Editor’s Note: This guest blog post was written by Brenda Blunt, ORAU Senior Director of Health Policy.
Brenda Blunt, ORAU Senior Director of Health Policy
Anyone who has spent time talking with me about my personal passions related to health knows that one of my primary soap boxes is a phrase I usually say like this: “If we would get back to real primary care and make it look more like palliative care or hospice, we could improve outcomes and save money.”
What stands behind this sentiment is my experience in hospice, both professionally and personally. I am a huge advocate for hospice care. I believe in the mission, when carried out with the right intents and focus, and believe in focusing on the patient and family when developing a plan of care. I believe in coordinating across all providers, diagnoses, medications, activities together with what is important for the patient and family, how do their beliefs and level of understanding get accounted for in the plan.
Our care system has become fragmented at best, even when a consumer stays within a specific healthcare system, often the diagnoses, specialists, and therapies are not coordinated. Consumers go between specialists and subspecialists with the primary care provider spending more effort in referrals and paperwork than in actual coordination and creating a plan of care with the patient/consumer at the center. The policies around payment, including quality measures and rating scores, are at the center.
Before I offend too many people, let me clarify, I do not believe providers do this intentionally. I believe providers go into medicine to care for people. I believe they would love to have more time with patients, actually focus on healing, be able to recommend additional resources like nutritionists, or offer in depth reviews of medications and diagnoses. However, our payment system is not designed to facilitate those things and as altruistic as we would all like to be, there are costs associated with providing care and those bills must be paid.
I will also clarify that most of what I will write about relates to chronic diseases and most Americans. There are instances where a case will be too complex for what I am about to propose. I have cared for those patients as well.
What if we were to prioritize the patient / consumer / beneficiary (pick your chosen term for someone seeking medical care) and connect them with a provider that is responsible for coordinating all care, diagnoses, medications and other therapies. Someone that actually knows the patient/consumer, their social story, their challenges, their level of understanding, their primary concerns, and can connect all the dots between the consumer and the system.
This is what we do in hospice. We pull the whole story together. We look at the medication lists and consider the interactions not just of the medications with each other, but with the symptoms the patient is having, the potential side effects of each medication, the patient’s goals, the finances of it all. We consider what other therapies are or would be helpful, which ones are creating more issues for the patient than helping. We dive deep into the patient’s and family’s goals, significant distresses, needs beyond the physical realm (read as emotional and spiritual), and identify ultimate desired outcomes.
Research has shown that patients get a rebound burst when entering hospice if they enter early enough. We often reduce the number of medications they are on, and provide services to address the patient’s emotional, social and spiritual needs. We reduce the number of appointments they attend. We reduce the need for their family to coordinate care, because we take that on. If we, as a nation, incentivized true coordinated primary care, we could improve outcomes and ultimately reduce costs because we would address the prevention pieces. We would:
- Educate and converse with the patient and family.
- Support behavior changes to drive better outcomes.
- Really look at prescriptions and symptoms.
- Consider therapies to improve health and ability.
- Consider “complementary and alternative” therapies and supplements.
- Have a wholistic picture of the patient to enable better identification of needs, better decision making for tests, treatments, etc.
For instance, let’s use a patient prescribed 10 medications as an example. Some of the medications may in fact be causing some of the patient’s distress or symptoms and could replace some of the medications with other therapies or supplements. We may eliminate some medications altogether because we address the “symptom” which was actually a side effect. We would drive better health.
We would spend time getting to know the patient and their individual circumstances, beliefs and knowledge levels. See, a patient’s ultimate goal may not match what the quality measure says a physician or other provider must achieve. The patient may never achieve the standard set by a quality measure because they are starting at a different place than the provider. There is no provider-patient partnership, and a divide is created. The patient gets labeled non-compliant and the provider writes them off.
Side note: I have always hated the term non-compliant because we don’t provide the factors behind that judgement. Our system is not designed to really uncover those factors or to address them.
For example, a middle-aged woman goes to her provider complaining of aches and pains, weight gain and fatigue. The provider asks which is the primary concern (because they only have time to address one issue) and she replies the achiness. So, she leaves with a prescription for an anti-inflammatory and is told to lose weight. The provider may draw some lab work which shows a slightly elevated A1C and borderline high cholesterol. When she returns to the office to discuss, she is put on two more prescriptions and told to lose weight.
In my proposed system, the provider would assess the activity level of the woman, her gynecologic history, and ask more questions about her fatigue. The provider would have some training in menopause and would inquire about other likely symptoms based on her age, sleep patterns and physical activity. Then, there would be a conversation about what may be happening and that she could be entering perimenopause. The provider would provide some education and recommend the patient sees her gynecologist. The provider would recommend resources like a nutritionist, a physical therapist or an exercise program to improve the achiness. The provider may draw labs to include some baseline hormonal labs. If the A1C or cholesterol markers come back borderline or slightly elevated, another educational discussion would happen that would also draw the possible connection with the physical changes occurring. This information would be shared with the nutritionist to be considered in those appointments. This would all be done before medications are prescribed. Therapies such as acupuncture, supplements and physical therapy would all be pursued first.
In this instance, the woman is empowered to make changes that will facilitate better health; instead, she is receiving the education and support necessary to make the changes to feel better. And, ultimately, we should start to see generational changes in how we approach issues because she has been educated and supported. This requires the patient/consumer to engage also. We must stop relying on a quick fix or pill when we can address the root cause. I am not against pharmaceuticals. I just think we over-rely on them instead of improving health.
In a more complex case, imagine a primary care provider sees a geriatric patient with Type 2 diabetes who is on a couple of oral diabetes medications and has insulin prescribed for when needed. The patient also has heart disease, chronic obstructive pulmonary disease (COPD), and is starting down the path of kidney failure. Her ongoing complaints include a persistent cough, aches and pains, swelling in her legs and fatigue. The primary care provider manages the diabetes prescriptions but refers the patient to a cardiologist for heart disease as she has already had a quadruple bypass, a pulmonologist for the COPD, and a renal specialist for the kidney disease. Then, the patient complains of gastrointestinal distress, resulting in a referral to a gastroenterologist. Not one specialist asks what her daily diet looks like. Not one specialist looks at the medication lists to assess whether any of her ongoing, bothersome symptoms medication related. No one has educated her about changing her diet or the impact of high insulin in the body and what happens with insulin resistance. In fact, when she was given insulin, she was told that she should monitor her sugar levels, use it as needed, and that enjoying the occasional treat is okay. She is also told that anything under nine grams of added sugar per serving size was okay to eat on a regular basis; however, there was no ultimate daily goal of the level of added sugar for her to monitor. We know that some of the side effects for her list of medications include muscle aches, diarrhea and cough. Yet, no one looked at this or changed her medications, instead she was given additional prescriptions to manage the ongoing symptoms / side effects. She eventually died from kidney failure and congestive heart failure without ever having been educated on her diagnoses and changes she could have made to improve her overall well-being.
In the model I propose, she would be well educated on how Type 2 diabetes manifests and the processes that impact the disease. She would have worked with a nutritionist when she was first diagnosed to understand the short- and long-term impacts of her blood sugar levels. She would have been supported through education to change her daily habits. This may have been enough to stop the heart disease. The COPD was caused by years of smoking. Once diagnosed, she would have been educated on how to manage it with the necessary medications and on the importance of daily movement. When she complained of gastrointestinal symptoms or a persistent cough, her primary care provider would have looked at her prescriptions to see if they could be causing the new and persistent symptoms. She would have been supported through her entire journey with education, resources to change lifelong habits, and a coordinated approach that would consider whether new symptoms were actually medication side effects.
A model that gets back to true primary and coordinated care engages the patient, educates the patient, empowers the patient, and focuses on the patient for decision making. In a recent research project I was part of, we saw that women leave the conventional healthcare system and seek “complementary and alternative medicine” to obtain that patient focus. We have an opportunity to drive better health through new models of care and payment.