Better outcomes for less than $15

All you need is a small card file box and the willingness to use it.

By Lee N. Newcomer, MD
Oncologist/Minneapolis

WEB POLL

Is it a doctor's responsibility to remind patients to get needed follow-up care?

Ninety sets of mouse ears pointed at me as I prepared to begin my talk about physician performance measurement. They were emblazoned on the polo shirts and baseball caps of the family physicians attending their annual CME courses in the mouse's Florida kingdom.

This crowd was on vacation. I looked like a funeral director in my suit and tie amid all the floral print shirts and golf shorts. Three young men sauntered in and took back row seats. They joked and bantered, sunburned from yesterday's golf game. Their bloodshot eyes told me that they'd spent too much time at the 19th hole the night before. Other attendees read tour guides and planned their afternoons.

"Did you know that you treat your patients correctly only about 60 percent of the time," I said, breaking the silence. Eyebrows arched; brows furrowed. I had their attention. The tour books were placed on the floor.

"Everyone knows that, with a few exceptions, beta blockers should be given to patients who've had MIs, right?" I said. Nods. "We searched the prescription records of patients immediately after they had been diagnosed with an MI. Only 40 percent of the patients received a beta blocker."

I'd given this talk before. As I went through the familiar data, I thought back to why I was here. I'd spent 10 years practicing oncology and wondering why doctors couldn't do a better job delivering care. Now, as the chief medical officer of a large insurance company, I had access to its huge database of claims. I profiled utilization patterns to figure out ways to make things better. Now I was presenting those results.

"The problems aren't limited to beta blockers," I continued. I showed them that 30 percent of kids with otitis media were treated too aggressively with broad-spectrum antibiotics. More than one-third of patients with CHF were not treated with life-saving ACE inhibitors. Less than one-third of insulin-dependent diabetics have their glucose control checked even once a year.

"What do you think causes these statistics?" I asked.

A hand shot up. "Your numbers are wrong," this doctor accused. "Everyone knows insurance claims aren't accurate."

I'd heard the objection before. "We confirmed our data with chart reviews," I countered. "The accuracy is within a 5-percent error rate. Even if we're off five points, that still means half the patients aren't being treated correctly."

Sullen silence.

"Is there anyone here who believes this data doesn't apply to his or her practice?" I asked. No hands.

"This isn't happening because we're stupid," I said. I made sure to include myself in the accused.

"How many of you track what you do in your office?" I asked. Three hands went up.

"We don't have any way to track this kind of information," a third-row physician said. "Who has the record systems to do this?"

"We could do it on our EMRs," replied a colleague. "It just takes extra programming."

The inevitable response shot out. "But who can afford an EMR?"

Money always dominated these conversations. Everyone understood the problem. They were omitting basic care because they didn't have a reminder system to make sure that simple things were done routinely.

"You don't have to have a sophisticated system," I said. I clicked a computer icon and a picture of my son hugging his golden retriever appeared on the screen.

"Mike and Hutch are each 6 years old," I said. "Guess which one receives better health care?"

Some amused grins. The three hangovers stir.

"Mike was initially denied admission to kindergarten because he'd missed three vaccinations. His pediatrician never sent us reminders," I explained.

"Hutch has never missed any of his shots. His vet has two records. The first looks like your medical chart; the second is a three-by-five index card. At each visit he reviews Hutch's vaccination record and marks the next due date on the card. The card goes to the receptionist who files it by month in a recipe box. Each month she pulls the cards out of the box and calls the owners until they make an appointment.

"That system costs $15," I said, "but only because they use a designer box.

"You don't need fancy. But you do need to start. Choose a topic and begin measuring. Find out how you're doing, and then try to improve." Heads nod.

The discussion becomes optimistic. Questions about technique and what to measure arise. But doubters persist.

"Your vet doesn't have as many complicated issues to follow as we do," said one. "At least he gets paid. What do we get for better diabetic control?"

The hour is gone. I wonder how many doctors will actually try a follow-up project.

As the others leave, one doctor walked toward me. He was lanky, had roughly cut hair, and his clothes were out of style by about 20 years. A rube, I thought.

"You were right about the recipe box," he said.

"Is that so?" I replied. Why didn't this guy speak up before?

"I've got 312 hypertensives in my practice," he said. "All but 10 are normotensive now. I've got all of them on regular potassium checks and renal function screens."

I stopped packing. "And you track them with a recipe card file system?" I asked.

"Yep," said the rube. "My nurse and I went through billing records and found all the patients coded for hypertension. Over the next four months we started them on a regular follow-up system until they were under control. If they miss a prescription or an appointment, we call them just like your vet does."

I was impressed. "That takes a lot of time," I said.

"It's worth it," he said. "I feel good about how well we're doing."

"But why didn't you tell us about this system when everyone else was here?" I asked. "People need to hear how good it feels."

He grinned. "You gave them what they needed. They have to want to do it. We can't make them."

He said good-bye. I watched him as he ambled toward the exit—my new hero.

"You're wrong," I said as he reached the door. "People need to see other successes."

"Then find a way to tell them," he said. He smiled and left.

"I will, rube," I said to the door. "I will."

 

Lee Newcomer. Better outcomes for less than $15. Medical Economics 2002;22:33.