Renegotiation Brings Better Health Outcomes, Lower Costs

The November 2011 issue of The Atlantic features an article on CareMore, a health care provider serving only Medicare Advantage plan patients. Through innovative renegotiation of everything from the care model to the business model, CareMore has delivered high rates of patient satisfaction, improved health outcomes, and lower overall costs. CareMore was recently acquired by WellPoint and its model is set to roll out nationally.

The CareMore model was borne of the insight and passion of Dr. Sheldon Zinberg. He both served an older population and was facing his own later years. He saw that there was something seriously wrong and set about to try to fix it. He envisioned a system of what is now more commonly known as “coordinated care” where a group of physicians and nurses work together (more unusual than you would think) to provide a full range of care — sometimes offering early interventions that don’t wait for the patient to the patient to ask. Here is one brief story from the article:

Dan, a retired letter carrier, is a patient at a clinic in the same system. At 87, he is decidedly frail, his once-sturdy legs now weak and unsteady. He is a classic candidate for a fall of the kind that has injured many of his friends, in some cases leading to weeks in the hospital and months of rehab. The elderly are prone to falls for many obvious reasons, including weak limbs, impaired vision, and medication side effects. But Dan’s doctors knew that some less obvious causes included shag carpets and long, untrimmed toenails. Because of this, they’d sent someone from the clinic to visit Dan’s apartment and make sure that his daughter replaced the 1980s-vintage carpets with low-pile rugs. Dan also visits the clinic regularly for light muscle-training sessions and periodic toenail clipping. Due to these preventive measures, Dan and his fellow clinic patients are one-fifth as likely as comparable patients elsewhere to suffer falls.

It took some time for Zinberg to convince other physicians to join him. It took more time to convince insurance companies to reimburse CareMore through a fixed per-patient fee rather than the traditional fee-for-service. It took time to get patients adjusted to the model. It is a story of massive — and masterful — negotiation.

CareMore’s model will soon be available to many more people as WellPoint expands them beyond their base in the western U.S. What is most interesting to us, however, is Zinberg’s approach. It is similar to several that we profile in Renegotiating Health Care — individuals with the the vision, persistence, courage, and persuasive ability to attempt change in the fundamental system. These people question assumptions, strive to perceive the entire system rather than just their small part in it, and they are not afraid to ask, “why not?”. Zinberg and his colleagues shifted the paradigm of the system from “sick care” to “health care” and everyone has benefited.

They also possess the negotiator’s necessary skill of enabling others to see a future that may be significantly different from the present, but that offers great benefits for all. In Renegotiating Health Care we lay out a pragmatic technique for doing just this. It is called The Walk in the Woods.

CareMore’s results are encouraging:

…a hospitalization rate 24 percent below average; hospital stays 38 percent shorter; an amputation rate among diabetics 60 percent lower than average. Perhaps most remarkable of all, these improved outcomes have come without increased total cost.

If we are to meet the larger health care challenges this country faces, particularly in the face of an aging population, we are going to need more Zinbergs, more people skilled and courageous enough to renegotiate the system.

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