Payer's Role in Care: Gatekeeper or Change Agent?

Healthcare is changing, but in Amy Tenderich’s view, some things remain the same. The founder of DiabetesMine.com and longtime patient advocate recounted her own experiences and those of others in dealing with insurers after a trip to the hospital: the bills that keep arriving that can’t be deciphered, the inability to figure out exactly what’s covered, the hours spent dealing with the call center.

The overall “lack of transparency,” as Tenderich described it, frustrates even savvy patients like herself, let alone those less skilled at navigating the healthcare bureaucracy. “We see the payers mainly as playing a gatekeeper role,” she said, “putting these hurdles between us and the things we need.” Patients, she suggested, just want honest conversation about what they have access to.

From his vantage point at Humana, Todd Prewitt, MD, FAAFP, knows that Tenderich’s observations are all too common. Humana did a study that surveyed consumers in their homes about whom they trusted in making healthcare choices. Those surveyed, in general, trusted family and friends and almost always their doctor and pharmacist; the pharmacy and the hospital, to a lesser degree; and their insurer, not at all. “We didn’t even make the list,” Prewitt said.

Issues of trust are not limited to matters of patients believing that their insurance companies will act in the company’s best interests. There’s also the matter of what payers will do with all those data they’re collecting, Tenderich said. “People are definitely concerned about their data being sold, that they are in an employer program or they’re being asked by their health plan to give a lot of data,” she said. “There’s definitely a lot of discomfort with that idea.”

And yet, according to Prewitt and Deneen Vojta, MD, using those data properly can lead to better care, in multiple ways. Aggregating data can spot trends. And if payers can give physicians data they don’t have—such as information about whether the patient actually filled the prescription written at the last visit—the result could be better interpretation of lab test results, or more honest conversations about whether financial hardships are preventing a patient from getting access to medication in the first place.

Already, using technology to connect providers, payers, and community organizations is creating relationships and reimbursement for care that would have been inconceivable a decade ago, Vojta said. “Who would have thought that we would have all these payers collaborating with the CDC and the YMCA and other organizations to roll out the National Diabetes Prevention Program?” she asked, referring to the initiative undertaken with the American Diabetes Association.

Certainly, there’s more to be done. Tenderich suggested payers could play a role in supporting patients’ need for engineering standards and compatibility of devices, so that continuous glucose monitors from one manufacturer and pumps from another can work together.

Dennis Scanlon, PhD, said he was impressed with work that Teresa Pearson, MS, RN, CDE, FAADE, had undertaken with the Southern Prairie project in Minnesota, especially expanding the number of partners to cover everything from the criminal justice system to Meals on Wheels. How, he asked, can this occur without the impetus of government bringing everyone together?

Pearson said a central element was colocation of services, including a public health nurse in the emergency department at hospitals who handled discharge planning. It also helps to have colocation of mental health services, because many diabetic patients who also have mental health conditions end up in the emergency department, and it’s especially important that these assessments and transitions be carefully handled.

Finally, she noted, dental care is an overlooked area: “Sometimes, as many as 60% of the patients who come into the emergency department are coming there because of dental pain, and they may be on Medicaid and don’t have access to a Medicaid dental provider.”

Prewitt discussed the importance of managing discharge properly, and of not overwhelming a patient with too many contacts after hospitalization. While follow-up is important, he said, it’s hard for a patient to understand why he or she might hear from both the original disease case manager and the pharmacy’s contact person regarding multiple drug changes. A typical response, according to Prewitt, would be: “I just talked to the case manager; now who are you?”

Both Pearson and Tenderich addressed this issue. Tenderich contrasted what she called “the myth of the healthcare team” (so stated because communication among a diabetic’s many providers can be rare) with the problem of multiple transitions between points of contact after a person with diabetes has already built up trust with a particular individual.

That’s what Southern Prairie is trying to avoid with the concept of the “quarterback,” Pearson said. “Who is that 1 person that they connect with the most, who can help communicate to the rest of the team? I think that is a really important piece that we’re trying to implement, to reduce some of the noise and confusion for the patient.”

Vojta said when she trained at Children’s Hospital of Philadelphia (CHOP), there was a nurse practitioner in charge of coordinating care for sickle-cell anemia patients from a large geographic region. It was clear that if a child with sickle-cell missed school, the officials knew to call this nurse practitioner. “No decision was ever made without going through the parent and the nurse practitioner,” Vojta said. “And it really did allow for true coordinated care.” Which led her to pose the question: “How are we going to replicate, from a business [standpoint], what we saw happen at the CHOP sickle-cell clinic, and make it more standard across the industry?”

Pearson said it’s essential that the providers, payers, and “systems” get coordinated, because patients are often confused, and too often blamed. “We constantly talk about patient noncompliance or nonadherence…patients unwilling to do what we have asked them to do,” she said. “We are too quick to blame.”

EBDM

Tenderich agreed. “I think it’s amazing that it’s 2014 and we’re just now scratching our heads and saying, ‘Maybe we should start with the patients. Maybe we should ask them why this is so hard. Maybe it’s not that they’re failing; maybe it’s the therapy that’s failing them.’”