Using What You Know to Improve Care for Your Members

In the current issue of the New England Journal of Medicine , a group of physicians from Harvard Medical School describe an unfortunate and instructive case.[1]  One of the system’s patients had her spleen removed after an automobile accident.  I would venture to guess that just about  every sophomore medical student knows  that people without a spleen are more likely to have infections, especially with streptococcus pneumonia, and that those infections can lead to death or, as in this poor lady’s case, severe, permanent complications.  Anyone who has had a splenectomy should be vaccinated against pneumococcus.  So far so good, but the vaccine was never given in this case because the problem list in her electronic medical record was never updated to include the fact that her spleen had been removed.

When these doctors looked at the records in their practice (over 1.7 million of them), they found 7125 patients who had had their spleens removed and only 5028 (29%) had the diagnosis on their problem list. And it gets worse from there.  Of the ones who had the diagnosis on their problem list, only 54% had been vaccinated; of those without the diagnosis, only 17% had been vaccinated.  (Remember, the guideline is vaccination for 100 %.)  And this is at one of the very best medical care delivery systems in the United States (probably in the world) and these patients all have electronic medical records.  You can guess what the numbers would be like out in the real world where solo practitioners are working with paper charts.

So we have two problems.  First, the list of diagnoses was incomplete.  Second, there was a clear and unaddressed gap in care.  How do you fix a problem like that?  The first impulse would be simply to better educate the doctors.  These authors conclude (and I agree with them) that “education alone is not a highly reliable intervention.”  Remember, these are some of the best doctors we have and they are using some of our best clinical tools.  The solution has to be in redesigning the system.  And that is where Medicare Advantage plans have something really important to offer.

These authors recommend “tools such as reminders and patient-level reports about guideline compliance” as the best way to change the system.  I would suggest that carefully designed and targeted member evaluations of Medicare Advantage members organized by the plans can bring together a wealth of clinical information from claims with directed face to face evaluations to yield accurate and complete diagnostic information and to identify gaps in care.  If that information is collected in a proper open access data base, actionable reminders can be generated for the member, for the member’s treating physician, and for plan case management—just the sort of tool the authors recommend.

And, once again, we have an impact that cannot be replicated by fee for service Medicare.

Note: You can join Jack at a MCOL-hosted webinar event  on September 13th, as he discusses further more powerful ways of addressing gaps in care, and integrating risk adjustment and medical management.  Click here for details on that event.