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Vol. 3. No. 1
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January/February 2001 |
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Why Physicians Find Disease Management Offensive
(Or Do They?)
By Paul Reich, M.D.
Today's comprehensive Disease Management (DM) programs include many different modules. They start with tools that identify the population to be managed, either by looking at historical claims data or by performing health risk assessments on the members. Once the population is identified, the nurse manager, through phone contact and home health nurse visits, assesses the member and sets in motion a monthly program. It addresses current or potential problems of a member with a chronic disease, such as congestive heart failure, diabetes or chronic pulmonary disease. At intervals, both clinical and financial outcomes are measured and reported; care plans are revised, if necessary. Physicians become involved from the beginning as their permission is initially sought to enter their patient in the DM program. Periodically they are asked to discuss and sign off on orders for the patient and help evaluate progress after receiving evaluations from the member's nurse manager.
Ask any DM nurse manager and you will hear his or her chief complaint: the physician either does not want the patient to participate or agrees reluctantly to enrollment, but delays signing off on permissions and orders.
Why is this the case? Several issues appear causative.
First, the physician is not usually paid for his or her time, although some plans include payment in the office visit or management fees and others are beginning to think about paying physicians for managing its patients in DM programs. Nurse managers respond by pointing out that they take some of the burden off physicians by arranging for services and filling out paper work for the doctor to sign, something the office staff would normally do.
Then, there is the issue of accountability for the care of the patient. Since many health plans vendor out their DM programs, physicians are leery of the care recommended by these vendors. They are quick to point out examples of poor outcomes that are associated with care from DM managers. Even when the DM program is developed in-house, similar complaints often arise. Nurse managers reply that, before implementation, the member's physicians must review, modify and approve all care plans.
Finally physicians become upset when DM programs take over some of their functions. Modern programs may |
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send nurses to the home to examine the patient and take a history. Or some may install an electronic sensor in the patient's home that via the telephone monitors blood glucose, blood pressure or weights, and even asks follow-up questions to see how the patient is doing and whether he or she is compliant with medications. The physician may feel he is being taken out of the loop, not to mention the loss of income from office visits.
What can plans do to enlist physician cooperation if they want to implement DM programs for their high risk, chronically ill members. Physicians need incentives, such as management fees, bonuses for improved quality of care and recognition and appreciation, if they are to participate. They must be involved in the design and implementation of programs as well as choice of vendor. Often this can be done through an advisory committee made up of physician leaders.
Once developed, an essential component of the DM program is education of all the stakeholders, especially the physicians. Everyone must know their role and understand how working together can improve the health status of many members/patients. Convince physicians that these programs improve compliance with recommended therapies as well as improve their patient's care and quality of life. Recently available outcome data from DM vendors shows physicians the value of these programs.
The secret weapon.
The secret weapon to gaining physician acceptance is the nurse case manager who daily communicates and provides services. His or her success with patients and education of skeptical doctors does more to make DM programs popular than any other means. Every Medical Director is thrilled when told by a member or physician about the help rendered by a DM nurse-manager, and these comments get wide distribution.
If physicians are to support DM programs rather than serve as impediments to implementation, then we need to communicate the benefits to them and their patients and define participants' responsibilities. Individuals knowledgeable about and experienced in changing physicians' attitudes are essential to this process of implementing DM programs without offending physicians. It can be turned around, so that patients and physicians welcome new DM initiatives and at the same time make the delivery of care more efficient.
About the author: Paul Reich's career spans 23 years as a practicing physician and eight years as a physician executive for Harvard Pilgrim Health Care, one of the leaders in health care innovation and care quality in the United States. As Chief Medical Officer for Scheur Management Group, Dr. Reich is responsible for coordinating SMG's clinical services to clients in the areas of medical management, disease management, quality improvement, financial accountability and the integration of information systems with medical management programs. |
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