Episode 040: Closing the Gap

Speaker 1: You are listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals. Brought to you by SVMIC.

Brian: Hello. Welcome to this episode of our podcast. My name is Brian Fortenberry, and today we have someone that I think you're going to find incredibly informative as we talk through some care management. Joining me is Michael Burcham, healthcare CEO, with a PhD in healthcare administration. Thanks for being here, welcome.

Michael: My pleasure. Good to be with you.

Brian: Before we get into this conversation, start by telling us a little bit about yourself, about your background and how you got into this business.

Michael: Well, I began as a physical therapist. I finished in '83. Came to Nashville to work in the space, and I found over time I enjoyed the business of healthcare more than bedside, let's just say. And by the mid to late '80s, I was working at Hospital Corp of America, doing health plan contracts and relationship-building for the company. One area that every insurer and every hospital couldn't figure out or agree on was how to support patients before they got to the hospital and after they left, which is the care management space. By the early '90s, I decided that it was probably time for me to scratch that itch and go do something myself in the space. And here I am 25 years later in the same space.

Brian: So my understanding, too, is that you have been not only on the medical side of medicine, but you've done quite a bit on the business side as well, correct, with the different companies?

Michael: Yeah. This is my third healthcare company that I've led. I really enjoy finding the gap spaces that exist between the physician, the patient, the payer, and the hospital, and helping fill those gap spaces so all of those stakeholders have a better experience.

Brian: Tell me a little more about your most recent company that you have.

Michael: So the company's named Narus Health. Narus is a Latin derivative of the word “expert.” I founded it in 2015. In 2014 I lost my father-in-law to ocular melanoma.

Brian: Oh, wow.

Michael: I was there with him for the three years of his cancer journey. And though we were a medical family, experiencing as the patient and the family we began to understand where care management could have been such a powerful assist. And we had great oncologists, great physicians, so this wasn't about having bad practitioners. This was about leaving the physician office and needing to make 12 calls to family members to update them, or being told, “Here's a trial drug you can try,” and then spending hours in libraries and online trying to figure out what that meant, the difference in a Phase 1 and a Phase 3 drug.

So after we lost him, it seemed a perfect time to think about a business. Later that year I lost my mother and my son. And so I think it was a perfect storm of not only understanding what it means to deal with an illness, but also to deal with loss. And so we started Narus for the purpose of changing the experience that people have in healthcare, so rather than feeling healthcare happens to them, they could have a voice and a say in how healthcare works for them.

Brian: And that first-hand unfortunate experience that you had really gave you a lot of insight when you began Narus.

Michael: Well, I think for many of us it takes a good whack on the side of the head to master the obvious and understand that there's probably a lot of other people just like me. The thing that stuck out most to me is that if it was this challenging for our family, who's very fortunate, and knows healthcare, and in a great city of healthcare for things to go well, I could only imagine what it's like if I was living in a more rural market with less access and I didn't know as much as I do about healthcare. And so that was the good reason to start Narus and do what we do.

Brian: What are some of the specifics that you saw evolving that really made you go, “I need to jump in that space?”

Michael: I would say in the early '90s, my original jump into the space was the realization that most care management and case management had been engineered and done by insurers, largely to understand risk that they held in their books for an insured population, or to help their employers understand how to manage their cost. So the patient and family was simply a byproduct of someone else's work. Even though it was all about what was going on with this patient, they were a passive participant, let's say.

I felt like with all the things I had studied in my own research and work, that until the patient was more active and no longer passive in this journey, their level engagement to change would be relatively low, and this would be a never-ending problem that would not find any real solutions any time soon. And with that premise, I decided it was probably time to try to make a difference.

Brian: Well, I think that is fantastic. I agree with you 100%. A physician can do anything and everything. But if they don't have the active participation of the patient, of the consumer, you're going to run into a lot of issues, wouldn't you agree?

Michael: I think they can do most anything and most everything. But if we could do it all, we'd be God.

Brian: Absolutely.

Michael: But I do think that the enormous amount of information that is growing every year is almost overwhelming for any medical practitioner. Just consider that 90% of the world's information was created in the last 24 months. If you finished medical school 10 years ago, without relying on some sorts of technology, you can't possibly practice at the top of your game.

Brian: No.

Michael: But a lot of that new information in the last 24 months is better knowledge of consumer behavior, which isn't even taught in a medical school for the most part. And you're not going to pick it up reading, you know, a Sunday Times columnist. So without some partnership involved to understand how consumer behavior has shifted and changed, it's hard to know exactly how to engage, I think.

Brian: I kind of want to go back just a little bit, just for our listeners that might be hearing “care management” and have a very broad idea of what that is. Can you kind of give us, when we say “care management,” exactly what we're talking about?

Michael: Sure. Care management is the process of helping a patient, an individual, and their family, understand what their disease is, understanding choices. Helping them gain access, whether that's to a physician for an appointment or a second opinion. Access to research to know their options, to even understand their benefit plan, because most people don't even remember where their benefit book is, let alone what's covered. And the minute they need help, it's not the time they want to go try to find what's in the benefit guide, if you will.

Brian: Yes.

Michael: So care management is helping the individual in that journey. It has evolved a lot over the years. It originally began fully paid by the insurer to understand who was at risk and how to mitigate risk. Today, care management is much more about the same notion as a concierge at a hotel would help you know a great place to have dinner. A health concierge is pretty much what care management is. Giving you options of where I can go for treatment. How do I get expedited into a physician office I've never met? What kind of data does that physician need about me? Or even after a physician visit, what did all that mean I just heard, and what should I be doing to think about what's the right decision for me and my family?

Brian: Right.

Michael: Because if you're carrying a third of the total cost, they should have a say in what's going to happen.

Brian: Absolutely. And it is becoming a much more consumer-driven industry, would you agree with that, over the last few years?

Michael: Absolutely. And that creates challenges for physicians as well, because I'm not so sure we've seen any improvement in the amount of time a physician gets to spend with an individual in the office. Yet the consumer probably has 10 times as many questions, because they're getting much more educated. And if they're not educated, they go on “Doctor Google” and search and get terrified of what they find.

Brian: I was just about to say the same thing. The problem is they're coming into the office having gone to Web MD or whatever, and they come in, and they're going, “I've got a cough. Certainly I'm about to die.” And they've already self-diagnosed and all of that.

Michael: Or even worse, they already know which pill they want because they saw the commercial. And they're not even a candidate for that medication, or they don't realize it costs ten thousand dollars a month, and there's a generic available for four dollars. The physician's trying to figure out, okay, do I really have the time to explain, one, how this pill probably isn't going to help you, and number two, the cost variance, if the physician even understands. So people are constantly self-diagnosing and self-prescribing. The physician has to deal with that in the practice while there's 12 other people in the waiting room waiting to be seen. That's never an easy game.

Brian: If they feel like you're kicking them out the door to get to those patients out there in the waiting room, then they're getting subpar care. And then, like you said earlier, they're footing a third of the price now. And so they're getting little more demanding on, “Hey, I'm paying for this. I'm paying for your time. You got to sit here and listen to me out.” How does care management really help with that part of it?

Michael: Let's slow down and think about that for just a minute. There's so many things a physician could benefit from knowing before the patient even arrives at their practice.

Brian: Okay.

Michael: We call those things social determinants of health. But it's things like, does this person live alone? Do they live in a rural zip code and they just drove 45 minutes to see me? Are their socioeconomic status such that even the copay that they're going to pay me today means they'll buy less groceries or not pay the light bill? And all of those factors are really important issues in determining even when a physician prescribes a medication or a plan, can the patient even afford to follow it?

Brian: Sure.

Michael: Care management can help a practitioner, physician, by having that information even before you see the patient. Because my belief is if a physician really knew those things, they would modify a plan to tailor...

Brian: Absolutely.

Michael: ...To the individual.

Michael: We were helping a cancer patient just last week who drives 45 minutes into the city. Seven different specialists want to see this person. They work in a factory as a single parent. And they can't drive four days a week, an hour each way, still have a job, and make an income, and feed their children. But by laying that out, we were able to get most all those appointments in a single day. The employer was willing to give them the day off for their treatment, and they didn't miss any pay, and they got to follow that the physician wanted them to do by simply marrying up the hard realities of people's lives with clinically what was going on. So that's one way care management can help a physician.

The second is that when a physician sees a patient, there's probably 10 to 12 things going through their mind that would really help this individual.

Brian: Right.

Michael: But they've got five minutes.

Brian: Sure.

Michael: So which three am I going to focus on today? Care management allows us to extend that physician's practice and help them do all 12 over the next 30 or 45 days. So quite often we will get the information from the physician that, “I just saw the patient. Thanks for your notes upfront. They really helped tailor what I'm doing today. Here's the series of things I really need this person to focus on over the next month.”

And my job as a care management team is to help the patient achieve those things, so when they see the physician next time, they're not revisiting old issues that were never addressed. We can update the physician on how they've done this 30 days, and the physician can advance their treatment rather than answering questions of what went wrong for the last 30 days.

Brian: That makes all the sense in the world. It's like having someone who has done quite a bit of the background work before they ever even step into the office, and therefore that helps the physician generate a care plan that is feasible, that is affordable, and that will probably fit that patient the best.

Michael: And that is really what today's care management is. Care management today is much more being an extension of the physician practice, alerting the physician to key issues the individual has before they ever see them, and then doing all the follow-up between visits. And the nice thing for the physician, it's paid for by their employer. So it costs the physician nothing to access it, and they can get a much better experience for the individual they're trying to serve.
Brian: And it's a win-win-win. It's a win for the physician, obviously, because they're getting all of this help on the front end, and then help with the follow-through. It's a win for the patient, obviously, because the physician is more informed and can have a plan that fits them better. But it's a win for the employer as well, because the needs of my employee are getting met, and getting done so in a timely manner, that it's not costing me all this time and money and in workforce, correct?

Michael: That is correct. It also does one or two other key things for the employer. I don't think any employer wants to be seen as a non-caring place to work.

Brian: Agreed.

Michael: And the truth is, when someone is really sick at work, and something's really bad going on, everyone gets to know. The word gets out.

Brian: It spread like wildfire.

Michael: Around the water cooler. If the workforce sees an employer actually trying to help a person in trouble with a new cancer or a bad injury, it speaks volumes to empathy that you can never put on a poster board somewhere or in a newsletter.

Brian: Absolutely.

Michael: Empathy is best demonstrated when shown, not talked about. One of the most powerful times to show it is when somebody's having some medical distress, because everyone can imagine themselves, their child, their parent in the same situation, and wondering, “Would anyone want to help me?” And so we can extend this feeling of empathy in the workplace in a very powerful way through care management.

Brian: I couldn't agree more. Because when you're dealing with a sickness, a disease, you're as vulnerable a person as you get.

Michael: Sure.

Brian: And if in that state of incredible vulnerability, you've got an employer that is willing to hold your hand and partner with you through that, it speaks volumes of the employer, I believe.

Michael: Right. There's not that many instances where people happily plan a medical event. I mean, outside of choosing to have a child, or an elective surgery, or a cosmetic surgery, for the most part, healthcare happens to us. It's not something we sought out to say, “Oh, I have a little extra time next week. I think I'll go have a gallbladder attack.” It just happens to us. So the consumer is rarely prepared. But when it happens, time is of the essence. And if we can all work together to share the knowledge we have of the individual, to expedite the opportunity to get the patient to the doctor, help the patient and their family understand their benefit design and what's covered and not, and do the follow-up for the physician, everybody wins. And so it's really a powerful way in today's market, where so many people live disconnected from families or on their own, that we can help individuals when healthcare happens to them to not feel like they're just being caught up in this stream of moving current that they have no say and no control in.

Brian: Absolutely. And for the physician ... like we have many physicians that are listening to our podcast. But that physician out there that is hearing about this, there's got to be excitement there, because there is a lot of benefit for the physician, because a happier patient means a lot of positive things.

Michael: And a more complaint patient means a lot of positive things for the physician.

Brian: That's right.

Michael: Because knowing what would help the patient and having a systematic way that that happens with the patient is quite different. Many times we find the physician writes a prescription, but it never got filled. As the care manager, because I see all the claims data, I know the prescription didn't get filled. Or I see someone lapsed their insulin, and they're diabetic dependent. Reaching out and getting that corrected and getting them back on, because they thought they couldn't afford it this month or they were making trade-offs, we can avoid a lot of really bad complications and unnecessary medical expense by doing that. And those are things that just seem the right thing to do for everyone involved.

Brian: Yeah!

Michael: There's also this move now, not among just employers but insurers and even Medicare, experimenting with various types of care management.

Brian: Okay.

Michael: The Medicare system has put in some new fee codes that allow a physician to bill for some of the overall surveillance or compliance work in between office visits.

Brian: Right.

Michael: Not a lot of physicians use that today, but should, even if you use a third party like us to help. Many employers are adding this kind of service to their benefit plan. It's good to know from the people you serve in their practice which employers are my market offer this. It could be as many as 20, 25% of your patient base has this benefit that would be a significant adjunct to you as the practitioner if you just knew.

Brian: Absolutely.

Michael: So I think there's early movement in the space, and I would encourage any of your listeners to research and evaluate how care management could think about improving their practice and improving follow-through for patients, because I think they would find themselves enjoying the practice far more when patients walk in informed and have been complaint since their last visit. And rather them bringing a notepad of all their questions, they're getting an update of the good things that've happened over the last 30 days. They can help the patient deal with the next set of issues they may have.

Brian: Absolutely!

Michael: And we start with their zip plus four.

Brian: Okay. Tell me about that.

Michael: There's been a lot of writing about it lately. I studied some of this in my own doctoral work. I personally believe your zip code with the four digit modifier on the end is a better predictor of your state of health than your genetic code.

Brian: Really? Okay.

Michael: The community you live in, where you live, whether it's urban or rural, wealthy or poor, gives me a lot of insight to diseases you may be exposed to, the prevalence of chronic disease in your market, how far it is to the nearest pharmacy, how far it is to the nearest doctor. So we can learn a lot through the zip plus four to know what to look for that may be causing noncompliance. It could be transportation. It could be I live alone, I don't have any resources to help me do that. It could be the medication you're asking me to get, I have to drive half hour to get. Could it get delivered to my door?

Or even just knowing up from that because of the socioeconomic status of the patient, that while you would love them to eat fresh fruits and vegetables, it's just out of their price range. They can only afford the cheap carbs. And so they're going to be more challenging to manage because they live in an urban market where they can't grow their own, and their income is so low. There's a reason salads cost more than a burger in the drive through.

Brian: Absolutely.

Michael: People pick the thing they can afford to eat.

Lots of ways we could address what appears to noncompliance is actually driven by social factors that are a bit beyond the person's control. Sometimes there is true noncompliance, but most of the time there's some underlying factor that we can find.

Brian: That is so true. And if you think about it, that makes sense. It just simply makes sense that this person may very well want to be compliant. And I think that's where a service like this really helps out. Because if they know they are only on a limited income, or they are X number of miles from the nearest pharmacy, you might be able to provide that physician information to help them tweak their care plan that alleviates some of those issues.

Michael: Exactly.

Brian: Dr. Burcham, I can't thank you enough for being here today and taking the time to share this information about care management.

Michael: Thank you. It was a pleasure to be with you.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes, at svmic.com/podcast.

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