It’s actually a serious question.
Let’s define a healthcare nanny as someone who calls you to tell you that you didn’t take your medicine, or that you didn’t get your prescription filled. They’ll also call you if you haven’t scheduled your routine follow-up appointment or gotten those screening tests that your age and sex suggests that you might want to have. Your nanny will scold you when haven’t been exercising enough, or when you eat too much. And, of course, (s)he’ll weigh in any other aspect of medical compliance that might come up. Just had an operation? Remember to change that dressing and walk around three times a day.
Now before you read on, please carefully consider your own answer to the following question: “Would you want a healthcare nanny?”
And if you’ve answered yes to that question, then here’s another one for you: “How much are you willing to pay for that privilege?” A dollar per week? Ten dollars per week? A hundred?
Now, how much are you willing to pay to ensure that everyone else in America has a healthcare nanny?
This question comes up as a result of an astonishing increase in the number and variety of organizations asking your doctor to either take on the role of healthcare nanny, or pay someone on his/her staff to do so. A large part of the justification behind forcing doctors and patients out of small private medical practices and into so-called “medical homes” and accountable care organizations (ACOs) involves their proposed use of intensive “communication” and “coordination of care”. A large part of this is inevitably going to involve the use of healthcare nannies (or their equivalent) to make sure that patients do what they’re told, when they’re told to do it.
Let’s take a couple of examples. First, take a look at these two letters sent to a physician by CVS Caremark, a large national pharmacy.
The basic message is:
- We did not fill/refill your patient’s medication as expected;
- Therefore your patient may be non-compliant with their medication;
- Therefore you should call them and do whatever is necessary to bring them back into line.
On the face of it this may seem like quite a reasonable thing for CVS Caremark to do. In fact, from one perspective it appears to be a valuable public service. Everyone wants patients to get well and save money by staying out of the hospital. If you don’t buy and take your medications, you might get sick and up in the emergency room. No one can accuse CVS Caremark of having anything but good intentions in launching and maintaining this program.
Here’s a second example from Medco Health Solutions, the largest mail-order pharmacy in the country. In this case a physician is being told that he/she should be sure to obtain a routine eye examination on a diabetic patient. As the letter explains, diabetes-associated eye disease is one of the leading causes of acquired blindness in the U.S.
The message here is:
- Somebody told us that your patient has diabetes. This means that they should get regular eye check-ups;
- As far as we here at the mail-order pharmacy know, this particular patient hasn’t had an eye exam lately;
- Therefore you should immediately check their records. If they have not had an eye exam lately, you should contact them and do whatever is necessary to get them in for an eye exam..
Here again it would be hard to fault Medco for wanting to help prevent blindness. clearly, good intentions are everywhere. Which leads one to wonder, “Hey, shouldn’t everyone be doing this sort of thing? In fact, why the heck aren’t all of those other lazy, loutish pharmacies doing the same thing? And if some is good, more is better. Presumably they should be joined by every other medical supplier, insurance company and government agency on the planet. After all, what could go wrong?”
Well, if you’re a regular reader of this blog you already know that the Road to Hellth is almost always paved with good intentions. Healthcare nannyism is no exception. And, as usual, the devil is in the details.
Detail #1: Nagging is only useful if your data is correct. Much of the information used to create alerts like these is inevitably going to be wrong. Patients routinely move, change vendors, and change insurers – all while trying to maintain a few remnants of medical privacy. Third parties such as pharmacies and health insurers base their alerts on purchasing or claims information. Their databases are typically incomplete, always delayed by 60-180 days, and often loaded with incorrect information. “Garbage in, garbage out,” as they say in the computer business,.
In the case of the first “non-compliance alert”, the patient had indeed had the prescription filled, but at a different pharmacy. Of course there was no way for CVS to know that, (and if they did, one might wonder how and why they knew.)
In the case of the Medco letter, the patient had already had a recent eye exam. Which raises the question, “why should the pharmacy that mails them their drugs pretend to know anything about what other medical care they’ve been receiving?” Did someone hand them this patient’s records? If so, why? Is it really any of Medco’s business?
The cumulative impact of all these alerts is substantial. Even computer-generated letters cost money to send and receive. Each one generates administrative overhead to produce, send, open, evaluate and process – overhead that is completely uncompensated by the existing healthcare system. Sending alerts that are incorrect or unnecessary is like “crying wolf”. It makes taking care of patients harder rather than easier.
Detail #2: Who’s you nanny? Now place yourself in the shoes of your typical busy, beleaguered physician who has just had a whole stack of these things placed on his desk. CVS is worried about this. Medco is worried about that. You’ve just gotten a bunch of notices from various insurance companies telling you that you may be over- or under-utilizing medical tests compared to your “peers”. The fax machine beeps. Mrs. Jones may or may not have filled her prescription for the medication you prescribed.
Is this really your problem? Are you a doctor, or a nanny?
Following up on alerts like these can be expensive. Let’s say that you ask your medical assistant to call Mrs. Jones. It takes her 15 minutes to bring up her record, dial the number, speak to her on the phone and record the results. At a typical hourly rate that call cost your office at least $5.00, regardless of whether the information was accurate. How much are you paid for being so fastidious? Nothing. The entire cost is going to either come out of your own pocket, or be passed on (directly or indirectly) to all of your other patients. Now multiply this by anywhere from 10-20 alerts per day, five days a week, and it adds up to $20,000 in additional expense per year. Multiply by say, 500,000 doctors, and you can easily spend $10 billion a year just by responding to this stuff.
Even Mary Poppins would think twice before generating that kind of nanny expense.
What’s the payoff? It’s very hard to tell. There is a substantial body of evidence that patient reminders do increase compliance with drug monitoring, reduce the number of appointment no-shows, and increases immunization rates. But do these types of nanny messages actually save anyone any money or improve health status? No one seems to to know. I’ve been unable to find any scientifically valid evidence one way or another. And even if there were, how would that benefit compare with spending the same amount of money on longer office appointments, more medicine or lower insurance premiums?
Which brings us back to the question we asked you to consider. Do you even want a healthcare nanny? Would knowing that it’s going to increase the cost of your health insurance premiums change your mind? To what extent should people be taking responsibility for their own reminders, appointments and medication refills? And most importantly, what cost are you willing to bear to hire and keep healthcare nannies for others?
We can expect to see a lot more of dedicated healthcare nannies under Obamacare, although you’ll never see this particular expense broken out anywhere. Part of the theory behind “medical homes” and “accountable care organizations” (and it’s only a theory – none of this stuff has ever been widely implemented let alone well studied), is that close, continual contact between patients and their clinical keepers will produce better medical results and save buckets of money.
Maybe it does, maybe it doesn’t. But you can be sure that more and more people will be watching to see if your medicine go down.