You Are Not Your Chief Complaint (Part 2)

In part 1, we looked at the story of Michael, a 48 year old warehouse worker who suffered from back pain. Michael, like a lot of people, was struggling with more than just back pain. He also had depression, was a smoker, was overweight and pre-diabetic. Also like a lot of people, he was only getting treatment for his chief complaint—his back pain. Journey with us as we break-down why our healthcare system is designed around treating just chief complaints, and how technology innovation and the idea of “Whole Person Care” is changing this.

Haven’t read Part 1? Get up to speed here.

Building Technology to Treat the Whole Person

We firmly believe we are entering a new era of healthcare delivery whereby we use a modern technology stack to deliver real-time, adaptable, and comprehensive care for patients. And this is what we largely describe as Whole Person Care.

Whole Person Care is an interdisciplinary approach that brings together the proven factors to treat a patient. The result is a patient-centered treatment that integrates physical, social, behavioral, mental, and environmental support to offer a fuller, durable recovery.

At PeerWell we’ve spent several years developing cutting edge patient-facing technologies such as our SMART Motion?system to capture clinically accurate measurements of a person's musculoskeletal status - all using just the smartphone. We quickly realized that a big part of the challenge is how this technology integrates with care teams to amplify their expertise to adjust care plans for patients. This meant making sure the data was accurate and it was aggregated with other elements to give providers a full view of the patient’s status.

For example, it was important for provider to know a patient’s Knee Range of Motion (ROM) - but it was much more relevant to know how the current ROM measurement compares to the person’s historical values, a benchmark of similar patients, and the measurement relative to a major procedure like a total knee replacement. Furthermore, it was important to include other aspects of the patient’s health such as a recent depression score (in case ROM improvement has slowed to the point of needing an additional intervention because of other health issues).

The technology to capture this information is now available and the challenge we needed to solve was how to package it up to be communicable and actionable by multiple parties on the care team. Additionally, it was important to close the loop so follow-on interventions could be tracked and made visible to members of the disparate specialties involved.

Without this technology, we would not have a connection to the daily health status of the patient relevant to their primary condition. The steady stream of data drives what care needs to be rendered or altered.

To change how care is provided, you need to be a provider

As most people lament, change in healthcare does not come easy. While we built the core technologies described above, we realized the change management required for traditional practices would take too long. In order to see the change in care delivery that we wanted - and our patients wanted - we needed to break new ground and establish a new provider practice with the ability to deliver care from end to end.?

This is no small feat and I have a great appreciation for provider practices today. In addition to the legal and regulatory requirements, we needed to decide what kind of practice was most relevant, each with different sets of consequences. For example, if we established ourselves first as a Physical Therapy provider (as is common in musculoskeletal care), we may not be able to address issues like medications or mental health which are necessary for Whole Person Care. In the end, to deliver on our mission of Whole Person Care that is accessible to all people, we needed to be a multi-specialty medical practice which provides the broadest mandate when delivering care.

Regulatory Compliance

As mentioned above, there is a lengthy legal and regulatory process to work through to establish a medical practice. There is a good reason it is hard, we are taking responsibility for the care of people in need. That should not be taken lightly.?

Each state has its own standards for how to establish a new medical practice and there are different medical boards to work with for each specialty included in your practice’s scope. There are state and federal guidelines for delivering care virtually (e.g. telehealth) as well as state licensure requirements for the practice and its providers. There are additional requirements if the practice will be prescribing medications, controlled substances or other. There are other requirements if the practice will be distributing durable medical equipment, or ordering lab tests.

If the practice will also be serving government beneficiaries, like Medicare or Medicaid, there are other requirements and inspections to go through.?

Once our practice was established, we then needed to connect with the payers so we could join their provider networks. We could have decided not to pursue this path and instead just attract patients that would be willing to pay out of pocket. However, our mission was to serve Whole Person Care to the most people we could. This meant we had no choice but to make our services available through insurance carriers as that is how the majority of people afford healthcare services. Additionally, we knew we needed to enroll in traditional Medicare and Medicaid programs. The populations accessible through those programs are heavily impacted by musculoskeletal issues and often most neglected when it comes to new care delivery programs. They can be seen as too hard to reach or too constrained by regulation.?

Organizational Development

Building a multi-specialty provider group requires providers from multiple specialties, obviously. The foundation for PeerWell’s patient-facing technologies and care programs has been our steadfast belief in Whole Person Care. When we describe Whole Person Care, we talk about delivering across our Five Pillars - Physical Therapy, Nutrition, Pain and Mental Health, Life & Environment, and Health Literacy.?

Just like we matched the 5 pillars to 1000s of evidence-based activities in our patient programs, we’ve matched the 5 pillars to the providers needed to deliver Whole Person Care. We started outreach to add care team members with specialty training in Physical Therapy, Occupational Therapy, Nursing, Licensed Clinical Social Workers, Registered Dietitians, Medical Doctors, Psychiatrists.?

Once we identified each provider type, and recruited the first few individuals, we then had to work with the providers to develop a training program to help these providers learn how to work with providers from other specialties. Whole Person Care is not standard today and oftentimes providers are limited in their interactions with providers from other specialties. The most relevant practice would be e-consults where a provider would connect with a specialist for clinical decision support. These are short-lived exchanges and are used mostly in high acuity and very complex cases like rare disease diagnoses.?

We developed custom training materials for our care team members to learn how to work with others to deliver Whole Person Care, leverage new technologies, and unlearn traditional practices that resulted in fragmented or siloed care.

Patient Operations

Delivering care as a provider is much different than building an app. We had to implement new intake processes for patients. We needed to guide them through the process of enrolling which included verifying their insurance coverage, providing guidance on costs and patient responsibility, collecting consent for telehealth visits, and scheduling their first visit with our care team members.?

Each one is not altogether difficult to do, but managing the end to end process while also making it less stressful for the patient requires iteration and practice. There is a lot more we can do here to make this experience seamless and easy for patients - it is similar in nature to developing AI that takes ongoing effort to improve accuracy and efficiency.?

Clinical Operations

As was discussed earlier, Whole Person Care is not a common paradigm for most providers. We found it useful to have forums, “Grand Rounds” with the providers to discuss with each other what they are seeing from patients in their visits. They also review data from patients like SMART Motion measurements, clinical assessments, and other relevant patient items to determine the best course of care for each patient.?

Based on these discussions, it is up to our care coordinator to ensure visits are scheduled or rescheduled with the right providers and explaining to the patient what is happening.

Billing Operations

After care has been delivered to a patient, there is a whole other process that kicks off to be paid for the work performed. Providers share their full visit summaries in clinical notes taken before, during, and after visits with the patient. These notes are formatted as SOAP Notes and logged in the electronic medical record system. These notes are then reviewed by the billing team to identify which clinical services were performed along with the right level of severity of the patient’s condition. The result of this process produces a Superbill which itemizes the patients’ diagnoses and procedure codes for each patient encounter. Each Superbill is then converted into a specific claim form that varies depending on the patient’s primary or secondary insurance. For example, Medicare and Medicaid programs use a HCFA 1500 to process and reimburse claims for Medicare and Medicaid beneficiaries.?

Once claims are submitted there is still the matter of claims review and potential adjudication from the payers to determine if the care provided was necessary. It is important to maintain all forms for documentation to ensure the practice complies with evidence-based care guidelines so adjudication is kept to a minimum.

The above is just what is related to obtaining reimbursement from the insurance carriers for services performed. There is also the matter of collecting patient responsibility for those services, meaning based on the patient’s insurance plan, they may be required to pay co-pays and coinsurance as well as basic costs until they’ve met their plans’ yearly deductible.

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?In the end, our transition from a technology provider to a care provider was the result of years of complex research, and pulling in numerous experts in patient operations, clinical operations, billing, and so forth. Becoming a virtual clinic for Whole Person Care is not for the faint of heart. It requires mastery over an incredible amount of detail and navigating an enormous amount of complexity. This is an area that most digital providers are just beginning to dip their toes into. However, this will be fundamental to this new era of healthcare delivery. We care about delivering the best outcomes, that will only be possible if we also take responsibility for end-to-end care delivery. Those that are brave enough to do so will be greatly rewarded - most importantly, patients (like myself, my family, my friends) will receive care fit for the modern times we live in. Outcomes will be better and receiving care when we need it will not be as broken as it is today.