UR managers must ensure all sides are heard in treatment decisions
Satisfaction must be balanced against outcomes
Conflicts between patient outcomes and patient satisfaction can be subtle: A hypertensive patient who feels fine is persuaded, pestered, and pushed to take blood-pressure medication that only makes her feel lethargic. Medical outcome: good. Patient satisfaction: poor.
Conflicts also can be more obvious: A 75-year-old amputee who is inactive, smokes, and has poorly controlled diabetes needs surgery to revascularize his stump right below the knee. The surgeon explains that the intensive procedure will require a week-long hospital stay with a sore leg, no cigarettes, and $400 in co-payments.
Removing the stump just above the knee also will stop the pain and coolness he is experiencing in the stump without such a long hospital stay or large co-payment. Since the patient's ability to walk would not be hindered (he has not used his prosthesis in 10 years), he chooses further amputation. Medical outcome: bad. Patient satisfaction: good.
Both situations present difficult questions for clinicians, patients, and payers to address. No answers are wrong, but the utilization manager must ensure all perspectives are at the table to make the best decision that balances medical outcomes against patient satisfaction. Patients who feel they've been empowered to make the best choice possible are more satisfied. (See related story, p. 3.) Frequently, the perspective missing in this discussion is that of the patient, says Joyce Kenny, RN, MPH, utilization manager at North Memorial Health Care in Robbinsdale, MN. She says the process of utilization management demands three questions that are neither pro-outcomes nor pro-satisfaction:
* Are the services we are delivering medically necessary?
* Are we in the appropriate setting to deliver these services, and is there a lower-cost setting where we can deliver them and maintain the quality?
* Is every resource being used efficiently?
"If you look at the question of patient outcomes and patient satisfaction from that perspective, you are going to look at it differently than if you have a pull-out-the-stops, save-the-patient-at-all-costs mentality," Kenny says. "Managed care might say a hospice is appropriate here. This is a dying patient. This is not a patient we are going to cure."
When presented with that line of reasoning, providers often accuse utilization managers of only being concerned with the cost and not with the life of the patient. As those two participants pull for their side, the patient is left out of the discussion.
"We need to put that patient first and understand what his goal is," Kenny says.
She uses an 85-year-old woman with ovarian cancer as an example. After the diagnosis, Kenny says providers should explain what treatment vs. no treatment will mean. "You talk to this 85-year-old woman and say, 'Yes, you do have cancer. Now, how do you want to manage the last five years of your life?'" Kenny says. "But we don't do that. We bias her decision making by coming at her and telling her we are going to do this procedure and this procedure and this. . . . We've had a paternalistic, 'I know what's best for you' approach and haven't listened very well."
Today, patients must play a role in health care decisions, especially when the treatment may be worse than the cure in the patient's mind, says Shirley A. Arizpe, MEd, quality improvement coordinator for the Prudential Health Care Plan in San Antonio, TX. For example, giving a chemotherapy patient a 20% chance of success might be clinically adequate, but not worth the pain from the patient's standpoint.
Patients must be engaged whether the issue is a $20,000 operation or simply taking their medications, Kenny says. "Obviously, you have got to convince the patient to take his blood-pressure medicine," she says. "That doesn't mean you can't hear his concerns and try to address them."
Patient satisfaction is not simply a yes-no decision for the patient. It cannot be, because the patient does not understand the medical processes and ramifications of going forward with treatment or not. "You hopefully get the patient's mind more engaged and more informed so he says, 'I'm probably not going to feel great for the first three or four months I'm on this medicine, but I know it's important I keep my blood pressure under control because I understand the risks of not keeping it under control.'"
Elderly patients, who often were raised to trust and not question physicians, tend to agree with treatment decisions by physicians, rather than asking about their options, says Tom Campbell, director of marketing and managed care at the 161-bed Deborah Heart and Lung Center in Browns Mills, NJ. He is seeing, nevertheless, more patients take an active role in their care and family members advocating on behalf of their elderly family members.
"I've gotten more than a few calls from someone saying, 'My father is needing open-heart surgery. I'm checking out a few places to find out how they approach it and what are the best places for him. Could you send me some information?'" Campbell says. He may then receive a follow-up call by the same person with a few more pointed questions about his father's options.
Patients, families search for better way
Campbell is familiar with several cases in which families have investigated alternatives and challenged the treatment choices by cardiologists. "This is geared not only for outcomes, but for the satisfaction of the particular patient," Campbell says. "There are more [challenges] that we're seeing, and that is driving patient satisfaction. Patients and relatives are doing what they think is best, which will have them more satisfied than just following a physician's lead of going to a certain place or doing a certain procedure."
Deborah Heart and Lung has embraced a philosophy that encourages patients to take part in the decision-making process. Campbell surveys physicians and finds that they are increasingly listening to patients more and involving patients in their decisions.
"There are beginning to be more joint decisions," he says. "In the last few years, more physicians are saying, 'We are discussing [procedures], and we are making a joint decision.' They're not just saying, 'Here's where you're going because I say you're going,'" Campbell says.
He acknowledges that many physicians still do not take patient preferences into their medical decisions, but that is changing. Utilization managers, in fact, are furthering the process.
"We have all of a sudden become more important," Kenny says. "The utilization review department used to be two or three nurses who would run around the hospital looking at charts, putting Medicare notices on them."
Now, utilization managers often work with caregivers to help them look at situations from the patient's perspective. For example, in the case of the 75-year-old amputee, the surgeon would be mortified to remove a part of a leg that he or she knows can be saved. Kenny might step in to get a dialogue going between the patient and the physician. She says she would ask the surgeon: "Tell me from a quality perspective what you are going to accomplish with this revascularization and why you think it is important to revascularize this stump. He may have some very valid reasons that I haven't thought of, but you want to get that dialogue going."
Kenny knows that many surgeons still view a call from the utilization manager as an intrusion. Utilization managers must realize that and not question the diagnosis, but make sure the treatment is appropriate for the particular case. "He may go ahead and revascularize this one, but maybe I've raised his consciousness a little," Kenny says. "Doctors view disease and death as the enemy. You can't change belief systems just by walking up to them and getting in their face. You have to work with them, engage them, show them data, and convince them there is a different way to think about this."
If that does not convince physicians, Campbell points out that managed care organizations are surveying their patients about their encounters with their health care system. The surveys ask if the patients were treated politely and on time. The MCOs also want to know if the patient was informed about tests and treatments.
"It's a question of educating the providers, the surgeons, and the consumers," Campbell says. "We've found consumers more data-driven and more aggressive in terms of second opinions and being involved in what care they are going to receive." *
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