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Rounds for Health Plans

Posted Feb 22 2013 3:26pm
Put yourself in the shoes of the health plan staff who collaborated on these tough patient situations:

The elderly man, just diagnosed with metastatic colon cancer, whose physician promised him that he could receive rehabilitation. It turned out that because of his condition, he was a more appropriate candidate for home care, and his care manager had to tell him so.

The pregnant, single woman with liver failure who ended up delivering her infant in the intensive care unit and has been hospitalized ever since. Friends are taking care of her little girl, who is now a year and a half old.

The anorexic, Hispanic teen whose parents spoke little to no English. Whatever communication did occur had to go through the father, leaving the mother on the sidelines.

These were all cases* discussed during Schwartz Center Rounds sessions at Tufts Health Plan , one of two health insurers (the other is Aetna) that now conduct our signature program.

Why does an insurance company need a forum for staff to discuss challenging patient cases? How much direct patient contact do payer staff really have? In the case of Tufts Health Plan care managers, there is quite a lot of in-depth complex care management being done!

"In complex cases, our care managers often make home visits. They are really embedded in our members' lives," says Tufts social worker Susan Garrels, LICSW, the program manager for Schwartz Center Rounds at Tufts Health Plan. "They're doing home visits, having discussions about end of life care, and advocating on behalf of members with providers," she said. "These cases can touch many people in our organization and bring out tremendous emotions. We often wall off these feelings in order to address our day to day responsibilities."

Lynn Weidenroth, RN, Debra Collins, RN, Sandy Rabison, MD
at Tufts Health Plan Rounds
Photo credit: Tufts Health Plan
Working for a health plan adds an additional dimension to these challenging cases, according to psychiatrist Samuel "Sandy" Rabison, MD, medical director of behavioral health at Tufts Health Plan and the Rounds facilitator there. "We face all of the ambivalence and antagonism some physicians and patients have toward insurers. A provider tells a patient that ‘of course he can go to rehab,’ but it turns out he doesn't have that benefit. Our care managers are put in a difficult situation of sometimes having to deny care when they'd rather not."

Rounds have been a big hit since they started at Tufts Health Plan last June, with more staff wanting to attend the sessions than the room can accommodate. The organizers are considering live streaming the sessions so more people can participate.

It's been especially helpful for the non-physicians to hear the doctors talk about the cases, according to Dr. Rabison. "There's sometimes the perception that physicians may not be experiencing the same emotional dilemmas that others in the organization are experiencing. Rounds show staff that everyone is working through the same issues."

*some details have been changed to protect patient confidentiality

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