknowledge that this might be their biggest obstacle.

What do we know?

Out of 100,000 patients at your institution, probably about a thousand of them would be high utilizers. They have a chronic disease, but also have been to your facility more than once with a diagnosis of chronic pain and have underlying behavioral health co-morbidity. Their per-member per-month (PMPM) utilization of health services is close to five times that of the average patient with chronic disease. They use the emergency room, inpatient facilities, and specialty and primary care providers. They “doctor shop” and can only be managed by targeted, intense outpatient care.

We all have these patients, and we know who they are. These are the people we worry about from a cost perspective; the cost of care needs to be managed. But what about the patients who need to be better managed from a quality perspective? They are the ones who escape insurer scrutiny. Most likely, when the insurer’s care management nurses call these patients, they just don’t return the calls. Let’s be honest: The average patient is very resistant to “management “by an insurance company. The solution? More female internists with strong, authoritarian personalities.

Case in point: My husband was diagnosed with Type 2 diabetes last year. Not a surprise; he would think nothing about downing a bag of jelly beans, Oreos, or a dozen warm Krispy Kreme doughnuts at a sitting. His poor pancreas just gave out. He was deaf to my counsel about his diet. He had some vague symptoms that sounded like a lower extremity neuropathy, so I sent him to a local female internist who had recently opened her practice. She was Eastern European, older, and had joined the office of an established female physician with good quality ratings.

Wow, when he came home with the diagnosis, he was angry that I had not told him about the consequences of diabetes. Actually, I think he was very scared. His internist had read him the riot act and shared in graphic detail the consequences of noncompliance with a sugar-regulated lifestyle. He said, “You never told me I could lose my legs!”

My husband now keeps his appointments religiously. He is actually afraid to miss an appointment because his doc will discharge a noncompliant patient from her practice in a heartbeat. If you are her patient, you are in a partnership, and you have to do your part.

My husband now reads food labels, watches his sugar intake religiously, and takes his blood sugar and records it. When he had instructions to get a colonoscopy (10 years late), he told me that we had to find a time when I could take a day off of work for his procedure, because he could not go to his next appointment without telling her that he had scheduled the appointment. This woman wields some serious power.

Dr. Charles Raison, CNNHealth’s mental health expert, articulated how powerful the doctor–patient bond really is.  He pointed out, “NIMH compared the efficacy of two types of psychotherapy with an antidepressant, while simultaneously comparing these interventions with a placebo.” The study found — not surprisingly — that medications and therapy are superior to placebo.

However, in a sub-study of the larger project, researchers videotaped doctor–patient interactions during clinical visits, then showed the videotapes to expert raters charged with assessing the doctor–patient relationship, based on what they heard and saw. Just by watching the tapes, the researchers were able to make strikingly accurate predictions regarding who would go on to get well and who wouldn’t, regardless of the treatment they were receiving.

A good therapeutic relationship between doctor and patient turned out to be more powerful in promoting recovery than whether the patient got an active treatment or placebo. Patients who showed a strong and positive emotional connection with their doctors were far more likely than others to improve during the study. I don’t think my husband would be as powerfully connected to an insurance care manger. There is something about the physician–patient relationship that is both positive and powerful.

One size does not fit all. The doctor–patient relationship in managing a chronic disease together is very personal. The connection helps get patients to do things that are good for their health but might not be easy or pleasant. Some patients need to be nagged, some threatened and some cajoled. Everyone’s button is a bit different. On ratings sites, my husband’s physician is described as professional, competent, and direct. She wouldn’t be a good choice for patients who are looking for gentle and supportive.

I need an internist myself, and my husband’s doctor sounds like my type of physician. However, I am reluctant to disrupt that powerful and effective bond they have by becoming her patient too.

—Joanne Conroy, MD, is Chief Health Care Officer at the Association of American Medical Colleges. She can be reached at Follow her on Twitter @joanneconroymd

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