What Does Patient Choice Have to Do With Integrated Care?

Recently I was taking care of a gentleman in one of our Emergency Departments named Paul. Paul is 55 with a history of alcohol abuse. He also had some psychiatric problems, and was diagnosed with rectal cancer approximately one year ago.

He was placed in one of our psychiatric rooms as he was visibly intoxicated and complaining of the abdominal pain. On further questioning he was concerned that his abdominal pain was getting worse and he was scheduled for surgery at a university referral center for possible release of adhesions (scar tissue) in his abdomen.

It was clear to me after review of the medical records and recent course of treatment with a local oncologist that his cancer was metastatic and end-stage in nature. Paul had not been taking any medications to alleviate the pain. It seemed he was using alcohol to self medicate.

It was at that point that I realized that this was no longer just the alcoholic patient in room 19 but someone with a range of serious medical problems who had been poorly managed by our healthcare system.

Paul and I discussed the seriousness of his disease and the likelihood that it would continue to progress and worsen. He said he knew that the pain would get worse but in his mind the next step was surgery. I counseled Paul that the next step should really be pain control with narcotics and a consultation for palliative or hospice care.

I spoke with our care manager in the emergency department to review Paul’s previous records. She said a palliative care consult was offered several months prior but he had been unwilling to move forward with the recommendation. After a second discussion with him though it was obvious he was now willing to hear other options, specifically and most importantly, regarding pain management.

A Patient’s Informed Choice

In the U.S., the top 1 percent of patients account for 21 percent of healthcare expenditures, while the top 5 percent account for nearly 49.5 percent. It is difficult to reach these patients. They require a unique skill set of care providers to manage their disease or diseases, and perhaps more importantly address their lifestyles.

And what about the patient satisfaction of these patients, who endure multiple hospitalizations, encounters with specialists, and interventions as their diseases progress and worsen?

Recently, I had a conversation with Dr. Thomas Smyth, the Director of Integrated Care at Chesapeake Urology Associates in Baltimore, MD. He had an interesting definition of patient satisfaction as “the right level of care as is determined by that patient’s personal informed choice.”

For a patient with incontinence, for example, having fewer episodes may be acceptable when measured against the complete correction via surgery for that particular patient. I thought Dr. Smyth’s definition was a much more appropriate description of patient satisfaction than a Press Ganey or HCAPS Score.

As physicians and important players in the healthcare system our conversations must change from what is best for an individual patient to what is best for that individual within the limits of what we can provide from a medical standpoint.

As those of us who have managed any medical condition in our own lives know, the real focus is usually on how to maintain our idea of a productive life while managing the illness or injury. None of us want to spend any more time than is absolutely necessary engaged with the healthcare system. We want to spend our time getting back to living our lives.

In order to change our healthcare system, physicians, surgeons, physical therapists, social workers, pharmacists, and everyone in between must change their mindset. Everyone must consider themselves part of the team that allows the patient in front of them to get back to living their lives as well as can be lived within the confines of their disease.

It is a monumental mindset change in the eyes of most physicians, who are focused on dealing with the next patient on their schedule.

Integrated care across the healthcare system means all of us are part of the team. Some of us may be bit players in the team. It is critical for a physician to manage that person’s diabetes, obesity, hypertension or prostate cancer. It is also important for the pharmacist be involved to review the long list of medications, the nutritionist to be involved to make sure the patient is eating as healthy as possible, and the social worker to make sure that that person has access to both the care and the resources necessary to keep them as well as is possible.

Physicians can’t do it all, nor is it appropriate for them to.

Integrated Care and Value-Based Medicine

The biggest challenge physicians face is the movement of fee-for-service medicine to value-based medicine. This is a hard bridge for most physicians to cross. My particular example showed how much time it took for me to review all of Paul’s previous medical records, discuss his care with both the patient and case manager in the emergency department to change his plan of plan of care. I could have not done any of that though, and just ordered a CT scan to evaluate his abdominal pain.

That said, it is a bridge that must be crossed. ACOs and Clinically Integrated Networks are two of the many paths that may get us across that bridge. If physicians are to maintain their place in the healthcare system as respected and critical members of this team they must find a way to truly move to patient centered care and deliver what is best for Paul as well as what is best for the long-term viability of our healthcare system.