FORUM
Nurse-in-box only answers to the insurer

Dr. Steven Wolfson
May 08, 2002

Education is crucial to the doctor-patient relationship. Even the most acute diagnostician, and the cleverest surgeon, will have limited impact on chronic diseases unless the patient is given the information that he or she needs to participate in the program of care.

For a patient newly diagnosed with heart failure, as an example, the program would include: as many as six medications; reduced sodium intake in the daily diet; measuring one's weight each morning and reporting significant changes to the doctor; knowing the danger signals that suggest calling 911; and assurance that all this work can lead to a long and relatively normal life style.

This is a lot of information to transfer, and much of it may be confused or forgotten. Follow-up visits or questions by phone are opportunities to reinforce and correct the process. But an ideal tool would be a routine follow-up letter and phone call from the physician's office, offering repeat instructions and the chance to ask questions in a leisurely fashion.

In their wisdom, however, no insurers will reimburse physicians or their office staffs for time spent on the phone or through mailings to ensure that patients understand their disease and its treatment.

With physician reimbursement being reduced year by year, few offices can assume a large burden of uncompensated care. This is particularly the case for primary care physicians, whose marginal fee schedule has mandated seeing more and more patients in less time. Most average 30 patients per day. Add to this the bureaucratic burden imposed by insurers and government, and little time is left for patient education.

The last decade has seen major insurers respond by introducing the concept of disease management to their array of tools for cost control. In fact, the Medicare funding agency, Centers for Medicare & Medicaid Services, has recently initiated a study of this process.

As practiced, disease management is usually represented by a proprietary company, paid by insurers, that employs nurses who are assigned to telephone patients with chronic diseases. The nurses ask and answer a scripted set of questions, remind patients about specific monitoring measures such as daily weighing, and the indications for calling physicians.

The expectation is that this will save money by anticipating and thereby avoiding problems. Studies have in fact shown that disease management techniques may reduce rates of hospital readmission for patients with congestive heart failure. But the studies have only compared disease management with no supplementation of standard care. No studies have compared this option to an approach that would empower physicians to perform this function without the intercession of a third party.

In essence, rather than paying doctors or their staffs, disease management is offering patients a nurse, affiliated with no physician, armed only with a telephone. This is poor recompense. None of us would applaud a physician who routinely made diagnostic and therapeutic decisions about patients over the phone, with little information about the patient, having no access to prior records.

No matter how well meaning and well trained, the nurses working for these concerns have not met the patients. They are paid by and trained by the insurer. Their charge is to save money. And they have no direct access to the treating physician.

Why not spend the money to reimburse primary care physicians adequately so that they can allocate more time to patients? Why not pay doctors for the time they spend with patients on the phone? If this were done, I suspect we would see a further decrease in the overall cost of the treatment of chronic disease, far more than might be offered by "disease management" firms. Identification of a problem by a physician's office, with prompt involvement by the doctor, offers the promise of action before an injury occurs.

In short, it would make more sense to leave patient care in the hands of physicians and nurses within the health care system, rather than setting up the "nurse in a box" as a parallel universe responsible only to the insurance industry.


Dr. Steven Wolfson is a New Haven cardiologist. Readers may write him in care of the Register, 40 Sargent Drive, New Haven 06511.