Author Archives: Dianne Savastano

New Models of Healthcare and How They Affect You

Everyday, we hear about significant changes that may be coming to the Affordable Care Act (ACA). There’s a ferocious debate going on over what should be done. Unfortunately, and as far as I’m concerned, far too much of the discussion focuses on insurance access rather than on how we reduce overall cost.

Healthcare is a $3.4 trillion system, one-third of which (according to many researchers) may be wasteful, not adding value and even causing harm. To me, that’s where the greatest opportunity for improvement lies.

Administrative Barriers

As consumers, a complaint for many of us as we access care is that administrative barriers get in our way. Often, systems are set up to meet the needs of the provider, not the patient. Ironically, I hear the same complaints from primary care physicians themselves, one of whom described the system she works in as, “an environment where I lose a piece of my soul every day.”

In practice, the long-term relationship that must be cultivated and nurtured for a physician to influence a patient to make the changes necessary to impact his/her health, is one that is impossible to foster in today’s transactional-based environment. Instead it requires a culture of “relationship building.”

Fortunately, many physicians are taking it on themselves to move in this direction. A recent Wall Street Journal article titled, With Direct Primary Care, It’s Just Doctor and Patient, describes how some physicians are attempting to do things differently, not only with care delivery but with alternative payment models.

Direct Primary Care Model

Direct Primary Care is one in which a direct relationship exists between the physician and the patient. It bypasses insurance by charging the patient a monthly membership fee. This fee covers things like office visits and some basic laboratory tests and ranges in price from $25 to $85 per month.

A Direct Primary Care arrangement with a practice does not eliminate the need for insurance to cover more costly items, such as diagnostic testing, outpatient procedures and hospitalization. But it may be attractive to people who find themselves in low premium, high deductible health insurance plans in which they must pay the first $5,000 – $10,000 of health care costs before the plan kicks in.

Some of these practices are small and independent and appeal to individual patients, while others are multi-state networks that work with large employers, insurers or unions offering unlimited primary care as part of an employee benefit package. Still others are focused on the Medicare Advantage Plan market and/or insurance for those using Medicaid products.

A major advantage of the Direct Primary Care approaches is that the culture of the practice is different – it is less focused on individual transactions (for which a provider will be paid) and more on what it takes for that provider to influence a patient to make the necessary changes in lifestyle to achieve good health and/or manage chronic disease. Overall, the atmosphere is “relationship based” – more compassionate and less hurried.

These models are often team-based and involve multiple means of communication beyond the in-person visit. Technology is leveraged so that email, texting, video conferencing and group visits are all incorporated into a patient’s experience, thus ensuring that the most appropriate professional, trained at the most appropriate level, is interacting with patients as needed. These teams are led by physicians, and also include nurses, social workers, physical therapists, health coaches, exercise trainers, etc.

Overall, Direct Primary Care practices are considerably less hierarchical than traditional environments. Here, all opinions about healthcare management – including those of the patient – are valued and incorporated into a plan of care.

The success of these practices has been demonstrated in improved patient satisfaction, physician satisfaction, medical outcomes and, lastly, decreased overall cost. And yes, in case you are wondering, I am a fan!

Concierge Practices

While Direct Primary Care Practices often attract lower socioeconomic populations, concierge practices tend to attract more affluent folks (monthly fees range between $100.00 and $250.00).

In concierge practices, physicians limit their patient case load from the usual number of 2,500 – 3,000 patients down to less than 1,000. They also offer visits that are 60-90 minutes long rather than the more typical 20-minute encounter with a traditional practice.

As with Direct Primary Care, participation in these concierge practices also does not eliminate the need for insurance for costlier items, such as hospitalization, etc. However, the fee may include additional services such as the development of a personalized wellness plan and some advanced testing.

Personally, and based on the experience of some of my clients, I’m not sure the higher fees of concierge practices are justified.

What really matters in choosing a practice

We have clients who participate in all manner of practices, including the ones described above, Patient Centered Medical Homes and, of course, more typical primary care practices. Overall, it’s not the structure that determines whether or not patients have a satisfying experience. Rather, it comes down to the following three factors:

  • Ease of access. Every healthcare consumer wants the ability to interact with his/her physician and/or an appropriate healthcare professional when needed. At one time, this was the major advantage of concierge practices. Today, however, and again thanks in no small part to available technology, I’m happy to say that it doesn’t require an additional monthly fee for this to be achieved. The culture and commitment of a given practice in making this a reality is what matters.
  • Coordination of Care. With older adults in particular, coordination of care becomes much more important. One of my patients, an elderly gentleman who at the time was paying nearly $25,000 a year for a concierge practice, needed this as he approached the end of his life. At this point, his physician was totally uninvolved in his care. Instead, and as a result of frequent hospitalizations and the need to transition to a long-term care facility, what his family needed most was assistance with coordination of care across a number of dimensions.
  • Relationship. This may be the most important factor of all. At the heart of things, what we all want is a positive and collaborative relationship with someone we trust, whether that’s our primary care physician, a specialist, or any other healthcare professional with whom we come in contact. And while that should certainty be the foundation for a profession focused on healing people, our current volume-based transactional system often undermines the process.

Summary

Alternative delivery models emerge because of multiple factors, including frustrated patients and physicians, as well as (more recently) a desire to provide quality care more efficiently and at less cost. I fully support the innovation that is going on today and applaud those who know things need to change and who are willing to stand up and take action.

And remember, whether you participate in one of these newer models or not, focusing on your relationship with your physician will always hold the key to success.

Repeal the ACA? Let’s First Make Sure We Understand the Impact

Changes to the Affordable Care Act now under consideration may very well have a significant impact on our current Medicare system and, as a result, on the coverage provided. I’ll explain what this may mean to you in a minute, but first, let’s talk about how Medicare began and has evolved over the past 50+ years.

A brief history of Medicare

Medicare was signed into law in 1965 during the Johnson Administration. Originally, it was only for those age 65 or older. In 1972, President Nixon extended Medicare coverage to people with End Stage Renal Disease and to those with disabilities.

Because Medicare, on average, only covers about 80% of health care costs, Medicare Supplemental Plans (also known as Medigap Plans) emerged in the 1990s. In 1997, Medicare + Choice plans (now known as Medicare Advantage Plans or Medicare Part C) came about.

In 2006, under President Bush, Medicare Part D Prescription Drug Coverage was enacted to cover some prescription drug costs. This was designed to be purchased from private health insurers and included a coverage gap (also known as the “Donut Hole”). This means there’s a temporary limit on what the drug plan will cover until one reaches a certain amount, at which point, catastrophic coverage kicks in.

Elements of the ACA you may not be aware of

In 2010, the Affordable Care Act was enacted under President Obama. Much of the press was focused on the expanding insurance coverage, thus increasing access. Indeed, we’ve seen the uninsured rate progress to an all-time low: “The uninsured rate for non-elderly Americans has fallen from about 16.6% in 2013 to 10% in the first quarter of 2016, and 8.6% taking into account seniors who have near universal coverage. ”

What you probably heard less about (and may not realize) is that there were three other elements included in the ACA, all designed to improve the health of Americans. These included:

  • Improving quality through innovation
  • Enhanced preventive health (thus preventing illness)
  • Promoting community and population-based activities

Many of the elements I discussed during the luncheon focused on the first element: improving quality (and reducing cost) through innovation. The ACA forced payment and delivery system changes which were designed to align incentives in the best interests of both health care consumers and providers. As a result, there was a reduction in growth in Medicare payments to hospitals, to other health providers and to Medicare Advantage Plans. At the same time, measurements of quality began to be used to define payment structures.

Money was even designated for Innovation Centers within the Center for Medicare and Medicaid Services (CMS), with the goal of finding alternative ways to improve quality and reduce spending. I’ve experienced some of this work first hand with many of our clients who receive their primary care from practices designated as Patient Centered Medical Homes.

What this means in practice

One excellent example of the ACA’s impact is the creation of incentives for hospitals to reduce preventable readmissions. Prior to the ACA, discharges from hospitals were not well coordinated with the healthcare resources to which patients were transitioned upon discharge. It was not unusual – especially for an older adult who had limited support at home – to be re-admitted within 72 hours of the initial discharge. This was awful for the patient and resulted in much greater cost than if more effort were made in the beginning to coordinate care with lower cost providers (such as home care companies) outside of the inpatient hospital setting.

Another example relates to the closing of the Coverage Gap (Donut Hole) by 2020. Many of our older adult clients take upwards of 20 medications. Because of the way costs are calculated, they can hit the Donut Hole early in the calendar year and have significant out-of-pocket expenses before the catastrophic coverage kicks in later on.

Lastly, the element to include preventive care at no cost to patients just makes great logical sense. It is so much more humane (and less costly) to prevent a catastrophic diagnosis or illness with good preventive care than to treat it once it happens. Prior to the ACA, Medicare had not covered all preventive care.

Here’s what the impact of a repeal would be

I’m astonished by the Congressional Budget Office’s estimate that repeal of the ACA would increase Medicare spending by $802 billion from 2016-2025 by restoring higher payments to healthcare providers and Medicare Advantage Plans. The increased spending would impact healthcare consumers causing higher premiums, deductibles and cost sharing, and would accelerate insolvency of the program. All the effort that has gone into aligning incentives to decrease the cost of care would be eliminated.

Changing the incentive to prevent hospital re-admissions also doesn’t make sense. Lack of coordination of care is continuously cited as a problem in our healthcare system, leading to waste and additional cost. Why halt the forward progress that’s been made on this front?

Finally, eliminating the closing of the Donut Hole will result in healthcare consumers (including older adults on fixed incomes) trying to cut corners by not taking prescribed medications as instructed (or at all), or by purchasing medications from other countries. Even with the progress made toward closing the Donut Hole, prescription drug costs are astronomically high and that still needs to be addressed.

Conclusion

I understand this issue is incredibly controversial, as the ACA has resulted in unintended consequences for some. However, we know that over the past few years, Medicare spending per beneficiary has grown more slowly than private health insurance spending; premiums and cost sharing are lower than they would have been without the ACA; new payment and delivery system reforms are being developed and tested; and the Medicare Part A Trust fund has gained additional years of solvency.

I know we have tremendous work yet to be done. I would prefer we spend our energy on innovative improvements in delivery and quality rather than on repealing and trying to re-create.


Shingles Update

I was amazed and touched by the number of people who wrote after last month’s newsletter, expressing concern for my well-being and sharing stories of their own experiences with the condition of shingles. I am deeply appreciative and thank you for writing.

I’m happy to say that although the pain is not completely gone (now ten weeks into this adventure!), it has lessened considerably and continues to improve every day.

If you have not been vaccinated, I want you to know that the shingles vaccine (Zostavax) is approved by the FDA for people age 50 and older (it had been 60). I encourage you to discuss vaccination options with your primary care physician.

Recommended Reading: Immigrants Make Up a Growing Share of Health Workers

In my work with clients, I interact with phenomenal healthcare workers of multiple ethnic backgrounds, many of whom immigrated to this country. This article, As New England Ages, Immigrants Make Up A Growing Share Of Health Workers, describes how as New England’s baby boomers grow older and live longer, the need for healthcare workers also increases.

This incredibly moving article about palliative care and dying helped me to work through some unresolved feelings about our recent work with a dying client.

Sharing a Personal Experience

“Empathy. The capacity to understand or feel what another person is experiencing from within the other being’s frame of reference, i.e., the capacity to place oneself in another’s position.”
– Wikipedia

In my 25 years as a healthcare professional, I’ve encountered many older adult patients, clients, friends and family who have been diagnosed with shingles. I’m well aware of the basics (you can read more about them here, if you like), but it wasn’t until I, myself, was diagnosed with this virus that I developed a true appreciation for the impact it can have.

It began when I noticed a suspicious rash on my lower abdomen that wrapped around my body, all the way to my lower back. I called my physician right away and scheduled a “same day” sick patient appointment (something I hope your primary care practice offers to its patients as well).

She acted promptly to prescribe treatment with prescription antiviral drugs that can speed healing and reduce the risk of complications. I also saw an Infectious Disease Specialist who prescribed a medication called gabapentin (Neurontin). Despite my reluctance to take this for fear it would make me sleepy – a feeling I don’t like or have time for – I took a very small dose at night because she convinced me it could reduce the risk of post-herpetic neuralgia. Six weeks into this experience, I’m wondering if I should have followed her recommendation that I take a higher dose for a longer period of time. (I never said I was the most compliant patient!!!)

My first emotion was fear

My first emotion upon being diagnosed was tremendous fear. I thought of two clients, both of whom had developed such severe cases of shingles that they required hospitalization and aggressive pain management for months and years. For one, she was never fully pain free again. She’d describe “pings of electricity” in her body, coming and going unexpectedly, that would just stop her in her tracks.

I’d seen it all before, but until now, it was secondhand. Realizing what lay in front of me, I had great concerns about the coming weeks.

What causes shingles? How do we prevent and manage it?

The reason for developing shingles is unclear, but it may be due to lowered immunity to infections as we grow older. Those older than 50 are at risk (I hope you’re surprised to learn that this includes me!), and some experts estimate that half the people 80 and older will develop shingles at some point.

Shingles is caused by the Varicella Zoster virus, the same one that causes chickenpox. The varicella vaccine (Varivax) has become a routine childhood immunization to prevent chickenpox – it is also recommended for adults who’ve never had chickenpox. Though the vaccine doesn’t guarantee you won’t get chickenpox or shingles, it can reduce both your chances of complications and the severity of the disease.

A second vaccine is the “shingles vaccine,” Zostavax. This also doesn’t guarantee you won’t get shingles, however it will likely reduce the course and severity of the disease and reduce your risk of post-herpetic neuralgia. (I found myself wishing I’d had this!)

Zostavax is recommended for adults age 60 and older, whether they’ve already had shingles or not. Most insurance companies use the initial recommendation of “over the age of 60” as to when they will pay for it, so getting it earlier can result in an out-of-pocket expense of between $200.00 and $250.00.

Living with the pain

During the first week, just moving from one position to another and trying to shower and dress caused a lot of pain. I was more fatigued than usual and my patience would wear thin as the day progressed – something my husband was incredibly patient with in the evenings.

By the second week, I was experiencing tremendous stiffness, as a result of limiting my mobility. My physician reassured me that I wasn’t going to harm myself by resuming my normal functional activities (although she did encourage me to get more rest than I usually do.)

So, I resumed life. I took mild over the counter medications to manage the discomfort, practiced my meditation techniques more frequently, and moved on with my work and personal life. I focused on all the good aspects as I did not want to miss a thing, and tried to use the power of distraction to the best of my ability. For me, that worked well – but I consider myself “young and resilient.” For the older people in my life, I developed a much greater appreciation for how resumption of normalcy can take much longer. Having tremendous patience when interacting with such individuals is necessary.

Reflections/Lessons learned

Recommendations for management of shingles include trying to reduce the amount of stress in your life. Oh no, was my mom right again?

My loving mother watches my lifestyle, something that is full of work and fun. But more recently, it’s been complicated by selling our home; moving to a temporary apartment and office because our new home wasn’t ready; travel, including multiple speaking engagements; my husband’s upcoming retirement; and Open Enrollment season for both Medicare and employer-sponsored insurance plans.

And so she asked, “Are you taking good care of yourself?” Maybe I wasn’t. In the past, I’d probably develop a respiratory infection or a GI bug to slow me down. This time, maybe it was shingles.

Conclusion

Everyone’s reaction to life’s challenges is different and as a healthcare professional, I must have empathy for another’s experience. I encourage you to follow my mother’s advice and pay attention to whether you are taking adequate care of yourself, getting enough sleep, eating healthy foods, exercising and maybe practicing mindfulness.

Hopefully, I’ll do a better job of this for myself in the future. I certainly encourage you to do the same!