Thelma, an 80-year old woman, had just met her new physician. Her long-time PCP had just retired because he was frustrated with “the way things were changing”. Although her new doctor did not seem old enough to have finished college, she was very attentive. She gave Thelma some new prescriptions which would “work better with less chance of side-effects”. Unfortunately, they were quite costly. First, Thelma had to buy food and kitty litter for her eight cats and then send a check for Christmas to each of her grandchildren. If she had any money to spare, she would get one or two of the new medicines filled.


Tom, a frugal 70-year old, was just released from the hospital after some worsening of his heart and renal failure. The hospitalists did a nice job caring for him and sent him home with handful of new prescriptions. They told him to see his internist in a few days to see how he was doing on his new medicines. Tom did not believe in wasting money; he had paid a pretty penny for the pills he still had at home. He would finish those first, then he would get the new medicines and see his PCP after being on them for several days.


Courtney is a 40-year old with a healthy lifestyle but bad genetics. Her blood pressure has been high, and non-pharmacologic attempts have not been successful. Her family doctor started her on a low dose of a common anti-hypertensive, but her pressure was no better one-check. Her doctor doubled her dose, but the BP still did not budge. The doctor explained that this was not unusual, so Courtney was switched to a different anti-hypertensive but tone avail. On recheck the pressure was still too high, so the new medicine was doubled also. She was told that if this did not work, she would be sent to a specialist. Because Courtney did not like the idea of taking medicine at her age, she had never started either of them but had not admitted that to her physician. She did not want to see a specialist so she took the higher dose of each medication to ensure that her pressure would be better next visit. Of course, she became hypotensive and so orthostatic that she had a syncopal episode. She was admitted for inexpensive unnecessary cardiac work-up.


Pat is 75 years old and was just started on Coumadin for atrial fibrillation. He really likes his Budweiser. His cardiologist told him that he could have two cans everyday but no more because he did not want his INR to climb too high. Pat did some research and learned about Vitamin Kind green vegetables. He decided that he could probably drink more beer if he ate more salads and broccoli. He thinks the extra broccoli is not agreeing with him because his stools smell bad and have turned really black…


The goal of population health management (PHM) is to keep a patient population as healthy as possible while minimizing expensive interventions such as ER visits, admissions, unnecessary procedures, etc. It is interesting to talk with physicians about PHM and hear how unfair it is that “we are responsible for their costs when they are not compliant and have no skin in the game”. Actually it is indeed the patients ‘skin that is truly at risk. Frankly, complaining is not productive. We reentering new method of reimbursement based on a new paradigm of care. We need to develop different strategies, start to think outside the small box that is called the standard of care.


I believe that the most important ingredient to outpatient management is an accurate medicine reconciliation—the patient is taking what you prescribe and ONLY that. So many complications, hospital admissions, and re-admissions occur because of poor compliance with taking medicine. This can never be fool-proof, but the team approach espoused by PHM can help by using a pharmacist to make sure that there are no drug-interactions or likely side effects, and that costs are reasonable; social workers or visiting nurses who can do an in-home thorough medicine reconciliation; and an IT system that can track when refills are obtained.


There are many other examples of other inexpensive interventions which can have a large pay-off. Keeping appointments is crucial. It can be cost-effective to provide transportation for some patients. Proper nutrition is an important, underrated aspect of health. Having a nutritionist shop with certain patients can ensure food selections appropriate for the problem list. Home visits, whether by social workers, case managers, visiting nurses, or physicians can be eye-opening and uncover psychosocial stumbling blocks to better health. Immunizations can be administered. Besides the medication supply, the refrigerator and pantry can be checked.


There are dozens more inexpensive interventions that can have a large benefit for lower costs and better health. I know that several of you are disgusted by the fact that patients are “being spoon-fed” and not learning to take responsibility. So noted. Five percent of patients are responsible for fifty percent of the costs. The most expensive diagnoses are heart disease, pulmonary disease, cancer, mental health, and trauma. The healthiest fifty percent account for only three percent of the costs. Remember that the vast majority of patients will need few to no interventions. Most of these interventions are done by the non-physician members of the team. These patients need to be cared for between acute episodes. Timely, savvy interventions with the sickest patients is a key to succession PHM. An important role for the physicians to encourage life-style changes. Many studies show that the biggest catalyst to stop smoking, decrease alcohol consumption, lose weight, or increase activity is encouragement by the physician. Additionally, patients and providers both need to develop a thorough understanding of the benefits of palliative care.


Last but not least, there is way too much psychopathology whether primary or as a result of living with chronic disease or because of substance abuse. There is a dangerous shortage of therapists. There are not yet proven clinical pathways for most psychiatric conditions. There is not a coordinated community approach in an area where medical and non-medical intervention is of paramount importance. So much of the pathology is because of environmental conditions or because of the misery associated with chronic diseases that frequent in expensive interventions to ease their burdens, guide, and support them will go a long way until best practices are established.


And remember end-of-life planning and palliative care.

brian moloney


Written By: Dr. Brian Moloney, Medical Director for Select Health and member of the MHIN Board of Directors

Select Health Network is a collaboration between Saint Joseph Health System and over 750 physicians and healthcare providers. Through responsible resource management and the promotion of quality healthcare, Select helps employers find innovative solutions to control healthcare costs.