1. Powell, Suzanne K. MBA, RN, CCM, CPHQ

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I have taken a temporary sabbatical from reading about, or listening to, the healthcare debate. Sometimes, it is best to stand at arm's length from an issue in order to see it with more clarity.


I took this sabbatical for several reasons. First, much of what goes through cyberspace is taken out of context, exaggerated to make a personal point, or just speculative. On the other end of the continuum, I try to impact those things in which I have even a small semblance of power-and what is currently occurring on "The Hill" leaves me feeling pretty impotent. But that doesn't stop me from looking beyond the hype and the arguing for real solutions that may help our healthcare quandary...and, by golly; I may have uncovered a nurdle of wisdom!!


In a Washington Post article (Miller, 2009), an innovative group of physicians redesigned their practices when fatigue and burnout increased and patient and physician satisfaction decreased. They began seeing their patients for longer periods. Going from the standard 15-min office visit to a 30-min visit, one certainly diminished the physician revenue stream-and changes had to be made; sometimes, fancy offices were simplified. And many of these physicians still contract with Medicare; use a sliding-scale, fee-for-service model; and work with patients on payments.


But interesting things started to happen. In addition to the obvious-improved patient and physician satisfaction-outcomes changed. During a short half hour, the physicians got to know the wishes of the patients and their support systems and, sometimes, unearthed critical facts. At the end of one session (of the half-hour kind), one patient casually mentioned a broken heater. This patient had already had a plethora of inconclusive medical tests for headache and fatigue. This casual remark revealed carbon monoxide poisoning: problem solved.


But, you say, this is a grassroots effort that may never materialize on a grand scale. And I must remind you that, in the 1980s case management was a grassroots effort-now materialized on a grand scale!!


Miller (2009) cites a yet-to-be-published study where a medical practice in Washington State took a large physician group and reduced their patient load from 2,300 to 1,800, thus effectively lengthening the office visit from 15 min to 30 min. At the end of a year, increase in patient and physician satisfaction spiked, but more importantly for those watching healthcare dollars, the number of emergency department visits decreased.


One physician reported that the extra minutes spent with patients translated into fewer prescriptions and less testing; this, in turn, led to fewer side effects and less unnecessary procedures. This is not just of anecdotal significance and should be seriously considered during all the healthcare reform, "How do we save Medicare?" debates. In one study, 310 clinicians from 22 institutions reported 583 cases with diagnostic medical errors (Schiff et al., 2009). Among the revelations, the study found the following:


* Errors occurred most frequently in the testing phase; 44% of the errors were from failure to order, report, and follow up on test results.


* 32% of the errors were due to clinician assessment errors such as failure to consider differential diagnoses.


* The remaining errors revealed problems in taking patient histories, physical examinations, or lack of/delay in consultations.



Is it possible that slowing down, taking time, and being careful could be just what the doctor ordered: for quality healthcare, for costefficiency, and for satisfaction?


One barrier to allotting "time" for patients is said to be a growing lack of practitioners. A recent survey by The Physicians' Foundation found that government mandates and regulations are the major reason physicians today, particularly primary care doctors, are leaving the practice of medicine in unprecedented numbers (Society for Innovative Medical Practice Design, 2009). Every case manager knows that government mandates and regulations are increasing, not decreasing: RACs, MACs, HIPAA, MICs, observation, 3-day qualifying stays, the list goes on (and on). Calculating optimal case management caseloads is a perpetual challenge (just like physician patient load) and the regulatory mandates add to our workload. But let's examine yet another finding where all this detailed regulation may be contributing to the problem(s). In a Bureau of National Affairs' (BNA's) Medicare Report (2009), it was noted that the Medicare error rate doubled in 2009, translating into $24.1 billion. But it went on to further state that "Medicaid improper payments more often were the result of inadequate documentation rather than fraud" (BNA, 2009, p. 1). Haven't we all, at some time, saved documentation to the end of the day, when you can barely remember your name, let alone all that you have done with every case? Aah, for more time....


A novice case manager asked a seasoned case manager, "What is the basis of your success?" He/she replied, "Good judgment." The novice case manager asked, "Where did the good judgment come from?" The seasoned case manager said, "Experience." The novice case manager further questioned, "Where did the experience come from?" The seasoned case manager said, "Poor judgment."


Often poor judgment-and poor outcomes-results from too much to accomplish coupled with too little time to think things through. Perhaps the answer to the complex healthcare quandary lies in learning from past experiences, not heaping poor judgment upon poor judgment. So, stepping back, the message is clear:


1. Go slowly when planning major healthcare reform.


2. Make changes thoughtfully.


3. Learn from past poor judgment.


4. And grant full use of case management when looking for answers. As stated many years ago, "(Case managers) will be recognized as shining lights, pulling the fragmented pieces of healthcare together" (Powell, 1996, p. xiv).



Postscript: It is now the morning of Christmas Eve 2009 and the Senate has passed the healthcare reform legislation (Yes, journal timelines are lengthy). My sabbatical is over and, by the time this Editorial is published in March 2010, it is likely that there will be lively debates from all fronts. While I delve into this reform in the coming months, I am not expecting to see anything that encourages less regulation or more time spent with patients. But we are a resilient people and, with a case management eyes and heart, our healthcare stands a fighting chance.




Bureau of National Affairs. (2009). BNA's Medicare Report. Retrieved November 20, 2009, from[Context Link]


Miller, D. (2009, September 15). Maybe it's time to slow down the pace of medical treatment. The Washington Post, p. E5. [Context Link]


Powell, S. K. (1996). Nursing case management: A practical guide to success in managed care. Philadelphia: Lippincott-Raven. [Context Link]


Schiff, G. D., Hasan, O., Kim, S., Abrams, R., Cosby, K., Lambert, B. L., et al. (2009). Diagnostic error in medicine: Analysis of 583 physician-reported errors. Archives of Internal Medicine,169(20), 1881-1887. [Context Link]


Society for Innovative Medical Practice Design. (2009). Retrieved December 23, 2009, from[Context Link]

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Mission Statement:Professional Case Management is a peer-reviewed, progressive journal that crosses all case management settings. PCM uses evidenced-based articles to foster the exchange of ideas, elevate the standard of practice, and improve the quality of patient care.