If I Had an ESCO…
If you are anything like me, you may feel the need to break into silent song right now. Perhaps If I Had a Hammer is now running through your head. Or, maybe If I Were a Rich Man, from Fiddler on the Roof. Interestingly, the former is about changing the world for the better, while the latter is about what it might feel like to be so wealthy that hard work wasn’t necessary—and both may apply to ESCOs, or “ESRD Seamless Care Organizations;” the CMS pilot program of global capitated payment for dialysis to reduce costs and improve health outcomes.
As a Kaiser Permanente (Mid-Atlantic) member, I see the value of global capitated healthcare. Kaiser is highly motivated to provide good clinical care, including prevention, and engage me in taking care of myself. To the extent that I stay healthy, they don’t have to spend as much money on me, and keep more of the fees for my care.
U.S. health plans most likely don’t come out ahead when people have cancer or need dialysis, the two most costly chronic diseases for insurers. These serious illnesses require tremendous resources from the healthcare system—as well as tremendous participation from patients themselves. (We tend to forget that part.) Our healthcare “system” and medical education are based on a Western medicine, acute healthcare approach that works very well for high intensity events like separating conjoined twins or treating trauma victims, but not well at all for long-term, complex, chronic illnesses.
Let’s look at two illnesses, one acute (bacterial pneumonia) and one chronic (ESRD). Here’s how they play out:
|Pneumonia (Acute)||ESRD (Chronic)|
|Duration||Short. No one lives for years with pneumonia—it is either cured or fatal.||Life-long. Once diagnosed, it is always present. Even a transplant is a treatment, not a cure.|
|Therapeutic Goal||Cure. We can cure this! (At least while our antibiotics still work…)||More good days than bad. We can’t cure a chronic disease. If we could, it would become an acute illness.|
|Care Team’s Job||Provide good clinical care. Once the patient is well, s/he will resume a normal life.||
• Provide good clinical care
• Teach patients to self-manage. There are many things they need to learn to do.
|Patient’s Job||Seek good care and comply with doctor’s orders. There is no time to become an expert, and no need.||Self-manage medicines, diet, fluids, access, and treatment. There is a lot to learn and follow through on. This disease has a daily quality of life impact.|
To put this another way, here is the Wagner Chronic Care model. As you can see, good health outcomes hinge on two key factors: informed, activated patients working in productive interactions with a prepared, proactive practice team. Self-management support is a big piece of this, along with delivery system design, decision support, and clinical information systems.
To succeed, ESCOs—and all other healthcare systems—must engage consumers in their self-management job, which is not compliance. Self-management support isn’t an optional add-on, it is a central requirement of chronic disease care, because:
- No one else can take a medication for a patient.
- No one else can eat or drink for a patient.
- No one else can show up to receive that person’s treatment.
Besides following a treatment plan that suits the individual’s lifestyle and values (MEI offers free decision support for dialysis here), self-management encompasses maintaining safety and managing and reporting symptoms. To motivate people who may be anxious, depressed, angry, and/or terrified to learn a seemingly endless mass of complex instructions (where mistakes can and are fatal), we have to start from their perspective—not ours as healthcare professionals. People who are terrified cannot learn.1 The fight-or-flight reflex kicks in, making learning impossible. Educating people without first addressing their fears and helping them feel hopeful is a waste of time.
Even if we do start from a place of compassion and offer hope, we still need to be able to help people along a motivational continuum from:
- Amotivation (“Whatever. Nothing I do makes any difference anyway…”) to
- Extrinsic motivation (compliance) to
- Intrinsic motivation, where people take on certain behaviors because they want to.2
As someone with prediabetes, I radically changed my diet, take a raft of supplements, sometimes use my FitBit, and routinely poke myself with a lancet to test my blood sugar, because it’s my best self-management tool. I’m intrinsically motivated to not get the disease my dad has, and so far, so good. That’s where we need people with ESRD to be, but they don’t get there by accident. We can help them by supporting their needs for:
- Competence – Feeling as if they can accomplish what they set out to do
- Autonomy – Making active choices
- Relatedness – Feeling connected to others
Each of these three psychological needs, critical from infancy through adulthood, has been shown by self-determination theory to boost intrinsic motivation.2
The question is whether the ESCOs will continue to apply U.S. medicine as usual (perhaps just more of it or with improved coordination) and miss the opportunity to apply the Chronic Care Model, to guide people across the motivational continuum, and to engage them effectively as expert patients and active self-managers—or whether ESCOs will apply adult learning principles and self-determination theory to help people produce their own best health outcomes.
If I ran an ESCO, I know which I would do.
- Perry BD. Fear and learning: Trauma-related factors in the adult education process, in The Neuroscience of Adult Learning: New Directions for Adult and Continuing Education, Number 110, by Sandra Johnson and Kathleen Taylor, July 11, 2006. Jossey-Bass, ISBN-10: 0787987042.↩
- Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist. 2000;55(1):68-78. DOI: 10.1037//0003-066X.55.1.68↩