Manage My Health. Please? (Part 1 of 2)

Sarah Maurer

Sarah Maurer

Managing Editor, Perspectives on the Acute Care Continuum

Published February 13, 2015

You'll never find a bigger supporter of healthcare reform than me. My dad had a heart attack — while uninsured. My mom had chemotherapy — while uninsured. When my mom was able to enroll in an exchange plan in fall of 2013, our family breathed a monumental sigh of relief.

A year later, my mom lost her part-time retail job. From a healthcare point of view, this shouldn't have been a big deal. She was insured through the federal exchange, not her job.

Unfortunately, the insurance company didn't see her that way. They informed her that because of her decreased income, she was no longer eligible for an exchange plan. To stay on the exchange in 2015, she would first have to apply to Medicaid — and be denied.

Considering an Ohio Medicaid application can take weeks to finalize, this potentially left her facing a dangerous lapse in coverage. And it begged the question — would she experience another coverage lapse when she started working again?

Has Reform Gone Far Enough?

Around the time this happened, I was editing an excellent post by Gail Silver, MD. Her thesis: in order for providers and payers to effectively manage population health (and indirectly, healthcare costs), there needs to be more assistance for your average consumer.

This is especially true, she says, for people who are in the middle ground health-wise. Maybe they're newly diagnosed with diabetes or have undiagnosed high blood pressure or a chronic condition like cancer. To stay healthy, they need quality care now. Instead they're sinking in the murky waters of exchange products, high deductibles and narrow network plans.

Dr. Silver's post really resonated with me, which is why over the next few posts, I'll be examining healthcare reform from a consumer's point of view. I'll start today with the possibilities and pitfalls of population health management. Tuesday, I'll cover the Anthem fraud lawsuit and the need for consumer protections in the changing healthcare marketplace.

Bright Ideas

Lest I descend too far into negativity about healthcare reform's progress (or lack thereof), I first want to point out some positives.

As editor of this blog, I'm privileged to work with brilliant authors who are striving to improve care for patients. They write about clinical integration, care transitions, teamwork and patient experience. And lately, they've been keen to discuss population health management (PHM).

From a consumer's point of view, PHM is a dream. It rewards providers for ensuring that a defined patient group (often, though not necessarily, an at-risk one) accesses appropriate care. It's proactive. It's preventative. It saves both consumers and the system money.

Above all, it encourages creative, collaborative solutions that address the systemic and social roots of health problems. For example, a coordinated care organization in Oregon decreased a homeless man's emergency room visits by providing him with shoes, a sleeping bag, and ultimately, adult foster care.

An Excited Consumer

When I first started hearing about PHM last year, I was pretty stoked. Seriously, I told all my friends and family about it. Finally, someone in DC was going to take responsibility! Maybe after paying a fortune in insurance premiums, we consumers could get some, you know, actual healthcare. Stuff like:
  • Seeing a doctor when we're sick — before the problem cures itself or we end up in the ED or retail clinic out of desperation
  • Obtaining a simple, on-time prescription refill called in to the correct pharmacy without five errors and a battle royale with the office staff
  • Getting some definitive answers about who's participating in an insurer's network without making six hours worth of phone calls to verify coverage
  • Not having to change insurance every few months or endure gaps in coverage as insurers exploit every possible loophole in order to control cost.
And on a personal note:
  • Not having to talk the urgent care doctor out of suturing the gaping hole in my leg because my insurance has a $7,500 deductible
  • Not having to drive my dad back to the hospital two days after discharge because he developed pneumonia symptoms, didn't have a primary care doctor, and didn't qualify for home health
  • Not having to hear that my cousin (who's diabetic) goes without testing strips so he can afford to test his two kids (also diabetic)

Acknowledging a Problem

The number one thing that made me excited about population health: it's very existence is an acknowledgment — albeit a tacit one — that our current healthcare system keeps people unhealthy.

Contrary to questionable media messaging, Americans aren't necessarily sick because we're lazy or entitled or lack self-control. We're sick because we lack access to preventative care, management and guidance.

We're sick because when it comes to scheduling your basic doctor's visit, our system throws every possible obstacle in our way. As my mom's experience shows, it doesn't matter if you have cancer and need to see your oncologist. The insurance company is still free to give you a ridiculous runaround just to save a few bucks.

And the scary thing is, I'm writing this from a position of extreme privilege. I'm insured, healthy, financially solvent, free of dependents and have incredible job flexibility that allows me to spend hours on the phone fighting with the insurance company (more on that Thursday).

How much more difficult is it for a working single mom to navigate the system? An elderly person in a rural area? Someone with a sixth-grade education?

To ensure reasonable access to care, either this draconian system needs to change, or someone needs to take responsibility for guiding consumers through it. PHM is a start because it incentivizes the creation of user-friendly delivery models. It also encourages providers to invest in models and resources that help patients navigate the healthcare maze.

Reason to Hope?

So will the coming push for population health management improve the lot of Americans who struggle to navigate our tortuous, chaotic healthcare system?

I really hope it will. Last year, a HealthLeaders intelligence survey found that 90 percent of respondents were committed to implementing PHM. Forty-six percent already had efforts underway. And Maryland and Oregon are experimenting with innovative statewide PHM models.

But it appears that for many, the impact will be slow in coming. So far, pilot models have tended to focus on a tiny percentage of very costly patients — ED frequent fliers, people with organ failure and those reeling from the effects of catastrophes like stroke.

On a more positive note, about 32 percent of respondents to the HealthLeaders survey said they will focus their early PHM efforts on patients with a chronic illness like diabetes. Given that these patients have the potential to become very sick down the road, this seems like an excellent starting point.

Alls Well That Ends Well?

So will change come fast enough for my mom? Well, happily it's now a moot question.

About a week after her insurance company announced it was canceling her, it sent her a bill for her January premium. She called the company, and the rep swore up and down that she was still enrolled and didn't have to go through the Medicaid rigmarole.

It seems maybe the chaotic, fragmented nature of the health system finally worked in her favor. At least we hope so.

[Image credit: "Longleat-maze" by Niki Odolphie licensed under CC BY 2.0]

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