Patient, not doctor, knows best

Ron Elliott and his co-workers at Peters Billiards in Minneapolis were struggling to pick health insurance for next year. The wrong choice could mean hundreds of dollars more out of pocket.

Elliott takes five drugs for a heart condition and acid reflux. Chest pains recently put the 61-year-old inventory analyst in the hospital for a night. Should he choose a traditional plan or risk a new one with a higher deductible sweetened by a company contribution?

"What makes the decision hard is the unknown. Am I going to have an injury or an illness or something that I can't forecast now?" Elliott wondered.

This kind of health roulette is playing out in workplaces across the nation as an explosion of choices confront health care consumers. Picking insurance is just the first step into the rapidly changing health care landscape. Many people can now lower their premiums by adopting more healthful lifestyles -- but that's easier said than done. New options online to compare cost and quality can help consumers choose doctors and hospitals -- or just add to the heap of complex information they must sift through.

Once at a clinic, more patients are also being asked to participate with doctors in care decisions -- an arena called "patient-centered care." Last week, Gov. Tim Pawlenty announced plans to bring this concept to health care for 50,000 state employees.

Top health policy makers are convinced that the path to a healthier Minnesota and cheaper health care is paved with active patient involvement at every step.

The question is, are Minnesotans ready for this?

"We're asking patients to take much more responsibility for their overall health," said Gary Oftedahl, medical director at the Institute for Clinical Systems Improvement in Bloomington.

"But we don't do a good job of providing the information to help them make good choices. It's the paradox of choice: The more choices, the harder it is to choose."

The institute, a nonprofit collaboration of 57 hospitals and clinics trying to improve medical care, is studying decision-making tools doctors could use to help patients.

Coaching patients is often a matter of timing. "If we feed someone too much information when they aren't ready, it's like standing them up in front of a fire hose," he said.

At Stillwater Medical Group clinic, patient Lynn Ogburn, 51, participated recently in a research project testing that process. The 3M manager was among 28 women with uterine fibroids, noncancerous growths that occur in more than half of women. They used a variety of decision-making techniques to guide them through choosing from among four common treatments: "watchful waiting" for symptoms, drugs, surgical removal or hysterectomy.

Engaging the doctor

"The choice became clear for me. I chose a hysterectomy. But it took two months of study and discussions with my doctor," Ogburn said. "She wanted to know how a choice might affect my work, my family life and lifestyle -- really so different from when the doctor just recommends what to do."

Not so long ago, doctors called all the shots. Some still do. But pulling patients into the decision process requires doctors to cede some control.

"Some patients -- and some doctors -- already are engaged in patient-centered care, but some aren't yet comfortable sharing authority," said Dr. Lawrence Morrissey, a pediatrician and medical director for quality improvement at the Stillwater clinic.

Morrissey and other Stillwater doctors are starting a similar research project for men with prostate cancer. "Eventually I'd like to integrate this approach into all of our care," he said.

He sat down recently with Bailey Garcia, 12, for a seventh-grade sports checkup.

"I feel like Dr. Morrissey really wants to know how we're doing as a family," said Bailey's mom, Katie Garcia. "He takes care of all three of our boys, and he probably listens more than he talks -- which is kind of unusual for a doctor. It means we have to do some thinking and planning, too, but I'm all for that."

That hit home after her mother had a medical procedure "that changed her life -- and not for the better. I really see how I have to take responsibility for my own health."

That metamorphosis also is required of doctors. "I'd guess that maybe one-third of Minnesota doctors know something about patient-centered care, and that's going to grow dramatically in five years," said Dr. Marcus Thygeson, medical director of consumer health solutions at HealthPartners, a Bloomington-based insurer and care provider. "This is more than just getting patient consent for a procedure." Efficiency pressures to rein in costs -- such as the "seven-minute clinic visit" -- haven't fostered patient/doctor discourse in recent years, he said.

"I need to speak carefully here because I don't want to sound critical of doctors. But we were trained much better to act than to listen," he said.

Targeting the chronically ill

One of Minnesota's top cheerleaders for retooling the health care system -- especially involving patients in the process -- is Dr. Sanne Magnan, state health commissioner.

"When consumers are actively engaged at every level of health choices, we get better health outcomes, eliminate unwanted, unneeded and wasteful services, increase the effectiveness of care and lower the costs," she said. "We'll be a healthier state, physically and economically."

Her department supplied much of the research muscle behind state legislation this year reorienting the health care system to emphasize patient choice.

The law begins moving the state toward paying doctors for results instead of by each procedure. It also expands information on cost and quality of care at clinics and hospitals to help consumers shop for health care.

An important force for change included in the law, she said, will be the Statewide Health Improvement Program, funding community-designed programs to combat obesity and smoking -- both prime causes of chronic illness.

"Eighty percent of the medical costs today are for chronic illness among 20 percent of the population," she said. "The best way to fight rapidly rising costs of health care is to create healthier Minnesotans who are less dependent on medical intervention."

The new law greatly expands the concept of "medical homes," clinics that coordinate care and involve patients in sharing responsibility for their health.

Building medical homes

Dr. Amy Burt, a Park Nicollet pediatrician in Plymouth, helped start one such medical home for children with special health needs.

"The parents of my patients love it. They tell me how empowering this process is for them," she said.

Here is how it works: Burt works in a team with nurses and social workers to engage patients before, during and after clinic visits. She frequently gives families referrals, helps navigate coverage from government and insurers, and finds social services.

"I can't know everything. I depend on the clinic team, and even on parents, to help educate me," Burt said. "I put in a lot of unreimbursed hours, but it's worth it. It makes me a better doctor, and -- usually -- it makes the job much more rewarding."

Among her patients is Jack Ebsen, 5, whose family has struggled for three years with his autism.

"I'm a nurse, for God's sake. I'm informed. But we were struggling so much. It's been an awful journey in many ways," said Jenna Ebsen, 36, of Edina, an RN who quit work to care for Jack and his sister, Sofia, 4.

"Without our faith, and without Dr. Burt, I don't know where we'd be," she said. "The strain of autism on our family has been almost overwhelming at times. But Jack has progressed so much. Now he smiles. He'll let me hug him sometimes. He talks. He doesn't hit people or scream very often anymore. That's because I've had amazing support from Dr. Burt. She's Jack's doctor, but she's also my partner in caring for Jack."

Guiding patients to a choice

Which drug is the right choice? What are the side effects? How often is it taken and how?

Being pulled into helping make choices about their medical conditions instead of leaving it up to the doctor is bewildering to some patients. That is spawning a cottage industry among health care providers to develop "tools" to make culling the options less intimidating.

At the Mayo Clinic, a decidedly low-tech approach is showing promise: Flash cards figure prominently in an experiment to help diabetes patients choose which drug to take.

The cards are grouped into topics such as weight change, side effects and extent of blood sugar monitoring. Patients pick drugs based on what matters most in their daily lives.

Researchers are finding patients who go through the process are more likely to stick with the drug regimen. Some patients volunteer to try diet or exercise first. Those lifestyle changes can be very effective, but are hard to impose.

The flash cards also seem to prompt richer patient-doctor encounters. One 90-year-old diabetic picked up the weight gain card, to the surprise of his long-time primary care doctor. Turned out his wife had died, and he was moving into a nursing home where he expected to meet lots of single women.

The flash cards elicited "what mattered to that guy at that time in his life," said Dr. Victor Montori, an endocrinologist leading Mayo's study. Mayo is now developing flash cards for osteoporosis and heart attacks.

A decision emerges

Back at Peters Billiards, there were doughnuts and brochures on the table as insurance agent Greg Dattilo explained the new options to employees.

For years they had a single health plan with rich benefits. But after a series of premium increases above 10 percent, management balked. Now the company is also offering a high deductible plan with a health savings account (HSA), giving employees a bigger role in shopping for medical care. Dattilo stressed the tax benefits of HSAs and the extra cash Peters will contribute to them.

Questions rolled in: Will fixing my kid's teeth count toward my deductible? If you've had cancer, are mandatory scans preventive care? Longtime agents say it can take double the time to sell HSA-linked policies because there's so much to explain.

"It's a scary thing," said Jan Peterson, the company's human resources manager. "You're always afraid you're going to choose the wrong thing and it's going to cost you."

Last year, just nine of the company's 30 employees chose the new plan. This year, another 19 switched over, effective last Friday. Those who switched last year have been crucial ambassadors. It's helped that they've accumulated an average of $1,260 in their HSAs, making the large deductible a little less intimidating.

After careful consideration, Ron Elliot, the inventory specialist, switched to the high-deductible option. He figures with prescriptions and other costs, he'll likely blow through the deductible and reach his maximum out-of-pocket costs -- actually coming out ahead. But he knows it's a gamble.

"You can do all the homework," he said, "and something can be very different next year."

wolfe@startribune.com 612-673-7253 mychen@startribune.com 612-673-7434