American College of Physicians: Internal Medicine — Doctors for Adults ®

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Will demand management work?

Health plans want to 'empower' patients, but doctors fear misuse

From the July/August 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Jennifer Fisher Wilson

A year ago, Kaiser Permanente in Northern California introduced a new tool to keep its members healthy: a handbook with tips on more than 170 common health problems and advice on when to self-treat and when to call the doctor. Today, when patients call the HMO to see a physician, receptionists remind patients to first read their handbooks. Kaiser also encourages its physicians to use the handbook to help explain patients' aches and pains. And at the close of patient visits, office staff remind patients about the availability of the Kaiser nurse triage line, another tool to answer health questions.

Kaiser hopes the handbook and triage line not only will help physicians work more closely with patients and improve patient satisfaction, but also will guide patients' use of medical services—and ultimately cut costs.

This two-pronged strategy of educating patients and reducing medical costs is an example of a growing trend in managed care known as demand management. Health plans around the country are espousing tools like brochures and videos to educate their patients about their health and to teach them when—and when not—to call the doctor. The theory is that by emphasizing self-care principles, patient education and health promotion, patients will learn to use medical care more appropriately and cost effectively. Research has shown that demand management can lead to a 7% to 17% drop in use of medical services, numbers that can translate to annual savings of a few hundred to a few thousand dollars per member.

There is a snag, however. Physician participation is crucial to the success of demand management, and many physicians are not happy about these new self-care tools. Critics claim that demand management is simply another way for health plans to increase their profits by limiting access to care. And some physicians, concerned about how these new techniques will affect their clinical autonomy and patient health, have resisted implementing managed care-sponsored demand management programs.

All the same, health plans are forging ahead, in part because they have realized that controlling who gets resources like X-rays, lab tests and drugs can reduce costs by only so much. They must go a step further. True believers in demand management also explain that the technique's popularity hinges on Americans' interest in taking responsibility for their health, as evidenced by the popularity of alternative medicine.

"I think demand management is a great idea, and it's very popular with consumers," said William R. Harlan, FACP, a general internist and the director of the Office of Disease Prevention at the National Institutes of Health. "It informs and empowers patients about some of the mysteries of how their bodies work. If we've learned anything in the past 20 years in prevention, it's that we're unable to just tell people to do the right thing and get them to do it. We have to get people invested in developing good habits and good behaviors."

To help patients develop those good habits—and encourage the appropriate use of costly health care resources—health plans are using tools like brochures, telephone triage systems, videos and counseling. Medical centers often offer support meetings for people with chronic conditions like arthritis, obesity or diabetes. Dow Chemical Company in Midland, Mich., for example, sponsors exercise classes, weight loss groups and stress reduction seminars as part of its demand management program. The company has also used videos to reinforce the message of other self-management materials.

Printed materials like Kaiser's handbook, however, remain most popular among health plans. "Self-care books fit in when you start talking to patients about how managing their health is their problem—not ours as physicians—and the responsibility is on the patient, and not the doctor, to get better," said Donald Vickery, FACP, the physician who coined the term "demand management" and heads Health Decisions International, a Golden, Colo. firm that specializes in demand management services.

Dr. Vickery said that in ideal circumstances, demand management actually increases, not decreases, access to care, and that the costs of care fall because only those who really need medical attention seek it out. In addition, he said, demand management programs provide consumers an alternative to costly trips to the emergency room during nights and weekends.

Research has backed up these latest findings. A Health Decisions International study that looked at households given self-care manuals found that the members of these households saw the doctor 15% to 17% less frequently than before they owned the manual. When paired with telephone triage, physician utilization dropped even further.

Larger health plans, therefore, often couple demand management tools such as health handbooks with more elaborate telephone triage services. At Kaiser Permanente in California, for example, a nurse triage system at the HMO's medical centers supplements the health handbook. Nurses in the triage system make appointments and answer medical questions using a script that Kaiser physicians have reviewed and modified. Patients can call another line for basic tape-recorded, information on different conditions such as diabetes, arthritis and osteoporosis.

A down side?

Despite the reduced utilization—or perhaps precisely because of it—and despite survey results from health plans that show most patients still see a physician when in doubt, many doctors don't trust the self-care message promoted by demand management programs. Some fear that demand management is simply another way for health plans to save money, one that leads patients to make decisions they shouldn't be making on their own, one that causes them to risk undertreatment by not seeing a doctor in time.

Dr. Vickery acknowledges that demand management can be misused. He said that telephone triage, for example, can be implemented primarily as a barrier to keep patients out of the doctor's office or emergency room. "The dark side of demand management is that it is slipped in as just another utilization barrier, that whoever is using it is trying to keep people out," he said. "It can be a new barrier to access that they think will be acceptable to their customers."

Dr. Harlan from the Office of Disease Prevention said he worries that the program puts too much decision making in the patients' hands. "A little knowledge can be a dangerous thing," he said. "One of the concerns is that people will determine that they have a very serious disease and take totally inappropriate action."

If a patient recognizes a stomachache, but not a concomitant fever, for example, the patient may procure inappropriate guidance from a manual or triage nurse, said Peter A. Ubel, ACP Member, a staff physician at the Philadelphia Veterans Affairs Medical Center and a bioethicist at the University of Pennsylvania. For those reasons, Dr. Ubel said, he would like to see the effects of demand management studied before the techniques are more broadly implemented.

In addition, the self-care emphasis may lead to the increased use of alternative or at-home therapies for diseases that need traditional medical attention, said Dr. Harlan. "The fear is that patients will use an alternative therapy that is inappropriate because they don't have the guidance," he said.

Some physicians dislike demand management programs for another reason: if the programs work as planned, the doctors will lose business. According to Dr. Vickery, however, the self-care movement poses no threat to physicians' jobs. "Most surveys suggest that doctors don't lose money because patients are taking good care of themselves. Schedules always fill up," he said. "It won't happen that we suddenly won't need internists."

Experts like to point out that internists accepting capitated payments could actually save money through demand management tools that keep patients healthy and out of the office. But because capitation makes up a relatively small percent of most physicians' income, many physicians continue to resist the idea of demand management.

Getting physician support

Harvard Pilgrim Health Plan in Boston, Mass., encountered physician resistance—or just plain passivity—when it distributed a health handbook to its 55,000 senior citizen members and set up a nurse-staffed telephone line last fall. "It's been very tough registering on the radar screens of busy physicians," said Helen Abrams, the manager of self-care promotions at the health plan. "We want to engage the physicians so they can see ways that they can incorporate the materials into their practices."

Getting physicians to support the Harvard Pilgrim program is critical to its success, explained Paul Mendes, MD, an internist who is deputy medical director for Medicare and Medicaid at the health plan. Patients are more likely to use the handbook if their physicians endorse it, he said. One problem with physician acceptance of the handbook, he said, is that physicians weren't involved enough in the planning process.

When Kaiser distributed its handbook, it allowed physicians to review and modify the text to suit their members' needs. Kaiser then educated physicians in how to use the handbook during medical appointments, how to talk with patients about it and how to encourage patients to use it. Physicians are expected keep a handbook in every exam room and are encouraged by Kaiser to refer to it regularly during visits to make patients comfortable with it.

For at least some physicians, those efforts appear to have made a difference. "Whenever a topic comes up that I think a patient would benefit from reading about in the handbook, I point it out," said Kaiser internist Pamela L. Kershner, ACP Member, of Walnut Creek, Calif. "Patients love it, and I think the book is great."

Dr. Kershner said that she has used the handbook with patients who come into her office with questions or concerns that they could have assuaged sooner by looking in the handbook. When patients complain of back pain or headaches, for example, she points them to a section of the handbook that explains symptoms—and tells patients when to seek medical treatment.

At first, Dr. Kershner said, she had to encourage patients to use the handbook, but they soon they embraced it. "Now patients frequently point things out in it to me when they come in for a visit," she said. "They use it as a reference." The book also has a section on how patients should prepare for an office visit, including what information they should know about their condition.

Physicians find it easier to accept the idea of patient handbooks than more sophisticated services like telephone triage lines, which can be seen as more of a threat.

When Boston's Harvard Pilgrim Health Plan introduced its handbook and nurse line, physicians feared the nurse line would remove some control from their practices, according to Ms. Abrams from Harvard Pilgrim. As a result, nurses on the line direct all patients who have active symptoms or who need an appointment to call their physician instead of offering any clinical triage themselves.

While Ms. Abrams acknowledged that sending a large number of calls directly to physicians limits the nurse line's effectiveness, she predicted that as physicians become more comfortable with the notion of a triage line, more care will be left to the discretion of those nurses. Initially, she said, relatively few members in the program accessed the triage line, but participation increased when Harvard Pilgrim mailed members stickers printed with the telephone number.

Ms. Abrams' optimism may not be entirely unfounded. While many physicians are wary about enforced demand management programs, most believe that increased patient health awareness can yield better medical care and greater satisfaction—a bonus to both physicians and their patients. For that reason, physicians may eventually become more comfortable with some type of demand management.

Even skeptics like Dr. Ubel from the Philadelphia Veterans Affairs Medical Center said that informally practicing some of the methods of demand management has improved the way he administers care at the VA Center in Philadelphia. Although he is not participating in a formal program, he said that he enjoys involving patients in their care. "When they come in with newspaper articles or questions about something they heard on the news, it's a good way to know what they're thinking about, what they're interested in," he said. "It offers us a way to include them in their care and it gives us an opportunity for shared decision making. The worst thing is for me to impose an agenda on their health care."

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