Trailblazing the Future of Care

As the nation’s healthcare system strains to manage a sour economy and an aging population, large academic medical centers like Massachusetts General Hospital are on the hot seat to cut costs. In the past, hospitals focused on finances when they wanted to reduce spending in one area to invest more in another.

Amid mounting budgetary pressure from both sides of the political aisle, that kind of strategic shifting is no longer an option. “Today’s market demands that we generate real savings for health care,” says Gregg Meyer, MD, MGH senior vice president for Quality and Safety. “Discussions about costs have expanded beyond controlling inpatient care and length of stay. Now it’s about outpatient care, how tests are done and what standards should be used.”

The way Mass General does business is about to change. For 200 years, the institution has saved countless lives, trained generations of medical leaders and discovered cutting-edge cures. Now, that same commitment to excellence and innovation must be focused on finding ways to more economically deliver the world-class care for which Mass General is known.

With the hospital’s reputation as a pacesetter, the results are likely to have repercussions nationwide. “Redesigning care to cut costs is the most important thing that we are going to do as an institution over the next five to 10 years,” says David Torchiana, MD, chairman and chief executive officer, Massachusetts General Physicians Organization (MGPO).

Integral to this process is discovering more efficient ways to care for the sickest patients, the 10 percent who use 70 percent of the resources. Because of its clinical reputation and expertise, Mass General has many such patients. Another challenge is providing for an influx of new patients. “Right now, we are in a situation where the state and country have finally stepped forward to address the problems of being uninsured and lack of access to care,” Dr. Torchiana observes. “The remarkable side effect — we are left with cost as the major concern.”

The trick is to cut costs without compromising care. Despite the often negative media portrayal nationwide, care is always evolving and improving. Treatment for every serious medical condition has improved over the past 50 years, sometimes dramatically. For example, from 1994–2004, the mortality rate from heart attacks dropped by about a third. “As we advance the quality of science, treatment, imaging and our understanding of disease, we have a tremendous obligation to more intelligently steward resources in a more responsible way,” Dr. Torchiana adds. In pursuit of that mission, scores of clinicians and others throughout the Partners HealthCare system are already engaged in a care redesign initiative. “We’re looking for ways to reduce waste, which includes reducing the risk of complications and readmissions,” says Elizabeth Mort, MD, senior medical director for Partners. “Our fundamental pursuit is to improve value for our patients and the system, that is, to deliver superb care at lower costs with the fewest possible errors. We also want to make the experience of care very focused on the patient’s needs.”

Nurse practitioner Barbara Chase, MSN, ANP-C, CDE, is passionate about the MGH Chelsea Health Center’s approach to managing diabetes.

Partners has created teams to redesign care for five conditions that are both common and expensive: colon cancer, coronary bypass, heart attack, diabetes and stroke. In addition, a Partners team is looking at how primary care should be organized to meet the challenges of the evolving health system. At the hospital level, Mass General has created teams in these areas as well as formed five more teams: endovascular procedures, lung cancer, obstetrics, total joint replacement and transplantation.

“As individual physicians, and as an organization, we do a good job of taking care of the patient in front of us,” says Dr. Meyer. “The importance of that is not going to diminish. Care redesign will help us look at the big picture by creating systems that improve the way we care for a population of patients.”

It would be hard to find a disease better suited for care redesign than diabetes. “No chronic disease has increased in frequency like diabetes and its evil twin, obesity,” says David Nathan, MD, director of the Diabetes Center at Mass General and co-chair of the Partners Diabetes Redesign Initiative.

Diabetes is one of the most common, costly and complex medical conditions. Nearly 26 million people in the United States have diabetes, and the percent increases with age — as many as 25 percent of all people over 60 are affected. Direct and indirect costs of diabetes combined reach around $200 billion annually. Diabetes is the leading cause of blindness, kidney failure and amputations. It also increases the risk for heart disease up to five-fold. Medical expenses for people with diabetes are more than two times higher than for people without diabetes.

“The good news,” Dr. Nathan comments, “is that we know what to do to control diabetes and make it a much less harmful disease. Yet we currently have little control over galloping costs. The challenge is how to deliver higher quality at a lower cost.” Diabetes is different from other diseases targeted for care redesign. It’s chronic and degenerative and affects many parts of the body, from the heart and the kidneys to the feet. Drugs were the first area that the team tackled.

“The cost of diabetes medicine has increased more than the cost of drugs for other diseases and is a major contributor to the healthcare apocalypse, especially when you consider the numbers of people affected,” says Dr. Nathan.

Meanwhile, the available evidence shows that less may be more when it comes to drugs and diabetes. The group’s recommendations involve switching to generic drugs that are at least as effective as brand name ones; reducing the number of drugs; and using insulin.

Diabetes nurse educator Eli Sanchez, RN, BSN, leads a group diabetes self-management education session.

Insulin can be a hard sell for some patients. Fear is a barrier. Dr. Nathan compares the anxiety around insulin shots with the angst before the first kiss on a date. One strategy is to give a first test shot in the office. “Get it over with, and then you can relax,” he advises.

Implementation of the recommendations to standardize and improve diabetes care is the charge of the MGH Diabetes Care team, co-led by Deborah Wexler, MD, an endocrinologist, and Stephanie Eisenstat, MD, a primary care physician in women’s health. The team of nearly 20 includes providers from primary care, nutrition, pharmacy, behavioral health and other fields. Dr. Wexler is the only endocrinologist. “Diabetes management is easy for me, because that what’s I do,” she says. “Making it easier in primary care practices — that’s what we are trying to do.”

Diabetes care redesign extends beyond drugs. The next wave focuses on prevention and providing support to help patients with diabetes and prediabetes change habits around food and exercise. A multi-hospital study (with Mass General as one of the leading participants) demonstrated the success of a lifestyle intensive program in preventing diabetes. The billion-dollar question is how to put that research into practice.

Dr. Wexler acknowledges that finding ways to help people change their behavior to lose weight and exercise is “really hard to do.” Mass General is fortunate to have expertise in this area, particularly in two practices that she calls “models,” Bulfinch Medical Group and Chelsea Health Center.

There is nothing special about the facility where Barbara Chase, MSN, ANP-C, CDE, a nurse practitioner, works. It’s a satellite site in a one-story strip mall a few blocks from the main MGH Chelsea Health Center. What’s special is the care that the team offers to diabetes patients.

Ms. Chase, who has worked in primary care for 40 years, is passionate about the center’s approach to managing diabetes. “Getting average blood sugar levels down is the first step, but what we’re really trying to do is prevent cardiovascular disease, blindness and stroke down the road,” she says.

Her team uses culturally appropriate services to meet the needs of the health center’s diverse population, more than half of whom are Spanish-speaking or new immigrants from Africa, the Baltic States or Latin America. The program includes nursing visits for diabetes education, medication dose adjustment, coaching, physical therapy, nutritional counseling and mental health services.

The adult medicine practice at the health center began to concentrate on diabetes in 2006 with support from the Massachusetts General Physicians Organization, MGH Community Benefits and the MGH Disparities Solution Center. The first step was to develop a diabetes registry, a database to help identify and track patients that could be used to measure outcomes.

“We’ve learned along with the patients,” Ms. Chase explains. “Information is important, but the way you give information is also important.” They started by presenting information to patients and soon realized that the top-down approach was ineffective.

“Engaging people has to be at the ground level,” she says. “It’s about developing personal relationships. We have to understand what happens outside the health center. Life gets in the way — transportation problems, layoffs, sick family members. Taxes are due, so you go to McDonald’s, instead of making a sandwich. You help your son with homework instead of going for a walk.”

Ms. Chase uses the word “team” again and again. And the patient is the center of that team. There are barriers — psychosocial, logistical and financial, to name a few. “Education alone does not ensure that patients will make healthy choices,” she says. “It can’t be just one intervention. If something doesn’t work, try again. We’re with them. And it has to be long term.”

Herman Gomez, MD, leads a shared medical appointment for diabetes patients at Mass General’s Chelsea Health Center.

One solution to managing a group of patients is through shared medical appointments. After meeting individually with medical assistants, patients participate in a group session covering treatment, medical nutrition therapy and exercise. Eli Sanchez, RN, CDE, a native of Puerto Rico, and a Chelsea resident, conducts his group sessions in Spanish. Prior to becoming a certified diabetes educator, Mr. Sanchez was a visiting nurse in Chelsea for more than 15 years and has a deep knowledge of the local community, an added benefit for his patients.

During the group session, patients, one at a time, step out of the group to meet privately with a nurse practitioner or a physician. Ms. Chase credits Herman Gomez, MD, a primary care physician in the health center, for his support of shared medical appointments.

“Not all doctors are used to working in a team,” she says. “Doctors don’t have to do everything. In Chelsea, we are fortunate that the doctors have empowered nurse practitioners to contact patients, order tests or change medicine. We work in teams to take care of a panel of patients. No one says, ‘That’s not my patient.’”

“I feel we have only begun to scratch the surface as far as learning how to help people change behaviors,” Ms. Chase concludes. “Sustaining metabolic control is a lifelong endeavor for patients and not something that we can improve with a few interventions and then think we are done.”

The most expensive part of diabetes care is the complications—bypass surgery, kidney failure, transplants. That’s where programs like Chelsea that use many different techniques to bring diabetes under control are critical. “They’re not necessarily saving money in the first year, but on a population basis over the long term,” says Dr. Wexler, who heads up the MGH Diabetes Care Redesign Team. “It’s huge opportunity for investment. It’s increasing the health of a high-risk population and putting the research into practice.”

Ms. Chase believes that this program is just the beginning. Her dream is to expand this kind of personal support to a population of patients with other chronic conditions including heart disease, arthritis and asthma. “Guiding, coaching, teaching, reaching out, problem solving and being there for patients is longitudinal work that I hope makes the journey a better experience and the destination a better place,” she says.

Dr. Torchiana, from the MGPO, agrees. “Care redesign is not something that you do once, and then you have it nailed,” he says. “It offers a great opportunity to help solve the challenge for the economy, generate knowledge and new approaches and improve satisfaction for both patients and clinicians.”

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