Measuring value that matters
Deborah Pfeifle is CEO of Gould & Lamb, the leading provider of Medicare program compliance services for the global insurance and self-insured
markets. Her Critical Challenge is to create a metric that will allow insurance underwriters to accurately value an individual
life care plan for so-called "dual eligible" patients who are enrolled in Medicare but receive their care through the Medicaid
program for the indigent. These are high-cost patients, usually with multiple chronic ailments, who also have very low incomes.
The Medicaid program has for some time been contracting with private insurers to cover this group and to find ways to deliver
care more efficiently—thus creating the rationale for Pfeifle's project. "It is a priority for the insurance industry and
actually for government and society as well, to be able to anticipate what dollar amounts will be needed to keep this population
well and out of hospital," Pfeifle told Pharm Exec. "A life care plan is designed to estimate what the cost will be in services and supplies to help a patient with a chronic
disease or condition maximize the ability to function for the rest of his/her life. This is hard to do for those who are ill,
but it is particularly challenging for dual eligible patients due to the constraints imposed by the harshness of their underlying
economic and social circumstances." Indeed, evidence shows that failure to anticipate these non-medical needs in a life care
plan ends up driving healthcare costs even higher. "We must work to incorporate that fact into our metric."
Pfeifle told Pharm Exec she is working with a private non-profit, the Foundation for Life Care Planning Research, to establish a research analytics
standard that allow underwriters to build cost estimates for this dual eligible population, which numbers more than 10 million
people. Says Pfeifle, "this is something that has never been done before—there is no prior research and we have extremely
limited precedents to go on. We are building this metric from the ground up."
Curative power of community
Nicolas Sandoval works for the patient at the most basic level, helping communities of economically marginalized workers to navigate the public
health bureaucracy to obtain essential primary care services—services that can make the difference between wellness and disability.
A bilingual health educator for Salud Para La Gente, a network of federally designated community health clinics in rural California,
Sandoval has a strong interest in the "whole person" approach of population health, especially in identifying the most cost-effective
way to treat poor patients with chronic illnesses. His Challenge project centers on the treatment of type 2 diabetes, a condition
affecting as many as 60% of farm workers in the areas of the state covered by Salud's network.
"Control of diabetes requires a huge commitment to patient education, a need accentuated in the communities I support by economic
troubles as well as cultural, linguistic, and even geographic barriers," says Sandoval. "Many of the people our clinics serve
are unregistered immigrants with no fixed address, transient seasonal workers who follow the harvest and speak no English.
Getting these diabetic patients to proactively self-manage their condition is almost impossible: how do we do it? This was
the essential question deserving an answer. My project seeks to provide it."
What Sandoval is introducing, with the help of colleagues from Salud, is a structured program of group visits for diabetes
patient treated in network clinics. It involves bringing 10-15 patients together for encounters with not only the physician,
but a nurse, pharmacist, medical assistant, dietician, and health educator. "It creates a setting where basic messages about
health maintenance are reinforced through a structured group exchange built around four behavioral pillars: physical activity,
nutrition, medication adherence, and stress management." Sandoval says the training he is receiving through the EMHL program
will move the project to the next step, which is developing a list of indicators to demonstrate the program's effectiveness
in improving outcomes for covered populations. "Under the ACA, as a federally qualified health clinic, this metric is going
to be necessary to scale up and obtain an ongoing source of funding."
Silo-busting precedents: Four lessons
All of the Critical Challenge projects undertaken by this first, 28-member 2015 class of the Brown EMHL program are intended
to grow beyond the shelf life of academia; the students expect these will shape their future assignments in the workplace
as well. Executing a project designed to establish something tangible around an academic program raises an inevitable question:
are there lessons from the experience that can be applied to create a generic lesson plan for business success?
The consensus appears to be yes, with Pharm Exec's discussions with the class yielding four strategic principles: (1) understanding the goals of the organization first, to
find ways to get others to align with your own goals; (2) avoiding the visionary prison of "thinking small," by going beyond
internal politics to identify outside stakeholders who will be affected, for better or worse, by what you intend to do, and
planning in advance to address each; (3) consider the underlying social and cultural aspects of health care, in addition to
its more prominent scientific and clinical dimensions—that elusive 360 degree picture; and (4) always be transparent, which
in the competitive precincts of healthcare is not an instinctive act, but learned behavior.
William Looney is Pharm Exec's Editor-in-Chief. He can be reached at email@example.com
. Disclosure: he is a member of Brown's EMHL Advisory Committee.